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Kenya DVI Comprehensive Multi-Year Plan 2006-2010

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REPUBLIC OF KENYA

MINISTRY OF HEALTH

DIVISION OF VACCINES AND IMMUNIZATION (DVI)

MULTI YEAR PLAN 2006-2010


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TABLE OF CONTENTS

LIST OF TABLES ......................................................................................................................... 5

LIST OF ACRONYMS ................................................................................................................. 6

EXECUTIVE SUMMARY ........................................................................................................... 9

1.0 BACKGROUND INFORMATION ............................................................................... 11

1.1 GEOGRAPHY AND DEMOGRAPHIC CHARACTERISTICS ..................................................... 11

1.2 HEALTH SECTOR PRIORITIES .......................................................................................... 12

2.0 HEALTH CARE DELIVERY SYSTEMS .......................................................................... 13

2.1 POLICY OF THE MINISTRY OF HEALTH ............................................................................ 15

2.2 THE NATIONAL HEALTH SECTOR STRATEGIC PLAN II (NHSSPII) ................................. 15

2.2.1 The Kenya Essential Package for Health ..................................................................................... 16

2.2.2 Service Delivery .......................................................................................................................... 16

2.2.3 Improving Financial Access ........................................................................................................ 17

2.2.4 Improving Health Worker Performance ...................................................................................... 17

2.2.5 Health Planning (Take note of the GoK finance/planning cycle) ................................................ 17

2.2.6 Monitoring and Evaluation .......................................................................................................... 17

2.2.7 Human Resource Management and Development ....................................................................... 18

2.2.8 Quality Assurance and Standards ................................................................................................ 18

2.2.9 Investment and Maintenance ....................................................................................................... 18

2.3 JOINT PROGRAM OF WORK AND FUNDING (JPWF) ......................................................... 19

3.0 SITUATION ANALYSIS................................................................................................ 20

3.1 THE EXPANDED PROGRAMME ON IMMUNISATION .......................................................... 20

3.2 PROGRAMME STRUCTURE ............................................................................................... 20

3.3 ROUTINE IMMUNIZATION ................................................................................................ 21

3.3.1 Immunization Schedule for Kenya .............................................................................................. 21

3.4 ROUTINE IMMUNIZATION PERFORMANCE, GAPS AND CHALLENGES ............................... 22

Trends of Routine Immunization ................................................................................................. 22

4.0 IMPLEMENTATION OF THE EPI COMPREHENSIVE MYP 2006-2010 ............ 28

4.1 THE NATIONAL HEALTH STRATEGIC PLAN II, GIVS AND THE CMYP ............................ 28


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4.2 THE KENYA DIVISION OF VACCINES AND IMMUNIZATION (DVI) ................................... 29

4.3 DVI GOAL ...................................................................................................................... 29

4.4 PROGRAMME OBJECTIVES .............................................................................................. 29

4.5 STRATEGIC AREAS .......................................................................................................... 31

4.6 PRIORITY TARGETS ......................................................................................................... 31

4.7 GOVERNANCE AND PARTNERSHIPS ................................................................................. 31

4.8 MONITORING AND EVALUATION..................................................................................... 31

5.0 THE IMMUNIZATION SYSTEM COMPONENTS .................................................. 33

5.1 SERVICE DELIVERY ........................................................................................................ 33

5.2 VACCINE SUPPLY, QUALITY AND LOGISTICS .................................................................. 33

5.3 DISEASE SURVEILLANCE ................................................................................................ 34

5.4 ADVOCACY, SOCIAL MOBILIZATION AND COMMUNICATION .......................................... 34

5.5 PROGRAMME MANAGEMENT .......................................................................................... 35

6.0 NATIONAL PRIORITIES BASED ON THE SITUATIONAL ANALYSIS ............ 38

7.0: NATIONAL PRIORITIES, NIP OBJECTIVES AND MILESTONES, .................... 39

8.0 CMYP ACTIVITY TIMELINE ..................................................................................... 54

9.0 COSTING, FINANCING AND FINANCIAL SUSTAINABILITY ........................... 61

9.1.1 MACROECONOMIC INFORMATION ............................................................................... 62

9.1.2 VACCINES AND INJECTION EQUIPMENT ...................................................................... 62

9.1.3 PERSONNEL COSTS (EPI SPECIFIC AND SHARED) ........................................................ 62

9.1.4 VEHICLES, AND TRANSPORT COSTS ............................................................................ 63

9.1.5 COLD CHAIN EQUIPMENT, MAINTENANCE AND OVERHEADS ..................................... 63

9.1.6 OPERATIONAL COSTS FOR CAMPAIGNS ...................................................................... 63

9.1.7 PROGRAMME ACTIVITIES, OTHER RECURRENT COSTS AND SURVEILLANCE ............... 63

9.1.8 OTHER EQUIPMENT NEEDS AND CAPITAL COSTS ....................................................... 63

9.2 COST PROFILE ................................................................................................................. 64

9.3 BASELINE FINANCING ........................................................................................................... 65


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9.4 COST BY IMMUNIZATION STRATEGY ..................................................................................... 65

9.5 PROGRAMME COST REQUIREMENT FOR 2006-2010 ............................................................... 66

9.6 FINANCIAL SUSTAINABILITY STRATEGIES, ACTIONS AND INDICATORS .................................. 72

9.7 IMPLEMENTATION AND FOLLOW-UP OF FINANCIAL SUSTAINABILITY STRATEGIES ................ 76

10.0 DVI ANNUAL WORK PLAN FOR 2008 ..................................................................... 79


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LIST OF TABLES

Table 1: Vital Statistics for Kenya ................................................................................................ 11

Table 2. Current Routine Vaccination Schedule for Children under 1 year .................................. 21

Table 3.1: Summary of situation analysis by Routine EPI system components, 2001-2005 ........ 23

Table 3.2: Situation analysis by Routine EPI system components, 2001-2005 ............................ 24

Table 4: Situation analysis by Accelerated Disease Control Initiatives, 2001-2005 ..................... 25

Table 5. Summary of Strengths and Weakness of the Immunization Programme ........................ 26

Table 6: Time Frames for NHSSP II/POW, cMYP and AOPs/annual implementation plans ...... 28

Table 7: Coverage and Wastage targets ........................................................................................ 30

Table 8.1: Service Delivery ........................................................................................................... 39

Table 8.2: Vaccine Supply, Quality and Logistics ........................................................................ 42

Table 8.3: Disease Surveillance ..................................................................................................... 44

Table 8.4: Advocacy and Communication .................................................................................... 46

Table 8.5: Management ................................................................................................................. 49

Table 9.1: Inputs to different EPI systems components ................................................................ 61

Table 9.2: Macro Economic Trends in Kenya, 2006 - 2010 ......................................................... 62


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LIST OF ACRONYMS

AD - Auto Destruct (syringes)

AEFI - Adverse Events Following immunization

AFP - Acute Flaccid Paralysis

AIDS - Acquired Immune Deficiency Syndrome

AIE - Authority to Incur Expenditure

AOP - Annual Operation Plan

BCC - Behaviour Change and Communication

BCG - Bacille Calmette-Guerin (Vaccine)

CAG - Cash Assistance to Government

CBAW - Child Bearing Age Women

CBHC - Community Based Health Care

CBO - Community Based Organization

CBS - Central Bureau of Statistics

CDC - Communicable Disease Control

CFC - ChloroFluoro Carbon

CORPS - Community Own Resource Persons

DANIDA - Danish Aid National Development Agency

DARE - Decentralized Aids and Reproductive

DDSC - District Disease Surveillance Coordinator

DIFD - Department for International Development

DHE - Division of Health Education

DHEO - District Health Education Officer

DHMT - District Health Management Team

DHP - District Health Programme

DMOH - District Medical Officer of Health

DMS - Director of Medical Services

DPT - Diphtheria Pertusis and Tetanus

DQA - Data Quality Audit

DRCO - District Registered Clinical Officer

DVI - Division of Vaccines and Immunization


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EPI - Expanded Programme on Immunization

FBO - Faith Based Organization

FIC - Fully Immunized Children

GAVI - Global Alliance for Vaccines and Immunization

GDP - Gross Domestic Product

GOK - Government of Kenya

HepB - Hepatitis B

Hib - Haemophilus influenza type b

HIS - Health Information Systems

HIV - Human Immunodeficiency Virus

NHSSP - National Health Sector Support Programme

ICC - Inter Agency Coordination Committee

IDS - Integrated Disease Surveillance

IDSR - Integrated Disease Surveillance & Response

IEC - Information Education and Communication

IMCI - Integrated Management of Childhood Illnesses

JICA - Japan International Agency

JPWF - Joint Program of Work and Funding

KAfI - Kenya Alliance for Immunization

KBC - Kenya Broadcasting Corporation

KDHS - Kenya Demographic and Health Survey

KEMRI - Kenya Medical Research Institute

KEMSA - Kenya Management and Supplies Agency

KEPH - Kenya Essential Packages for Health

KEPI - Kenya Expanded Programme on Immunization

KMTC - Kenya Medical Training College

MCH - Maternal Child Health

MDVP - Multi Dose Vial Policy

MLM - Mid Level Management

MNT - Maternal Neonatal Tetanus

MoH - Ministry of Health


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MTEF - Mid Term Expenditure Framework

MTRH - Moi Teaching and Referral Hospital

MYP - Multi Year Plan

NARC - National Rainbow Coalition

NCPD - National Council Population Development

NGO - Government of Kenya

NID - National Immunization Days

NPCC - National Polio Certification Committee

NPEV - Non-Polio Enteroviruses

NPHL - National Public Health Laboratories

NPEC - National Polio Expert Committee

NNT - Neonatal Tetanus

OJT - On the Job Training

OPV - Oral Polio Vaccine

PDSC - Provincial Disease Surveillance Committee

PHC - Primary Health Care

PHEO - Provincial Health Education Officer

PHI&RO - Provincial Health Information and Records Officer

PHMT - Provincial Health Management Team

PHO - Public Health Officer

PHT - Public Health Technician

PRSP - Poverty Reduction Strategy Paper

RED - Reaching Every District

SIA - Supplemental Immunization Activities

SDP - Service Delivery Point

SNID - Supplemental National Immunization Days


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EXECUTIVE SUMMARY

The Division of Vaccines and Immunization Kenya Expanded Programme on Immunization’s

(KEPI) overall goal is to increase access to immunization services, provide effective and potent

vaccines as and when they become available such as Pneumococcal and rotavirus vaccines and

increase demand for the services in order to reduce infant morbidity and mortality rates due to

vaccine preventable diseases. The EPI services are provided under the Kenya Essential Package

for Health (KEPH), which integrates all health programmes into a single package focused on

improving health at different stages of the human life cycle.

This cMYP for 2006 – 2010 has been updated in April 2008 as necessitated by Kenya’s

application to the Global Alliance for Vaccines and Immunisation for Pneumococcal Conjugate

Vaccine 7 valent. This cMYP will be revised in August 2008 in order to take account of the

lessons learned since 2006 and the inclusion of new antigens.

The country’s routine immunization trends have shown steady but slow increase. The support by

GAVI has accelerated this increase significantly, thereby also decreasing the disease burden

attributed to those diseases.

The National Health Sector Strategic Plan II (NHSSP II) 2005 – 2010) goal is to contribute to the

reduction of health inequalities and to reverse the downward trend in health related impact and

outcome indicators. The Joint Programme of Work (POW) for the Health Sector Wide Approach

developed in June 2006 outlines the operationalization of the NHSSP II, the different programme

areas including immunization, and financial support requirements. The priorities of the NHSSP II

are centered on the provision of Kenya Essential Package for Health as part of Kenyan Economic

Recovery Strategy for Wealth and Employment Creation (ERSWEC), known as ERS. The

foreseen risks during the implementation of NHSSP II includes: unpredictable macro-economic

status of the country; increasing levels of poverty, shortage of drugs and essential supplies,

critical shortage of human resources and the devastating impact of HIV/AIDS.


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This Comprehensive Multi Year Plan 2006 - 2010 will guide the immunization activities in

Kenya. It highlights the national goals, objectives, and strategies derived from the EPI situational

analysis. The analysis has been done through comprehensive review of DVI’s Annual operational

reports, immunization coverage reports, programme sector’s assessment reports, programme

evaluation reports, findings of surveys carried out during the plan period, and the KEPI joint

review of April 2006. In addition to this, interviews were done with key staff at all levels to fill

gaps in information and to enrich the review information. The review focused on the strengths

and weaknesses and suggested recommendations for future improvements. This strategic

planning is carried out by immunization system components rather than by targeted disease or

initiative.

Major areas of focus include:

Provision of services to hard-to-reach populations;

Introduction of new vaccines;

Integrated interventions aimed at reducing child morbidity and mortality.

The cMYP 2006-2010 is the programme’s main strategy in its contribution towards achievement

of the fourth Millennium Development Goal. The success of the programme largely depends on

adequate financing for all proposed activities to be undertaken during the planning period. It will

be the responsibility of the EPI through the Interagency Coordinating Committee to ensure that

the programme gets adequate financial and material support both locally and internationally.

Kenya is now moving towards establishing a health Sector Wide Approach (SWAp) during the

NHSSP II plan period. The programme will be monitoring the trends in financing to ensure it is

moving towards financial sustainability by reducing financing gaps, and converting more

probable financing to secure financing.


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1.0 BACKGROUND INFORMATION

1.1 Geography and Demographic Characteristics

Kenya is situated in East Africa; it borders Tanzania to the South, Uganda to the West, Ethiopia

and Sudan to the North, Somalia to the Northeast, and the Indian Ocean to the Southeast.

Administratively, it is divided into 8 provinces, and further into 149 districts covering an area of

582, 646 square kilometres. Approximately 80 % Kenya is either arid or semi-arid and only 20%

is arable.

The population of Kenya was 28.7 million in the last census of 1999 and projected to be 35,112,181 in 2008, and 36,287,423 by 2010. Of the total population, 4% are children aged under one year; 16% under five years and 44% under 15 years. Women of childbearing age 15 – 49 years make 24% of the population. Annual population growth rate was 3.2 per cent (1989 – 1999 inter-census growth rate). Average life expectancy is at 54 years with the HIV/AIDS impact factored. Infant mortality rate (IMR) is 77 per 1,000 live births according the Kenya Demographic Health Survey, 2003 (KDHS 2003). It is however imperative to note that most of the vital statistics have deteriorated between 1998 and 2003.

Table 1: Vital Statistics for Kenya

Statistic Indicators 1998 2003

Annual Growth Rate 3.0% 2.9 % 2 Crude Birth Rate 34.6 per 1000 37.5 per 10001 Crude Death Rate 12 per 10002 Total Fertility Rate 4.7 children per woman 4.9 children per woman1 Infant Mortality Rate 74 per 1000 live births 77 per 1000 live births1 Under-five Mortality Rate 111.5 per 1000 live births 115 per 1000 live births1 Maternal Mortality Rate 590 per 100,000 live births 414 per 100,000 live

births1 Male Life Expectancy at birth 52.8 years2 Female Life Expectancy at birth 60.4 years2 1Source: KDHS 1998/2003 Source: 21999 Population Census

The proportion of the population residing in the rural areas is higher than in the urban areas. The

urban population proportion has increased from 10 percent in 1969 to 19 percent in 1999.


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1.2 Health Sector Priorities

The Government of Kenya (GOK) is determined to improve both access and equity of essential

health care services, and to ensure that the health sector plays its essential role in the realization

of the Kenyan Economic Recovery Strategy for Wealth and Employment Creation (ERSWEC,

known as ERS). As a signatory of the Millennium Declaration with its internationally defined

Millennium Development Goals (MDGs), Kenya has expressed its commitment to reach these

targets by 2015. Kenya has incorporated these and other international goals into its national

targets. These are further being translated into regional and district level targets as part of the

MoH’s annual operational plan to inform and guide local priority setting and resource allocation.

Specific outcomes to be achieved in the ERS programme period represent the achievements of

the targets by MOH, through the implementation of the annual operational plans.

At national level, the ERS3 and National Development Plan 2004 – 2009 presents Kenya’s road

map for economic recovery, whose four pillars are: achieving rapid economic growth in a stable

macroeconomic environment; strengthening the institutions of governance; rehabilitating and

expanding physical infrastructure; and investing in the poor. A key component of the ERSWEC

policy as relates to the health sector is the introduction of the National Social Health Insurance

Fund (NSHIF) in a phased approach to eventually achieve universal coverage of free health care

to the Kenya Population.


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2.0 HEALTH CARE DELIVERY SYSTEMS

Kenya’s Ministry of Health offers health services through its public sector health facilities that

account for 69% of the 4,634 health facilities in Kenya. FBO/NGO and the private for-profit

sector ‘own’ the remaining 31%. However, all EPI services in 3200 Public/FBO/NGO/Private

facilities are supported by the Division of Vaccines and Immunization (DVI). The major private

health care providers include: AMREF, CHAK/NCCK (Christian Health Association of Kenya),

KCS (Kenya Catholic Secretariat), and the Kenyan Aga Khan Foundation.

Faith based organisations, Non-governmental organisations and Private health providers are key

actors in contributing to the achievement of the current National Health Sector Strategic Plan

(NHSSP II). The NHSSP II recognizes that ‘reversing the trends’ cannot be achieved by the

government health sector alone.

External Policy Environment

The Kenya national health system is operating within the context of other international health

initiatives. In this regard, achievement of the MDGs targets is of primary importance, especially

MDG 4 for DVI. Other policy documents are the Global Immunization and Vaccines Strategies

(GIVS) and the African Region EPI Strategic Plan for 2006-2009.

Internal Policy Environment

The policy frameworks within which the Annual Operational Plans and programmes are

implemented include: The Kenya Health Policy Framework of 1994; the NHSSP II 2005-2010;

and the new 10/20 policy on cost sharing. Another potential policy of importance will be the

implementation of the proposed National Social Health Insurance Fund (NSHIF) Act of 2004

once it is implemented; These form the internal policy environment for programmes’ and AOPs’

implementation.

The 1994 Kenya Health Policy Framework and the NHSSP I 1999-2004 re-structured the

implementation of health sector reforms in Kenya into addressing clearly identified imperatives.

Kenya’s NHSSP II 2005-2010 went a step higher and aims to reverse the downward trends of

most health indicators by correcting the following:

Poor access to health


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Limited utilization of promotive and preventive health services

Poor quality of service delivery

Limited efficiency and effectiveness of the support services

Insufficient collaboration and coordination with the other stakeholders that contribute to

health provision; and

Insufficient funding to health sector.

The overall health sector performance indicators and targets provide for collective monitoring

framework for NHSSP II and also for specific MOH programmes. Targets have been defined on

the basis of the ERS and the MDGs, together with preliminary assessments of what is planned for

the next the five years.


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2.1 Policy of the Ministry of Health

The Kenya Health Policy Framework of 1994 provides the health policy and strategic direction in

improving the health status of the population by ensuring provision of equitable quality health

services through a decentralized health system. The health sector’s vision is to create an efficient

and high quality health care system that is accessible, equitable and affordable for every Kenyan

household. The mission is to promote and participate in the provision of integrated and high

quality curative, preventive, promotive and rehabilitative health care services to all Kenyans.

The policy directs immunization services to improve on access and equity specifically.

2.2 The National Health Sector Strategic Plan II (NHSSPII)

The goal of the NHSSP II is to contribute to the reduction of health inequalities and to reverse the

downward trend in health related impact and outcome indicators. This will be achieved through:

i) Shifting service delivery from a curative and disease burden modality to a human

capital development approach, which is named the Kenya Essential Package for

Health (KEPH). Its approach aims at shifting interventions towards the promotion of

healthy lifestyles, integration of vertical services and ensuring continuum of care,

through strengthening the various levels of care across cohorts (from community to

national referral hospital). Additionally the NHSSP II has introduced a Human Rights

Approach in all its interventions, in particular when strengthening community based

health care through the village health committees and Community Owned Resource

Persons (CORPs)

Under the new community strategy that aims to bridge the gap between the

community and the first level of health service provision – the dispensary, each

dispensary will have a Community Health Extension Worker (CHEW) who will be

responsible for the training and supervision of the Community own Resource Persons

(CORPs) under its jurisdiction. In turn each CORP will be responsible for the health

of 20 households

ii) Articulated priorities and outputs that each annual plan should achieve if the

downward trend of health indicators is to be reversed. NHSSP II acknowledges that its


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effective implementation requires further strengthening of its various support systems,

such as planning, human resource management, quality assurance and health

standards, procurement services, infrastructure/equipment and communication.

iii) The higher level provides overall management support which is needed in areas like

policy development, joint planning, sector coordination, the institution of common

resource envelop to which all stakeholders contribute, and a joint monitoring/review

of performance.

2.2.1 The Kenya Essential Package for Health

The Kenya Essential Package for Health (KEPH) integrates all health programmes into a single

package focused on improving health at different stages of the human life cycle. It requires a shift

in the prevailing paradigm, which is focused on service delivery. NHSSP II therefore adopts a

broader approach that entails moving from the emphasis on disease burden to the promotion of

healthy life styles of individuals, with attention to the various stages in the human life cycle. In

this approach health programmes centre around the different phases of human development and

in this way complement each other, so that synergy and mutual reinforcement among the

programmes can be achieved. Once all programmes jointly focus on a particular phase in human

development, their combined outputs are expected to be better than each one could have achieved

individually. KEPH distinguishes six distinct life cycle stages:

Pregnancy, delivery and the newborn child (up to 2 weeks of age)

Early childhood (3 weeks to 5 years)

Late childhood (6 to 12 years)

Adolescence (13 to 24 years)

Adulthood (25 to 59 years)

Elderly (60 years and over)

These phases represent various age group or cohorts, each of which has special needs.

2.2.2 Service Delivery

The KEPH approach has defined six service delivery levels:

Level 1: the community level is the foundation of the service delivery priorities, because

it allows the community to define its own priorities so as to develop ownership and


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commitment to health services. Communities will be empowered with information and

skills. Only in this way can real change towards healthy life styles be achieved. (Ref:

MoH Community strategy 2006)

Levels 2 and 3: are respectively, the dispensaries and the health centres and

maternity/nursing homes, which will primarily handle Promotive and Preventive care and

some curative services covered within the PHC package.

Levels 4-6: are the primary, secondary and tertiary hospitals, which will focus mainly on

the curative and rehabilitative aspects of the service delivery package.

2.2.3 Improving Financial Access

The MoH’s plan during the NHSSP II period is to strengthen resource allocation to regions and

districts on the basis of pro-poor and gender criteria, in order to address long-standing inequities.

More resources will be targeted to the hard-to-reach areas of the country. In addition, resource

allocation will also focus on services targeted for women and children, such as Immunization,

and reproductive health.

2.2.4 Improving Health Worker Performance

The MoH is taking a number of important steps during the NHSSP II plan period so as to

improve the performance of health workers at all levels. These include the development of better

schemes of service, training and performance management initiatives.

2.2.5 Health Planning (Take note of the GoK finance/planning cycle)

NHSSP II sets a specific objective of strengthening district health planning in a way that focuses

on providing the necessary resources and monitoring on the achievement of the set targets.

District targets are already fully integrated into the national health.

Prioritisation of activities in district are based on access, demand of services and cost-effective

interventions. A planning guideline is already in place.

2.2.6 Monitoring and Evaluation

The objective of the M&E support system is to assist health managers to make informed

decisions and contribute to improving planning and management. The overall thrust is to


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introduce performance based monitoring throughout the system that is linked to performance

indicators, outputs and targets set for NHSSP II. The indicators developed in this document are

derived from the NHSSP II. DVI will routinely report to the Child Health ICC on the progress of

achieving of the country’s EPI indicators. Further monitoring will be done during the joint annual

reviews and the annual summits.

2.2.7 Human Resource Management and Development

NSSP II aims at improving the performance staff, increasing the numbers, quality and the mix of

the workforce. The objectives set in the human resource component involve instituting sound

management principals at the central levels; decentralizing certain functions where appropriate;

building additional human capacity in line with the health needs of the population; aligning

human resource development activities with KEPH priorities and making the development of the

health sector workforce more demand driven (rather than supply driven). Empasize is placed on

optimizing staffing norms of Levels 1, 2 & 3 service-provision as this is where the bulk of

preventive health activities occur. This has impacted positively on EPI services..

2.2.8 Quality Assurance and Standards

The major objectives of the quality assurance support system are to ensure the development and

use of clinical standards, protocols and guidelines; to strengthen patients’ rights; and to revitalize

and strengthen the relationships between MOH and the various professional bodies. Although

monitoring of vaccines has been weak, the National Regulatory Authority (NRA) is expected to

be established during the life of this cMYP so as to ensure vaccine quality. In addition, the Kenya

Pharmacy and Poisons Board will be strengthened.

2.2.9 Investment and Maintenance

The objectives for investment and maintenance are to ensure the continuous availability of care

related equipment, reliable energy supply, adequate provision of water and waste disposal tools..

Moreover, the transport system will be upgraded to ensure that an adequate number and type of

vehicles are available and well maintained. All districts will be provided with vehicles to conduct

supervisory and outreach activities, whereas health activities are to be conducted in a secretoral

approach


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2.3 Joint Program of Work and Funding (JPWF)

A key shift in NHSSP II is the emphasis on improvement in coordination of activities across the

sector in order to enable efficient and effective delivery of services. To this end, the sector is

moving towards initiating a comprehensive Sector Wide Approach (SWAp) to guide the

implementation of the NHSSP II. This has led to the development of the Joint Program of Work

and Funding (JPWF). This is the sector’s multi year operational document that details the key

interventions the sector is focusing towards the attainment of the NHSSP II objectives, their

costs, and committed financing. As such, it is the sector’s fundable document, guiding all

Government and development partners Investments.

Identification of areas for investment focus requires a detailed evaluation of actual activities and

planned interventions in order to achieve the highest impact (under-funded and priority areas).

This cMYP is aimed at providing this level of detail for investments in immunization in Kenya,

during the period of the NHSSP II. The cMYP is therefore the document that details out, for the

period of the NHSSP II, the operational interventions that are to be focused on to enable

achievement of the immunization related objectives of the sector. It is hoped it will act as a guide

to future investments in immunization in the country.


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3.0 SITUATION ANALYSIS

3.1 The Expanded Programme on Immunisation

The Kenya Expanded Programme on Immunization (KEPI) was established in 1980 and is integrated

within the Department of Preventive and Promotive Health Services of the Ministry of Health as part of

the Essential Health Package (EHP). KEPI is currently renamed to Division of Vaccine and Immunisation

(DVI).

3.2 Programme Structure

Figure 1: Organogram for DVI

DIRECTOR OF MEDICAL SERVICES

HEAD, DEPARTMENT OF PREVENTIVE & PROMOTIVE HEALTH SERVICES

HEAD, DIVISION OF VACCINES & IMMUNIZATION

COMMODITY SECURITY & QUALITY ASSURANCE

POLICY DIRECTION, ADVOCACY, TRAINING &

PERFORMANCE MONITORING

GENERAL ADMINISTRATION

Advocacy Training Officers

Data Officer

Cen

tral

Vac

cine

Sto

re

Sta

ff

Gen

eral

Sto

reS

taff

Col

d-ch

ain

mai

nten

ance

staf

f

Clerical Officers o Transport o Registry Secretaries Drivers Support staff

CHILD HEALTH ICC


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3.3 Routine Immunization

The goal of the Division of Vaccine and Immunisation is to reduce morbidity, mortality and disability due

to life threatening infections due to vaccine preventable diseases.

The Government of Kenya provides vaccines for the vaccine preventable diseases free of charge

through DVI. During the period of this plan, the following diseases have been targeted:

Tuberculosis, poliomyelitis, diphtheria, pertusis, tetanus, hepatitis B, Haemophilus influenza type

b and yellow fever in selected districts. Pneumococcal pneumonia and Rota virus are planned for

introduction, subject to availability exchequer co-financing and GAVI support.

DVI’s key activities focus on the following areas during the plan period:

i) Routine Immunization

ii) Supplemental Immunization

iii) Integrated Social Mobilization

iv) Training.

3.3.1 Immunization Schedule for Kenya

The table 2 below depicts Kenya’s immunization schedule:

Table 2. Current Routine Vaccination Schedule for Children under 1 year

Vaccine (do not use trade name)

Ages of administration (by routine immunisation

services)

Indicate by an “x” if given in:

Comments Entire countr

y

Only part of the

country

BCG At birth X

OPV At birth, 6wk, 10wk and 14wk X

DPT-HepB-Hib

6wk, 10wk and 14wk X

Measles 9 months X Measles SIA planned in 2009

Yellow Fever

9 months X Given only in four districts ( Baringo, Keiyo, Koibatek and Marakwet) at high risk of yellow fever disease

TT Pregnant women X Given in pregnancy under the 5TT schedule.

Vitamin A 6m,12m,18m,24m,30m,36m,42m,48m,54m and 60m

X Also given to mothers within six weeks after delivery


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Unlike other antigens, Yellow fever vaccine is not administered throughout the country, but in

only four high risk districts, whereas additional strategies are used for TT also in high risk

districts. The additional strategies for TT include SIAs for Child Bearing Age Women (CBAW)

districts and School-Based TT immunization activities.

3.4 Routine Immunization Performance, Gaps and Challenges

Trends of Routine Immunization

Figure 2 above illustrates that Kenya’s immunization coverage has generally been on positive progress

since the early 90’s. However, from 1998 – 2000, there was stagnation of all antigens coverage leading to

a drop in fully immunized due to withdrawal of support, by the then main immunization programme

sponsor DANIDA. Even so, with GAVI support and heavy GoK investment, this has been reversed and

progress is now on a positive note.

Table 3.1 and 3.2 below show further situation analysis details on the performance of all the EPI

components from 2001 – 2005. Table 4 shows details on the progress of accelerated disease control

initiatives, while Table 5 puts together data from the three tables to generate the strengths and weaknesses

of the EPI programme.

Figure 2: Routine Immunization performance Trend, Kenya (administrative coverage)

0

10

20

30

40

50

60

70

80

90

100

1992 1993 1994 1998 1999 2000 2001 2002 2003 2004 2005

Measles BCG DPT3 / Penta3 Fully Immunized

Hib-HepB DPT introduced

2006


23

Table 3.1: Summary of situation analysis by Routine EPI system components, 2001-2005

Component Suggested indicators National status

2001 2002 2003 2004 2005 Service delivery

National fully Immunized Children 46 46 55 59 61

National DPT/Penta3 coverage 65%

66%

73%

76%

77%

National Pneumococcal coverage (New vaccine) NA NA NA NA NA

Proportion of regions with DPT3 coverage > 80%

12.5% 0% 37.5% 37.5%

37.5%

National DPT1-3 drop out rate

15% 11% 18%

11% 6%

Proportion of regions with DPT1-3 dropout rate more than 10%

ND ND 18%

14% 16%

Proportion of provinces with micro plans on immunization 100% 100% 100% 100% 100% Vaccine supply, quality and logistics

National stock out of vaccines reported during the year NO YES NO NO YES How many months were stock outs experienced for: BCG DTP HepB OPV Measles TT

NR 2 NA 1mo 2 NR NR NA NA NA NR NR NA 3mo 1 NR NR NA NA 1 NR NR NA NA 1

Reported vaccine wastage in %: BCG DTP HepB OPV Measles TT

ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

Proportion of regions using AD syringes for immunization NR 100% 100% 100% 100% Is there a waste management plan No No No No No


24

Table 3.2: Situation analysis by Routine EPI system components, 2001-2005

Component Suggested Indicators National Status

2001 2002 2003 2004 2005 Cold Chain /Logistics % of regions with adequate functional cold chain

equipment 50% 50% 50% 50% 75%

Is there a national system to monitor AEFI Yes Yes Yes Yes Yes Advocacy and communication

Availability of a communication plan at national level ND YES YES YES YES Was there a budget for advocacy and communication ND Yes Yes Yes Yes

Surveillance/Monitoring Completeness of regions reporting to national level 84% 85% 82% 100% 100% Timeliness of regions reporting to national level 56% 65% 80% 72% 92% Written feedback on immunization system and surveillance provided to regions level

Yes Yes Yes Yes Yes

How many times in a year 4 4 4 4 4 Programme Management Number of ICC meetings held

4 4 4 4 4

Sustainable financing Percentage of total routine vaccine spending financed

using government funds 100% 100% 100% 100% 100%

Linkage to other health interventions

Immunization services systematically linked health intervention (malaria, nutrition, child and maternal health)

Yes Yes Yes Yes Yes

Human Resource Capacity

Number of health workers per 10,000 population 16.9

16.9 16.9 16.9 16.9

Management Planning Are series of regional indicators collected regularly at national level (Y/N)

Yes Yes Yes Yes Yes

This refers to all vaccines, but excluding DPT-Hep B-Hib (pentavent). When all are included, it is 56% for all the years above


25

Table 4: Situation analysis by Accelerated Disease Control Initiatives, 2001-2005 Component Suggested indicators National status

2001 2002 2003 2004 2005

Polio Eradication

National OPV3 coverage

56% 62% 72% 73% 68%

Proportion of regions with OPV3 coverage > 80% 12.5% 0% 25% 37.5% 25% Non polio AFP rate per 100,000 children under 15 years of age

1.8 1.7 2.2 2.0 1.9

Proportion of regions with non polio AFP rate > 1 per 100,000

100% 100% 100% 100% 100%

Number of confirmed wild polio virus cases 0

0 0 0 0

NIDS/ SNIDS conducted

0 1 1 1 1

Maternal and Neonatal Tetanus Elimination

TT2+ pregnant women coverage

34% 29% 52% 69%

71%

Number of regions reporting > 1 case per 1,000 live births

1 0 0 0 0

SIAs conducted

0 1 0 0 0

Measles Control Measles coverage

56% 69% 73% 67% 69%

Proportion of regions with measles coverage > 90%

0 ND

0 0 0

Reported suspected measles cases (Surveillance) NA

NA 202 90 98

Proportion of suspected measles cases with serum investigation

NA NA 99 99 90

Proportion of regions that have investigated at least 1 measles case

NA NA 88 88 90

NIDS/ SNIDS conducted; Coverage attained

0 1 (97.9%) 1 1

1

Table 5. Summary of Strengths and Weakness of the Immunization Programme

STRENGHTS WEAKNESSES

Service Delivery Political comment to funding part of EPI activities, including procurement of vaccines.

Good relationship with partners

Experience in introduction of new vaccines (Pentavalent and yellow fever).

Micro plans at all levels

Low immunization coverage

Irregular annual programme review.

Dropout rates greater than 10%

Outreach services not regularly conducted

Vaccine supplies, Logistics and Quality

Budget line for vaccines Multi dose vial policy in place There is a policy in place that ensures uniform distribution of vaccines. Back up generators at central and regional stores Back up gas cylinders available at each health facility Solar powered generators installed where appropriate. Cold chain technicians deployed at all regional depots. AD syringes and safety boxes used in all facilities. Adequate capacity at central level for vaccines distribution.

Aged cold chain equipment ( plan to replace is in place)

High vaccine wastage rate in regions.

Two out of eight regions report vaccine utilization Push system used for vaccines distribution No defined budget line for cold chain equipment and maintenance.

Inadequate incinerators at district level.

Advocacy and Communication

Draft advocacy and communication strategy developed

A national social mobilization committee supported by partners in place.

Brochures for health workers and the public “Improving immunization services”.

BCC strategies for Injection Safety – MOH/JSI project.

Inadequate funding for planned communication and advocacy activities. Strategic plan for programme communication yet to be finalized. Weak linkages with the community at levels.

Kenya DVI Comprehensive Multi-Year Plan 2006-2010 27

STRENGHTS WEAKNESSES

Surveillance Quarterly surveillance review meetings

Well established structure for integrated diseases surveillance Relevant committees and advisory groups in place. Job Aide for clinicians (measles, tetanus and polio) available

Lack of proper guidelines on measles case based surveillance during outbreaks. Lack of guidelines for community surveillance. Inadequate supportive supervision. Poor reporting of AEFI

Sub-national gaps in surveillance indicators.

Programme Management

Available capacity for performance monitoring and evaluation Clear organization structure Operation funds disbursed on timely basis to the districts.

Lack of a well-established system for defaulter tracing Staff shortage in most parts of the country.

Inadequate technical capacity:


4.0 IMPLEMENTATION OF THE EPI COMPREHENSIVE MYP 2006-2010

4.1 The National Health Strategic Plan II, GIVS and the cMYP

The NHSSP II (2005 – 2010) and the Joint Programme of Work and funding (JPWF) for the Health

Sector Wide Approach was developed through a consultative process and consolidation of work

programmes from the various programmes and central Ministry of Health departments in 2005 and

2006 respectively. The JPWF outlines the operationalization of the NHSSP II and the different

programmatic areas including immunization. The prevention and treatment of Vaccine Preventable

diseases is outlined as key intervention for the health sector to implement during the time period.

This Comprehensive Multi Year Plan takes account of the immunisation component as outlined in the

NHSSP II while taking cognizance of GIVS, which will determine activities, government and

immunization partners investment decisions in immunization activities over the NHSSP II time

period. It acts as an advocacy document for sector-funding in addition to that of planning. The actual

implementation will be elaborated in the annual implementation plans in line with MYP activity

timeline below (section 8). The detailed activities to be carried out for the respective immunization

operation systems are outlined in section 7, tables 8.1 – 8.5 of this cMYP, whereas the timeline and

costing are in sections 8 and 9 respectively. This relationship is outlined in the table 6 and Figure 3

below.

Table 6: Time Frames for NHSSP II/POW, cMYP and AOPs/annual implementation plans

2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 NHSSP II & POW Immunization cMYP Annual Implementation Plan (AIP)

AIP 1 AIP 2 AIP 3 AIP 4 AIP 5 AIP 6


NHSSP II 2005 - 2010

AOP 1

AOP 2

AOP 3AOP 4

AOP 5

AOP 6

Figure 3: cMYP and AOP Relation in respect to NHSSP II, MDGs and GIVS

4.2 The Kenya Division of Vaccines and Immunization (DVI)

DVI falls within the Department of Prevention and Promotive Health services of MOH. This cMYP

has been developed by DVI based on the priorities referred to in the NHSSP II. In addition, the plan is

further guided by evidence gathered through a desk review of the programme for the period 2001 –

2005 carried out in March 2006. This process has been enriched by a financial analysis and costing of

the cMYP to apportion available funds and highlight funding gaps. Covering the period 2006-2010,

the cMYP focuses on the main components of the immunization operational and support systems with

key strategies and activities aimed at addressing national priorities identified by MOH and

supplemented by a thorough programme-based situational analysis. In each of the next five years

beginning with 2006, annual EPI plans will be derived from this cMYP.

4.3 DVI Goal

The overall focus of the immunization activities is to actualise the intervention to prevent Vaccine

Preventable Diseases, as outlined in the NHSSP II and GIVS. This is elaborated in the programme

goal, which is to increase access to traditional and new immunization services, provide effective and

potent vaccines and increase demand for the services in order to reduce morbidity, mortality and

disability due to vaccine preventable diseases.

4.4 Programme Objectives

To fully immunize at least 80% of infants in all districts against childhood immunisable

diseases before attaining the age of 12 months by 2010;

MDGs GIVS cMYP


To reduce child mortality by increasing the National coverage of one-year old children

immunized against measles to 85% by 2009 in-line with MDG 4;

To eliminate maternal neonatal tetanus by 2008 through vaccination of all pregnant women

and women of childbearing with at least two doses of tetanus toxoid vaccine;

To sustain high community awareness on the importance of completing the immunization

schedule.

To achieve polio free status and certification by 2008

Contribute to the strengthening of the National Health System

The defined coverage and wastage objectives the sector is focusing on are detailed in the table 7

below.

Table 7: Coverage and Wastage targets

Coverage targets Wastage targets

Type of Vaccine 2006 2007 2008 2009 2006 2007 2008 2009

Routine Immunization (%) (%) (%) (%) (%) (%) (%) (%) Traditional Vaccines

BCG 90% 98% 98% 98% 75% 70% 60% 60% TT - Pregnant women 75% 85% 85% 85% 35% 30% 25% 20% TT - Child bearing age

women 20% 25% 30% 35% 35% 30% 25% 20% Measles 70% 90% 90% 90% 50% 45% 40% 35% OPV(1) 85% 95% 95% 95% 20% 15% 10% 10%

Underused and New Vaccines

Yellow Fever 50% 60% 70% 80% 50% 45% 40% 35% DTP-Hep B-Hib(1) 85% 95% 95% 95% 12% 10% 10% 10%

Campaigns (%) (%) (%) (%) (%) (%) (%) (%) Polio 90% 90% 90% 15% 15% 15% Measles 95% 95% 15% 15% MNT campaigns 80% 80% 15% 15% Outbreaks 95%


4.5 Strategic Areas

The 2006-2010 Comprehensive EPI Plan shall be implemented within the framework of Global

Immunization Vision and Strategies (GIVS) in the four main strategic areas namely:

i. Protecting more people

ii. Introducing new vaccines and technologies

iii. Integrating immunization, other linked health interventions, and surveillance in the health

systems context

iv. Immunizing in a context of global interdependence.

Activities for the above areas have been outlined within the immunization system components

summarized as:

i. Service Delivery

ii. Vaccine Supply, quality and Logistics

iii. Disease Surveillance

iv. Advocacy, social Mobilization and Communication

v. Programme Management

4.6 Priority Targets

Each component of the system has a set of planned activities with different targets for each year up to

2010. These targets have been outlined in section 7, tables 8.1 to 8.5 that are to be accomplished in

order to achieve the objectives.

4.7 Governance and Partnerships

The implementation of the NHSSP II will be guided through Annual Work Plans, which are based on

activities outlined in the District Integrated annual work plans and Annual Work Programmes for

Central MoH departments. The cMYP will be used to develop Annual Work Programmes for EPI.

Coordination of partners is done through the Child Health Inter-agency Coordinating Committee

(ICC). The ICC was fully involved in the development process of the cMYP. It is therefore expected

that the Child Health ICC will advocate and support the implementation of the plan.

4.8 Monitoring and Evaluation

The monitoring and evaluation framework for cMYP will be based on annual joint reviews involving

all stakeholders of the plan. A monitoring framework will be developed based on usage of routine

data, and feedback (bulletins, newsletters, review meetings) and implemented, accompanied by a set

of indicators to monitor the performance of the cMYP.


Annual evaluations on the implementation of the cMYP will be conducted every January for the

subsequent implementation year under review. Mid-term review will be conducted in August 2008.

The final review will be done in January 2011 before the next planning process. To enable the

implementation for the above activities, significant additional resources will be required.


5.0 THE IMMUNIZATION SYSTEM COMPONENTS

5.1 Service Delivery

In the next five years, the programme will endeavour to sustain and improve on the gains made over

the years by providing quality immunization services. In Kenya, a significant proportion of

immunizations take place in outreach clinics and the programme will ensure that the outreach strategy

is not only sustained, but re-energized within the RED strategy framework. In hard to reach areas,

catch up campaigns will be implemented locally.

Immunization coverage will be increased from current administrative coverage of 68% to 90% for the

fully immunized child. However, special attention will be given to improving the routine

immunization coverage of populations of low access or utilization of immunization services. These

include those in the urban slums, the internally displaced, refugees, and those residing in

geographically remote areas. A mixture of strategies will be used.

Table 8.1 contains details of the activities to be covered.

5.2 Vaccine Supply, Quality and Logistics

The EPI programme will ensure that adequate vaccines bundled with injection materials are procured

through WHO/UNICEF approved mechanisms. Through the Child Health ICC, procurement of

vaccines and other logistics will be prioritised to avoid disruption of the services. The current storage

capacities for both vaccines and dry store materials at central and regional vaccine stores will be

expanded in tandem with the growing population.

The National Regulatory Authority will be strengthened through the support of the Pharmacy and

Poisons board and by external technical assistance, so as to ensure that vaccine quality is guaranteed.

DVI internal quality assurance mechanisms will in-turn ascertain vaccine quality is maintained to the

point of utilization thus minimizing AEFIs’. In addition, AEFI surveillance will be improved through

production of guidelines, adequate tools and specific AEFI training which will require extra resources

from the current allocation. Introduction of a computerised stock management system is planned for

the regional vaccine store rooms so as to improve management of vaccines and injection materials.

This will require procurement of computers and accessories. The programme through the Ministry of

Health will identify land for the construction of a larger Central Store and administration offices.

At district and health centre levels, trainings will be conducted to improve stock keeping. Adherence

to vaccine management guidelines and target settings will be monitored during the period. Transport

availability for distribution of the programmes critical logistics will be improved at all levels through

procurement of appropriate types of transport during the plan period. This will be accompanied with

resources for maintenance and other operational costs of the vehicles. In addition to increasing the

total numbers of cold-chain equipment, there will also be replacement of unserviceable and CFC


refrigerators in the 2006-2010 plan. The programme will therefore advocate for adequate resources to

achieve this obligation.

Injection safety and waste management will be strengthened through ensuring continued use of AD

syringes in both routine and supplemental immunization services and proper disposal of injection

materials. Immunization waste management guidelines will be developed in line with the National

Health Care Waste Management Policy. Health workers will from time to time receive training on

safe injection and waste management practices. Since health care waste management has to be tackled

in a broader perspective, the EPI will compliment efforts made by the MOH and other stakeholders by

providing support for the construction of incinerators to cover the remaining District Hospitals to

achieve 100% coverage during the planned period. Details for activities are contained in Table 8.2.

5.3 Disease Surveillance

Disease surveillance activities will be transferred to the Division of Disease Surveillance and

Response (DDSR). DDSR fall’s under the same department of Preventive and Promotive health

within the Ministry of Health with DVI. Even though DDSR will be responsible for disease

surveillance activities, DVI will endeavour to work closely with DDSR and also to offer support as

need arises. Disease surveillance activities are outlined below.

Trainings for health workers will continue to be conducted to improve their knowledge and skills in

EPI disease surveillance in line with the Integrated Disease Surveillance and Response approach. The

National Reference Laboratory capacity will be further improve through procurement of adequate

supplies of laboratory reagents and specialized training of its staff. Laboratory networks locally will

be supported for the monitoring of trends of occurrence and actual burden of vaccine preventable

diseases. In addition, collaboration with laboratories in neighbouring countries will be enhanced.

Vaccine preventable disease surveillance data (Polio, measles, PBM, Rota virus) will be monitored so

as to address gaps in immunization coverage in a timely manner as appropriate.

In this multiyear plan, we hope to maintain or improve the tempo of detection and notification of

AFP, measles, and NNT at current levels, but being more efficient through utilizing the same current

resources. However, additional resources will be required for Hepatitis B and Peadiatric bacterial

meningitis surveillance. Details for activities are contained in Table 8.3.

5.4 Advocacy, social Mobilization and Communication

Advocacy, social mobilization and communication are very crucial in EPI services. Through the Child

Health ICC and the health SWAp, the programme will lobby for more resources for effective

implementation of the planned activities. Of priority, will be the development and dissemination of

the EPI Advocacy Guidelines, in conjunction with the Division of Child Health, which will be aligned

to the National Health Promotion Policy. As part of the dissemination, health workers will be trained


on the new guidelines. Advocacy meetings will be conducted with District Health Management

Teams and District Health Stakeholders for more EPI specific resource mobilization. Key EPI

messages will be developed and disseminated through print media and electronic media both

nationally and at local levels where this capacity is available. Other channels such as drama and

community meetings will be encouraged and strengthened, spearheaded by the CORPs in conjunction

with their respective CHEWs. The quarterly EPI newsletter will continue to be published and

distributed to all health facilities and pre-service health institutions. In addition, posters, leaflets and

fact sheets will also be developed. Details for activities are contained in Table 8.4.

5.5 Programme Management

5.5.1 Planning

Management of the Division of Vaccines and Immunization will be aligned to the new principles of

management of health services as outlined in the Kenya Essential Package for Health. Annual

planning guidelines will be developed and disseminated to the districts and provinces in order to

provide programme direction in terms of objectives and targets. The development of the annual

objectives, targets and indicators will refer to this cMYP which takes into account NHSSP II, the

respective AOP, global immunization guidelines and the deliberations of the Child Health ICC.

Beginning with the AOP III, all health planning process will be decentralized to the district and

provincial levels, from which the national plan will be derived. Further details pertaining to activities

under programme management are contained in Table 8.5.

5.5.2 Financing

DVI will endeavour to mobilize adequate resources for implementation of all its activities. It will

ensure that all gaps and challenges noted in the past years are addressed. Since DVI activities are

supported through multiple funding sources, both programme planning and resource mobilization will

take into consideration the comparative interests of the different funding sources.

The main sources of support for this cMYP are

The Government of Kenya – personnel emoluments, commodity support and main

operational costs

World Health Organization - Technical assistance for routine and supplemental immunization

activities, operational costs of disease surveillance activities

United Nation’s Children’s Fund – Technical Assistance for routine and supplemental

immunization activities especially regarding advocacy and social mobilization, procurement

agent services, emergency response

Global Alliance for Vaccines & Immunization – national commodity support (Pentavalent,

yellow fever and new vaccines/initiatives) and health systems strengthening.


African Development Bank –III Project – this is a three-year loan facility limited to 7 districts

and primarily for health facility infrastructure improvement, but also addressing human

resource skills improvement

British Department for International Development – a new five-year project for health

systems strengthening, with special emphasis on (but not limited to) improving M&E

However, even with the above support, gaps are anticipated in the funding of this cMYP as identified

in the costing tool. The Child Health ICC will therefore play a critical role in advocating for the

needed resources.

Details of financing and sustainability were update following Kenya’s application for the introduction

of the Pneumococcal vaccine and are covered under section 9 and the attached updated cMYP Costing

tool.

5.5.3 Coordination and Integration

The Coordination framework will be adopted from NHSSP II, where coordination levels fall under

Child Health ICC, and the district health sector stakeholders’ forum for the National and District

levels respectively. The various cross-cutting challenges in the Health Sector are best addressed

through an integrated approach. In addition integration will ensure sustainability of services. This plan

will adopt the framework outlined in the NHSSP II were planning, human and overall financial

resources, and logistics at all levels are integrated. In addition, the Child Health Strategic Plan will be

developed in order to articulate other issues beyond immunization in an integrated manner. Broad

programmatic concerns such as surveillance, monitoring and evaluation, and social mobilization will

continually be integrated.

5.5.4 Human Resource Management

Three thousand additional health workers are required within the planned period. However, the

funding for only 1500 has been secured, leaving a gap of another 1500. In service training of both the

current and in-coming health workers will be conducted throughout this planned period. In addition,

CORPs training will be incorporated as part of the implementation of the community strategy under

NHSSP II.

5.5.5 Supportive Supervision

The programme will ensure that supportive supervision is conducted regularly and that district micro-

plans are followed up. It will also ensure that EPI policies are reviewed to incorporate any new

developments in the EPI.

5.5.6 Monitoring and Evaluation


Monitoring and Evaluation will be strengthened at all levels of programme implementation through

the development of tools and facilitating skills improvement at all levels. District and Rural Health

Facilities will continue to analyze the immunization and disease surveillance data on monthly basis

and take action on identified gaps. Monitoring activities will be aligned to both the GoK financial year

cycle and calendar year. Activities to be monitored are those related to performance of immunization

coverage and cost-effectiveness of the different immunization strategies. Routine immunization and

IDSR monitoring tools will continue to be standardised nationally to ensure that data from peripheral

levels can be easily merged with the national database. Annual review meetings will be conducted

with districts and provincial EPI staff to assess the immunization data and status of implementation of

activities. Periodic surveys and operational research will be conducted in collaboration with partners.

Evaluation of this cMYP will be conducted in January 2011.

5.5.7 Innovations

The planning/resource mobilization for major innovations and any new vaccines introduction during

the plan period will be considered through a wide consolatory forum, with initial inputs from the

Child Health ICC.


6.0 NATIONAL PRIORITIES BASED ON THE SITUATIONAL ANALYSIS

1. Attain and sustaining high routine immunisation coverage in respect to the fully immunized child.

2. Availability of adequate vaccines , supplies and appropriate cold chain logistics

3. Procurement and rehabilitation of existing National and Regional cold rooms and the

replacement of cold chain equipment at the district level;

4. Procurement of appropriate types of transport, replacement and maintenance of transport

equipment

5. Improved documentation and data management

6. Integrated implementation of child health interventions

7. Sustaining high quality surveillance on AFP, Measles, Yellow fever, Hib and NNT

8. Strengthening advocacy and social mobilization activities; strengthening of partnerships in health

and improved community participation; improving Radio/TV messages and print media coverage

9. Continued training of staff at all levels

10. Improved monitoring, supervision and feedback on performance to lower health facilities

11. Strengthening safe injection practices and waste management

12. Establish burden of disease for other vaccine preventable diseases of public health importance

(e.g. Rotavirus, Streptococcus pneumonia) through sentinel surveillance, and prepare for

introduction for vaccine.

13. Construction of a new KEPI headquarters with adequate furniture and equipment


7.0: NATIONAL PRIORITIES, NIP OBJECTIVES AND MILESTONES, STRATEGIES, STRATEGIC ACTIVITIES, NATIONAL, AND ORDER OF PRIORITY Table 8.1: Service Delivery

National goals (until 2010)

National objective

Targets Strategies Key Activities Order of priority

By 2010 or sooner all districts will have routine immunization coverage of >= 80% and a national average of at least 90%.

100% of districts achieving >=80% Penta 3 coverage by 2010. National coverage >=90%

Baseline: 2006: 45% districts achieve Penta 3 coverage of >=80% 2007: 60% districts achieve Penta 3 coverage achieve >=80% 2008: 75% districts achieve Penta 3 coverage achieve >=80% 2009: 90% districts achieve Penta 3 coverage achieve >=80%

- Strengthen implementation of RED strategy in all districts - Support use of provincial level data management system for analysis and feedback - - Strengthen continuous professional development

- Conduct program review and micro-planning workshops at all levels - Strengthen/establish sustainable outreach services - Strengthen/establish defaulter-tracing systems in the district - Develop facilitative supervision schedules at all levels - Integrate EPI supportive supervision into existing district health programs - Open more SDPs in far to reach population - Train HWs in MLM and other relevant trainings e.g. RED and GIVS strategy

1

Reduce child mortality by measles by 95% by 2008

100% districts achieving >=90% measles coverage by 2010. National coverage >=95%

Baseline: 68% national coverage 2006: 75% districts achieving >=80% coverage 2007: 80% districts achieving >=90% coverage 2008: 85% districts achieving >=90% coverage 2009: 90% districts achieving >=90% coverage

- Strengthen implementation of RED strategy in all districts - Use a combination of approaches to reach everybody targeted for immunization - Integrate vitamin A administration with routine immunization

- Open more SDPs in far to reach population - Select appropriate number of districts each year for breakthrough improvement in order to reach annual targets - Implement Rapid Results Initiatives (RRIs) in districts targeted for breakthrough improvement - Integrate/strengthen data collection, reporting, analysis and feedback of vitamin A

2


By 2010 or sooner all districts will have achieved a drop out rate of less than 3% By 2010 or sooner all districts will have achieved measles drop out rate of less than 10%

100% districts achieving <10% penta1-penta3 drop-out rate by 2010 100% districts achieving <10% penta1-measles drop-out rate by 2010

Baseline: 84% districts 2006: 80% districts achieve penta1-penta3 drop-out <=10% 2007: 90% districts achieve penta1-penta3 drop-out <=5% 2008 Penta. 3 drop out rate <3% Baseline: 13% districts … 2006: 60% districts achieve penta1-measles drop-out <10% 2007: 70% districts achieve measles drop-out rate of <10% 2008: 80% districts achieve measles drop-out rate of <10% 2009: 90% districts achieve measles drop-out rate <10%

- Strengthen implementation of RED strategy in all districts - Increase community demand for immunization services - Improve HW interpersonal communication skills

- Train health workers from districts with low utilization on interpersonal communication and how to motivate clients to return for immunization - Provide quality EPI services (SOPs)

3

By 2010 all district will have a TT 5 for pregnant women of 80% and a national average of 75 %

80% of districts achieving >=80% TT5 coverage by 2010. National coverage >=90%

2007: 40% districts TT5 coverage >= 80% 2008: 60% districts TT5 coverage >= 80% 2009: 70% districts TT5 coverage >= 80%

- Expand immunization beyond the traditional target age group - Assess and develop appropriate interventions for integration - Strengthen/establish outreach/mobile - Enhance routine immunization for TT - Use a combination of approaches to reach everybody targeted for TT - Strengthen system for TT5 reporting

- Initiate TT programs for school going children in high risk districts - Integrate anti-helminths with TT immunization for school children - Conduct TT SIAs for child bearing women in high risk districts (14 districts) - Train HWs and scale up the 5 TT schedule program for pregnant women in all health facilities - Screen mothers (CBAW) to reduce missed opportunities - Revise tools for capturing TT5

5

Protect Districts bordering Somalia, Sudan and Ethiopia from polio and measles outbreaks

Border districts conduct campaigns synchronized with neighbouring countries

- Cross border collaboration - Partner collaboration

- Synchronize polio immunization campaigns with neighbouring countries - Strengthen cross-border surveillance and communication

7


By 2010 all district have 90% FIC

FIC coverage in the hard-to-reach areas improved

2006: <=5 districts with <50% FIC 2007: No district with <50% 2008: No district with <60% 2009: No district with <80% 2010: No district with <90%

- Use a combination of approaches to reach everybody targeted for immunization - Provide additional resources as needed to support RED plans in districts with hard to reach populations

- Open more SDPs in far to reach population - Collaborate with other sectors in providing immunization services - Initiate and sustain Integrated immunization activities into other community outreach services - Integrate outreach/mobile clinics in hard to reach communities - Provide & sustain transport for outreach activities

4

Maximize benefits to mothers and children attending health facilities

Child health services integrated into Immunization services

To be developed – see activities - Use a combination of approaches to reach hard to reach populations - Assess and develop appropriate interventions for integration

- Integrate vit A and anti-helminth administration and other child health services with EPI outreach services -Integrate follow-up of HIV exposed children into routine immunization - Screen all sick children for immunization and ensure provision of missed antigens - Establish baseline measures and annual targets of integrated services and - Strengthen data collection, reporting, analysis and feedback of integrated services

6

Prevent against importation of vaccine preventable disease from neighbouring countries

Provide access to immunization services in humanitarian emergencies

- Provide immunization services to refuge camps bordering Ethiopia and Sudan (Turkana district, Kakuma Camp) and Somalia (Garissa district, Dadaab Camp, etc.)


Table 8.2: Vaccine Supply, Quality and Logistics National goals

(until 2010) National objective


100% districts reporting no stock outs of any antigen or injection materials and documentation tools and consumables by 2010

2006-2007: 80% of districts reporting no stock outs of all antigens and supplies

2008-2010: 100% districts reporting no stock outs of all antigens and other supplies

- Improve and strengthen vaccine management systems at all levels. - Improve health care worker skills in vaccine management - Ensure reliable supply of vaccines at all levels - Ensure availability of Injection equipment (AD & reconstitution syringes), safety boxes at all levels - Improve supply of documentation tools and consumables.

-Train on forecasting, requisitioning and prompt reporting by facilities - Integrate procurements by the agents - Forecast vaccines and supplies at facility, district, province and national levels - Distribute vaccine management guidelines -Train and update staff on vaccine management guidelines - Distribute vaccines and other supplies to SDPs on monthly basis. - Involve facilities in the EPI planning processes - Computerize vaccine management system - Mobilize locally available resources to avail materials and consumables

1

Adopt the multi dose vial policy by 2007

90% districts achieving required wastage standards per national policy by 2007

2006- 80% districts achieve required standards

2007- 2010: 90% districts achieve required standards

Institute vaccine wastage monitoring system - Develop vaccine wastage data entry and analysis functions into existing EPI INFO immunization module- national and provincial levels - Regularly update HWs on vaccine management and administration - Regularly monitor vaccine wastage at all levels

4

Ensure reliable national supply of vaccines of assured quality

2006- set up task force on vaccine quality 2007- develop and disseminate guidelines 2008- functional national regulatory authority in place

Strengthen capacity of Pharmacy and Poisons Board to monitor the quality of vaccines and other related biologicals

- Train and sensitize Pharmacy and Poisons Board - Institute vaccine quality task force - Develop guidelines - Regularly monitor adherence to guidelines

5


All eligible health facilities having basic functional cold chain equipment by 2010 Obsolete equipment (non-CFC free) replaced in all health facilities by 2010

Baseline: 50% health facilities with SDP# are equipped with functional cold chain equipment 2007: >70% of health facilities with SDP No. are equipped with functional cold chain equipment 2008: > 80% 2009: > 90% 2010: = 100%

- Develop and implement a system to replace cold chain equipment in current and new SDPs. - Institute a system to annually assess functionality of cold chain system

- Carry out an inventory of all cold chain equipment in the country - Replace non CFC free and unserviceable cold chain equipment - Procure and distribute cold chain equipment to new SDPs. - Support KEMSA to stock cold chain equipment and spare parts at regional KEMSA stores - Decentralize cold chain maintenance workshop to regional level - Update staff on cold chain management and maintenance - Provide cold chain technicians with appropriate cold chain tool kits - Provide appropriate source of energy to support cold chain

2

All levels adopt and implement technologies for safe disposal and destruction of injection materials and other sharps by 2010.

Provide functional waste management system in all of immunizing facilities 100% of district and provincial hospitals have functional incinerator

Baseline: 2006-2010 100% availability of safety boxes Baseline: 64% hospitals with functional incinerators 2007: 75% hospitals with functional incinerators 2008-2010: 100% hospitals with functional incinerators

- Ensure local availability of safety boxes and low-cost incinerators - Ensure proper waste management at all levels in accordance with national policy

- Carry out a baseline inventory survey on incinerators - Develop an incinerator construction and maintenance plan - Avail AD syringes & safety boxes to all immunization service points - Design cost effective incinerators at district and sub district levels - Support districts to construct incinerators at district and sub district levels - Support immunizing facilities to burn and bury waste for those with no incinerators - Adopt checklist for supportive supervision from CDC/KEPI/WHO Pilot project

3

Establish DVI offices and storage capacity up to 80% at all levels by 2010

Baseline: -2006_65% -2007_70% -2008_75% -2009_80% -2010_>80%

Improve infrastructure space and layout

- Review office and storage capacity of EPI at all levels (technical report) - Procure land for KEPI HQ for construction of offices and cold rooms - Construct new and rehabilitate existing cold rooms and stores in the regions and districts

6


Table 8.3: Disease Surveillance


National objective


Ensure capacity for surveillance in every district

100% districts implementing IDSR by 2010

Baseline: 0% Districts implementing IDSR 2006 - 25% 2007 - 50% 2008 - 75% 2009 - 90% 2010 – 100%

- Strengthen disease surveillance at all levels including the community - Improve district capacity on disease surveillance and response to outbreaks - Strengthen / sustain laboratory network capacity to manage and analyze specimens - Strengthen data collection, analysis, interpretation, use and exchange of data at all levels - Strengthen case-based surveillance

- Conduct quarterly progress meetings between KEPI, PHMTs, DHMTs and Partners. - Revise surveillance guidelines for health workers. - Train health workers on IDSR (VPDs) and redefine their role on disease surveillance. - Develop guidelines for introduction of community surveillance. - Train existing CORPs and facility health committees on disease surveillance. - Establish links for surveillance reports at district level - Provide financial support to district level regularly for AFP/measles/MNT, HIB, and Rotavirus surveillance - Provide funds for maintenance of transport for DDSCs, PDSCs and NDSOs - Provide funds for communication for DDSCs, PDSCs, NDSOs - Provide funds for National Disease surveillance coordinators, PDSCs, NPCC, NPEC and NTF - Provide access to laboratory network capacity to neighboring countries

1



National objective


Achieve high quality AFP surveillance

NPEV isolation rate of > 10%

- By end of 2006 all districts achieve and sustain the standard of NPEV > 10% - By end of 2008 - guidelines on community surveillance developed

- Strengthen monitoring of VPDs - Strengthen inter-country surveillance

- Develop guidelines for introduction of community surveillance - Support procurement of laboratory supplies and equipment in liaison with IDSR Unit - Create/enhance local laboratory networks - Provide all levels with adequate reporting tools - Co-opt DDSCs as members of DHMT - Train DHMT to analyze and use data at their level - Conduct annual cross border meetings with inter-country surveillance officers - Annual inter-country surveillance meetings starting 2007

1


Table 8.4: Advocacy and Communication

National objective

Targets Strategies Key Activities National goals (until 2010)

Order of priority

Strengthen ICC

Sustain high routine immunization Achieve elimination status for measles

- Develop and implement communication plan - Use existing structures within the community - Greater partnerships in childhood interventions

- Produce EPI bulletin - Feedback to health workers following

supervisory visits. - Hold regularly meetings with DHMTs on

prioritization of EPI services. - Review meetings with Health workers - Develop key messages and IEC materials on

EPI. - Conduct ICC meetings - Conduct sensitization of communities on the

importance completing immunization - Conduct social mobilization activities on

immunization and surveillance through public rallies

- Airing of radio & TV messages - Discussions with local leaders on scheduling

and sustaining outreach services - Hold press conferences & press releases - Conduct meetings with NGOs other

childhood disease interventions - Broaden partnerships in ICC - Conduct advocacy meetings local MPs,

councilors, and other local leaders


National objective


Order of priority

Ensure availability of appropriate IEC messages for various target audiences

Baseline Lack of appropriate IEC EPI messages for various populations: 2006: A representative sample districts would have done the IEC inventory survey. 2007: relevant IEC materials developed and disseminated to 100% districts.

- Improve communication and dissemination of information - Technical support of communication expert for EPI

- Develop and maintain inventory of IEC materials and messages

- Identify communication gaps on routine EPI messages

- Develop plan to address gaps - Translate various IEC materials

appropriately according to set-up. - Distribute as brochures, leaflets etc to

community members, schools, popular meeting spots.

- Develop radio; TV, internet and other media spot messages for Routine Immunization.

By 2007 an IEC inventory report of survey in place.

1

Establish and strengthen functional communication structures in all the districts by 2010.

Baseline: Weak communication and advocacy strategy. 2006: 40% districts achieved. 2007: 100% districts achieved. 2006: 50% achieved.

2007:100% achieved.

2007: 100% Audio and videotapes developed.

2008: Distribute developed tapes to all district, sub district and major hospitals

- Ensure adequate and sustainable financing for advocacy and communication activities. - Develop and implement cost effective immunization information communication plan. - Apply multimedia approach to social mobilization - - Strengthen and sustain Inter-sector collaboration with partners and stakeholders at all levels by 2010.

- Advocate for increased and sustained budget allocation for advocacy and communication.

- Encourage business partners to support advocacy for immunization

- Create liaison offices at provincial and district levels

- Recruit and train officers at national, provincial and district levels.

- Create partners forums at all levels for advocacy of routine immunization and special immunization events

- Conduct quarterly joint meetings with partners and other stakeholders

- Develop joint work plans - Review progress of implementation - Shoot 4 videos on routine EPI messages - Record 4 audio tapes on routine EPI

messages - Disseminate and Distribute IEC materials - Develop and distribute newsletters on

immunization information on a quarterly basis.

By 2008: All levels to have advocacy and communication component in integrated plans BY: 2010 or sooner EPI messages on routine immunization should be disseminated at 80% of all levels through audio and videotapes.

2

To ensure 2006: Integrate EPI Include EPI communication plans in the - Attend annual district planning workshop 1


National objective


Order of priority

all districts have EPI communication integrated within district plans

communication plan in annual district health micro plans in all districts and sustained to 2010

annual district plan. and ensure EPI communication plan is integrated into district health plans. - Develop an integrated routine reporting tool which include social mobilization activities of EPI

To achieve 100% of districts with health workers who are trained in IPC focusing on attitude change

2006: train health workers in IPC in 50% 2007: train health workers in IPC in 100%

Capacity building for communication for EPI staff Institutionalize health worker – community dialogue

Train health workers in IPC (including attitude change)

3

To strengthen advocacy for EPI at all levels

-2006-2010: Sensitize CORPs and community leaders on benefits of immunization, -2006: develop systems for monitoring communication activities at all levels and providing feedback. -2006-2010: orientate/sensitize broadcasters, reporters in media and broadcasting houses on immunization issues.

- Build partnerships with the community and the media for EPI mobilization activities - Monitor communication activities at all levels .

- Sensitize CORPs, key community leaders and stakeholders on the benefits of immunization - Conduct biannual meetings with community leaders to provide feedback and plan for mobilization activities - Orientate/sensitize broadcasters, and reporters on immunization. - Develop an integrated routine reporting tool which include social mobilization activities of EPI - Prepare message and for broadcast using appropriate media

2


Table 8.5: Management

National goals (until

2010)

National objective


-100% of all the Districts will have >90% immunization coverage by 2010

Ensure availability of trained, motivated staff at all health facilities

Recruit 4500 nurses for SDPs by 2010 95% health workers to be EPI updated/training by 2010

- Improve management of human resource - Establish links between private service provider and GoK facilities - Advocacy with MOH for recruitment of staff

- Rationally re-distribute available HWs within the districts and the country as whole - Motivate HWs and CORPs by recognition, appraisals and allowances - Carry out training needs analysis - Draw and implement a training plan in all the districts - Advocate for staff employment for specific disadvantaged areas - Annual review of the KEPI organogram to fit the demand of the future

1

Ensure high quality service delivery at all SDPs

Conduct field visits at all levels and give written feedback: National to Province: Quarterly Province to district: Monthly District to LHF: Monthly

Improve management of human resource - Strengthen supportive supervision at all levels - Strengthen role, accountability and resources for EPI at district level - Where appropriate consider addition of supervisory responsibility for division coordinator - Disseminate use of supervisory checklist - Develop two way information pathway between various operational levels - Provide instant, monthly, and quarterly feedback (verbal and written)

4

90% of GOK health facilities will deliver EPI services by 2010

Baseline: 43% 2006- 60% 2007- 70% 2008- 80% 2009- 85%

Advocacy with MOH for recruitment of staff

- Align staff, cold chain and management resources with increase in number of health facilities delivering EPI services

6



2010)

National objective


By 2010 or sooner all districts will have routine immunization coverage of >= 80%

Baseline: 60% districts below 80% coverage for one or more antigen 2006- 45% districts 2007- 30% districts 2008- 20% districts 2009- 10% districts

Implement Rapid Results Initiatives in districts targeted for breakthrough improvement

- Collaboration between national, provincial management teams in targeting districts for RRIs and monitoring progress of districts

5

Ensure that all districts have current RED micro-plan

Baseline: Lack of EPI plans in most districts and health facilities 2006- 45% 2007- 55% 2008- 70% 2009- 80% 2010- 90% 2006 – 10% of districts fully implementing the RED strategy 2007- 50% of districts implementing the RED strategy 2008 – All districts fully implementing the RED strategy

Strengthening annual Programme review and planning Strengthening decentralization process

- Develop annual plans at all levels - Monitor districts plans at Provincial level - Hold Provincial bi-annual review meetings with DHMTs, PHMT and National EPI staff - Provide logistical and financial support to districts - Develop and disseminate timely AOPs - Provide timely funding, logistic support and supplies to every district - Conduct micro-planning for the district and facility facilities - Re-establish regular outreach services for hard to reach communities - Conduct supportive supervision: on-site training - Create community links with service delivery - Monitor and use of data for action - Improve planning and management of human and financial resources

2



2010)

National objective


All districts have access for 90% of the time to appropriate, serviceable, and adequate transport for EPI activities by 2010

2006- 80% 2007- 90% 2008-2010 - 100% districts have adequate access to serviceable vehicle for EPI

- Develop a cost effective and sustainable transport management system for PHC - Implement fleet management

- Conduct a study on fleet management system for PHC services - Advocate at various levels for fleet management - Provide appropriate serviceable transport - Develop and implement vehicle maintenance and replacement plan

7

Construct national KEPI office complex Increase storage capacity for vaccines at national and depot levels

Baseline: 40% of depots with adequate vaccine storage capacity 2006- 65% 2007- 70% 2008- 75% 2009- 80% 2010- >80%

Improve infrastructure space and layout

- Review vaccine storage capacity of EPI at all levels (technical report) - Procure land for KEPI HQ for construction of offices and cold rooms - Increase vaccine storage capacity at depots with inadequate capacity

10



2010)

National objective


Increase government allocation from 1% to 13% of EPI activities by 2010

Baseline: Inadequate allocation for new vaccines and EPI support activities Lack of a sustainability plan after GAVI funding 1% GOK contribution to Penta vaccine purchase 2006_1% 2007_4% 2008_7% 2009_10% 2010_13%

- Advocacy meetings with MOH top management and treasury - Establish partners forum at all levels - Advocacy meeting with organized private sector and H/F committee and boards for resource mobilization to support EPI operational costs - Strengthen immunization programmes within the context of health systems development

- Set up national immunization resource mobilization steering committee - Conduct joint biannual meeting of ICC, MOH and treasury staff to mobilize GOK resources for immunization - Create inventories of all potential private /corporate organization - Organize meeting with potential private sector partners/ donors - Contract an organization to coordinate resource mobilization - Assess and develop appropriate interventions for integration with EPI

10

Implement M&E systems all districts

2006 - roll out EPI INFO Immunization Module and DQS to 30% of districts 2007-2010: EPIINFO and DQS to 100% of districts Accurate EPI information exist at all levels and is used for monitoring and planning immunization activities District technical monthly progress report submitted to KEPI

Strengthen the management, analysis, interpretation, use and exchange of data at all levels

- Capacity build EPI staff on data collection, management and use - Implement EPIINFO Immunization Module to districts -Train data managers on EPI INFO at district levels - Expand the existing EPI INFO program to include collection, analysis and feedback of information on wastage - Update health workers on EPI data collection, presentation, reporting and use - Provide and maintain computers and accessories for all levels - Provide monitoring tools for immunization services - Train supervisors at all levels on EPI reporting - Provide quarterly feedback to districts on their performance - Monitor data quality through DQS at all levels

3



2010)

National objective


Protect more people against vaccine preventable diseases

Expand vaccination beyond traditional target groups

- Develop and implement protocol to address immunization needs of HIV-exposed children and immuno-compromised populations

11

Introduction of new vaccines

- Strengthen capacity to determine and set policies and priorities for new vaccines - Develop a systematic process for the introduction of new or under-used vaccines

- Conduct disease burden study - Technical review - Ensure appropriate disease surveillance to support disease burden study - Conduct advocacy with ICC, financing ministry, NGOs/partners to create financial support for new vaccines w on feasibility of introduction of new vaccines - Develop recommendations and protocols for use new vaccines - Introduce new vaccines

9


8.0 cMYP ACTIVITY TIMELINE

Key Activities 2006 2007 2008 2009 2010

Service Delivery

1. Intensify & sustain outreach services X X X X X

2. Conduct supplementary SNIDs X X X X X

3. Develop facilitative supervision schedules X X X X X

4. Screen all children <5years who present to the health facility to reduce missed opportunities X X X X X

5. Open more SDPs in far to reach population X X X X X

6. Conduct daily maintenance of cold chain X X X X X

7. Maintain vaccine potency at all levels X X X X X

8. Distribute vaccines and other supplies to SDPs on monthly basis. X X X X X

9. Involve facilities in the EPI planning processes X X X X

10. Replace the un-serviceable refrigerators X X X X

11. Train/update health workers on cold chain maintenance X X X

12. Review KEPI policy on immunization sessions particularly BCG and measles X X

13. Hold meetings with school management to develop schedule for school health programmes (TT) X X X X X

14. Conduct the school health programmes (TT) X X X X X

15. Print, disseminate and distribute immunization schedules X X X

16. Conduct TT SIAs for child bearing women in high risk districts (14 districts) X X X X X

17. Conduct routine immunization as per schedule (TT) X X X X X

18. Screen mothers (CBAW) to reduce missed opportunities X X X X X

19. Motivate clients to return for immunization by providing services & information for the need to

complete schedule

X X X X X

20. Provide quality EPI services (SOPs) X X X X X


Key Activities 2006 2007 2008 2009 2010

21. Provide home visiting tools for CORPs X X X X X

22. Liaise with community leaders and FBO leaders – Drop out rates X X X X X

23. Sensitize PEER educators on EPI X X X

24. Develop/review and provide defaulter tracing tools X X

25. Motivate CORPs X X X X X

26. Update/training CORPs on EPI including home visiting X X X

27. Conduct catch up campaigns for integrated measles in 2008 X X

28. Conduct outreach/mobile clinics X X X X X

29. Provide & sustain transport for districts hard to reach X X X X

VACCINE SUPPLY, QUALITY AND LOGISTICS

1. Train on forecasting, requisitioning and prompt reporting by facilities X X X

2. Integrate procurements by the agents X X

3. Forecast Vaccines at facility, district, province and national levels X X X X X

4. Distribute vaccines and other supplies to SDPs on monthly basis X X X X X

5. Distribute vaccine management guidelines X X

6. Train and update staff on vaccine management guidelines X X

7. Computerize vaccine management system X X X

8. Regularly monitor vaccine wastage at all levels X X X X X

9. Support Pharmacy and Poisons Board to establish a system for vaccines quality checks X X X X X

10. Institute vaccine quality task force X X

11. Develop guidelines for quality assurance X X

12. Regularly monitor adherence to guidelines X X X X X

13. Carry out an inventory of all cold chain equipment in the country X X


Key Activities 2006 2007 2008 2009 2010

14. Replace non CFC free and un-serviceable cold chain equipment X X X X X

15. Procure and distribute cold chain equipment to new SDPs X X X X X

16. Support KEMSA to stock cold chain spare parts at regional KEMSA stores X X X X X

17. Decentralize cold chain maintenance workshop to regional level X X

18. Update staff on cold chain management and maintenance X X X

19. Provide cold chain technicians with appropriate cold chain tool kits X X X

20. Avail AD syringes and safety boxes to all immunization service points X X X X X

21. Design cost effective incinerators at district and sub-district levels X X

22. Support districts to construct incinerators at district and sub-district levels X X X X X

23. Support immunizing facilities to burn and bury waste for those with no incinerators X X X X X

DISEASE SURVEILLANCE

1. Conduct quarterly progress meetings between KEPI, PHMTs, DHMTs and Partners X X X X X

2. Train health workers on VPDs and redefine their role on disease surveillance X X X

3. Develop guidelines for introduction of community surveillance X X

4. Revise surveillance guidelines for health workers X X

5. Train existing CORPs and facility health committees on disease surveillance X X X

6. Establish links for surveillance reports at district level X X X X X

7. Provide financial support to district level regularly for AFP/measles/MNT surveillance X X X X X

8. Provide funds for maintenance of transport for DDSCs, PDSCs and NDSOs X X X X

9. Provide funds for communication for DDSCs, PDSCs, NDSOs X X X X X

10. Provide funds for WHO surveillance officers, NDSCs, PDSCs, NPCC, NPEC and NTF X X X X X

11. Provide funds for Hib, MNT, Measles and Rotavirus surveillance X X X X X

12. Train focal point persons on IDSR (VPDs) at all levels X X X


Key Activities 2006 2007 2008 2009 2010

13. Support procurement of laboratory supplies and equipment in liaison with IDSR Unit X X X X X

14. Create/enhance local laboratory networks X X X X X

15. Provide all levels with adequate reporting tools X X X X X

16. Train DDSCs to analyze and use data at their level X X X X X

17. Provide and maintain computers and accessories for all levels X X X X X

18. Conduct annual cross border meetings with inter-country surveillance officer X X X X X

19. Conduct field visits at all levels and give written feedback: National-quarterly; Prov.- Monthly;

District – daily/monthly

X X X X X

20. Provide instant, monthly, & quarterly feedback (verbal & written) X X X X X

ADVOCACY AND COMMUNICATION

1. Conduct a survey on communication gaps on routine EPI messages X

2. Translate various IEC materials appropriately according to set-up. X X

3. Distribute as brochures, leaflets etc to community members, schools, popular meeting spots X X X X X

4. Train social mobilizers from community on the translations X X X

5. Develop radio, TV, Internet and other media spot messages for Routine Immunization. X X X X X

6. Recruit and train liaison officers, provincial, district and divisional levels X X

7. Develop and distribute newsletters on immunization information on a quarterly basis X X X X X

8. Develop an integrated routine reporting tool on EPI activities X X

9. Conduct quarterly joint meetings with partners and other stakeholders X

10. Develop joint work plans X X X X X

11. Shoot 4 video productions X X

12. Record 4 audio tape messages X X

13. Disseminate and Distribute copies of (1) and (2) above X X X X

14. Advocate for increased and sustained allocation in the national budget for advocacy and X X X X X


Key Activities 2006 2007 2008 2009 2010

communication

15. Encourage business partners to support advocacy of particular immunization events X X X X X

16. Attend annual district planning workshop and ensure EPI communication plan is integrated into

district plans

X X X X X

17. Train health workers in IPC (include attitudinal change) X X X

18. Sensitize CORPs, key community leaders and stakeholders X X X

19. Monitor communication activities at all levels and provide feedback X X X X X

20. Develop an integrated reporting tool X X X X X

21. Hold feedback meetings X X X X X

22. Orientation/sensitisation of broadcasters and reports on EPI X X

23. Prepare messages for broadcasting and for feedback meetings X X X X X

MANAGEMENT

1. Rational re-distribution of available h/workers within the districts and the country as whole X X

2. Motivate H/workers and CORPs by recognition, appraisals and allowances X X X X X

3. Carry out training needs analysis X X

4. Draw and implement a training plan in all the districts X X X X

5. Advocate for staff employment for specific disadvantaged areas X X

6. Annual review of the KEPI organogram to fit the demand of the future X X X X X

7. Develop annual plans at all levels X X X X X

8. Hold quarterly review meetings at the Districts with stakeholders involvement X X X X X

9. Provide logistical and financial support to districts X X X X X

10. Develop and disseminate timely Annual Operation Plans X X X X X

11. Carryout and implement a study on fleet management system for PHC services X X X X X


Key Activities 2006 2007 2008 2009 2010

12. Provide appropriate serviceable transport X X X X X

13. Review office and storage capacity of EPI at all levels (technical report) X X

14. Land procurement for KEPI HQ for construction of offices and cold rooms X X

15. Construct new, and rehabilitate existing cold rooms and stores in the regions and districts X X X X X

16. Construct incinerators in 40% of all health facilities X X X X X

17. Carry out assessment of cold chain inventory X X X

18. Replace 90% of old fridges with CFC free fridges X X X X X

19. Procure CFC free fridges for new facilities X X X X X

20. Procure assorted cold chain spare parts X X X X X

21. Provide appropriate source of energy to support cold chain X X X X X

22. Avail AD syringes and safety boxes to all SDPs X X X X X

23. Mobilize locally available resources to avail documentation tools and consumables X X X X X

24. Set up national immunization resource mobilization steering committee X

25. Joint biannual meeting of ICC, MOH and treasury staff to mobilize GOK resources for

immunization

X X X X X

26. Inventories of all potential private /corporate organization X X

27. Organize meeting with potential private sector partners/ donors X X X X

28. Contract an organization to coordinate resource mobilization X X X X X

29. Re-establishment of regular outreach services X X X X X

30. Supportive supervision: on-site training community links with service delivery X X X X X

31. Monitoring and use of data for action X X X X X

32. Better planning and management of human and financial resources X X X X X

33. Reduce the number of immunization dropout through micro planning at the district or local level X X X X X

34. Strengthen managerial skills of immunization providers at all levels X X X X X


Key Activities 2006 2007 2008 2009 2010

35. Provide timely funding, logistic support and supplies in every district X X X X X

36. Develop monitoring tools for immunization services X

37. Train supervisors at all levels on monitoring systems X X X

61

9.0 COSTING, FINANCING AND FINANCIAL SUSTAINABILITY

9.1 Costing and financing methodology

The success of the programme largely depends on adequate financing for all proposed activities to be undertaken

during the planning period. It will be the responsibility of the EPI through the Ministry of Health to ensure that the

programme gets adequate financial and material support both locally and internationally. In this section, we review the

cost implications of the proposed programme activities, and relate these to the known available financing for respective

cost categories of the programme to derive information relating to financing gaps. Also proposed are strategies and

interventions the programme will to carry out, to improve its financial viability. The cMYP includes a series of

interventions, which have associated activities, and inputs needed to actualise. These are illustrated in the Table 9.1

below.

Table 9.1: Inputs to different EPI systems components

System Components Inputs Activities Service delivery Human resources/salaries,

outreach per diems, fuel for transport, operation costs for campaigns

Training, workshops

Advocacy and communication

IEC materials, radio, print media advertisements etc.

Social mobilization, IEC, developing advocacy and communication plan

Surveillance Surveillance equipment, laboratory networking and reagents etc.

Surveillance meetings and activities (sentinel sites, outbreak investigation)

Vaccine, supply, quality and logistics

Vaccines, AD syringes, safety boxes, other injection supplies, cold chain equipment, vehicles, spare parts, incinerators etc.

Monitoring, vaccine stock management activities

Programme Management

Procurement of land and construction of KEPI HQs, computers, office supplies.

Meetings, planning, research, data management, EPI reviews, cold chain assessment.

The above listed activities and inputs are what are costed. The costs for the programme are derived in a variety of

costing methodologies, depending on the interventions planned. These include:

The ingredient approach, based on the product of unit prices, and quantities needed each year, adjusted for the

proportion of time used for immunization. This is used for costing inputs such as vaccines, personnel, vehicles,

cold chain equipment, etc.

Rules of thumb, which are based on immunization practice, such as a percentage of fuel costs as representative

of maintenance costs for vehicles. This is used for deriving costs for injection supplies, and maintenance of

equipment, and vehicles.

62

Past spending, where lump sum past expenditure is used to estimate future expenditure. For example, past cost

per child for specific campaigns, training activities etc.

These different approaches are all brought together in a pre-designed cMYP excel costing tool and derived costs based

on the following components:

Vaccines and injection supplies

Personnel costs (EPI specific and shared)

Vehicles and transport costs

Cold chain equipment, maintenance and overheads

Operational costs for campaigns

Programme activities, other recurrent costs and surveillance

Other equipment needs and capital costs

Overhead costs.

9.1.1 Macroeconomic Information

For purposes of placing the costing and financing information into wider financing framework, some macroeconomic

information has been included. This information is detailed in the Table 9.2 below.

Table 9.2: Macro Economic Trends in Kenya, 2006 - 2010

2005 2006 2007 2008 2009 2010

$ $ $ $ $ $

GDP per capita 460 483 507 533 559 587 Total health

expenditures per capita (THE per capita) 19.2 19.2 19.2 19.2 19.2 19.2

Government health expenditures (GHE%THE) 30.0% 30.0% 30.0% 30.0% 30.0% 30.0%

THE and GHE%THE estimates are derived from the NHA country estimates. The GDP is estimated to increase at 5% per annum.

9.1.2 Vaccines and Injection Equipment

Costs are a function of the unit prices for individual vaccines, with quantities determined by the target population,

adjusted for by coverage and wastage objectives. Prices are based on UNICEF prices, as supplied by the UNICEF

Supply Division. Target populations for different antigens, coverage, and wastage objectives have been expounded on

in earlier chapters.

9.1.3 Personnel Costs (EPI specific and shared)

As with vaccines and injection equipment, cost estimates are based on unit expenditure on different personnel cadres

working in EPI at the different levels of the system, and numbers of personnel, adjusted for by time spent on EPI-

related activities. In addition, costs and time spent on supervision and outreach activities were included for the different

63

cadres at the different levels of the system. Unit expenditures are based on Government gross wages. Time spent on

EPI was estimated by a panel of experts, made up of operational staff at national, provincial and district

levels. Quantities available and needed in the lifetime of the cMYP were included.

9.1.4 Vehicles, and Transport Costs

The costs for vehicles were derived in the same manner as personnel. Additional maintenance costs were estimated as

represented by 15% of fuel expenditure. Quantities available and needed in the lifetime of the cMYP were included.

9.1.5 Cold Chain Equipment, Maintenance and Overheads

Costs were derived as with personnel and vaccines. Quantities available and needed in the life time of the cMYP were

included.

9.1.6 Operational Costs for Campaigns

These were based on operational costs for past campaigns, with the cost per child derived.

9.1.7 Programme Activities, other Recurrent Costs and Surveillance

Costs for programme activities were also derived based on the past trends in expenditure, with future estimates for

costs based on these, modified where necessary. Social mobilization costs for 2006 are based on the social mobilisation

plan, with estimates for future years adjusted for the reduction in start-up activities. Costs for trainings, meetings and

surveillance activities are based on the 2005 expenditures, with future costs estimated with an adjustment factor to

cater for activities not included in 2005.

9.1.8 Other Equipment Needs and Capital Costs

Additional costs for equipment such as computers etc. were included and costed using the same methodology as with

other equipment. Overhead costs were included in the estimates, based on past expenditure trends.

64

9.2 Cost profile

Table 5.3 shows that program expenditure in the baseline year at over US$ 2334 million, of which US$211 million is

attributable to the routine recurrent program, with just under US$ 2 million to the immunization campaign activities.

The expenditure breakdown for the routine immunization program is further illustrated in the Figure 4.

Figure 4: Routine Immunization Programme Expenditure Breakdown

Baseline Cost Profile (Routine Only)*

9%

69%

3%

13%

0% 6% 0%0%0%

Traditional Vaccines New and underused vaccines

Injection supplies Personnel

Transportation Other routine recurrent costs

Vehicles Cold chain equipment

Other capital equipment

The three major baseline cost drivers are new vaccines contribute to nearly 6970% of the routine immunization

program expenditure in the baseline year. This was followed by personnel costs at 13% and traditional vaccine at 9%.

The rest represents costs relating to other recurrent cots and injection safety.

65

9.3 Baseline Financing

In terms of baseline financing, the bulk of the baseline funding was done by the GoK (56%) followed by GAVI at

44%. The funding by other partners was so small that they were masked by rounding up in excel. The details are shown

in Figure 5.

Figure 5: Baseline Financing Profile

Baseline Financing Profile (Routine Only)*

56%

0%

0%

0%

0%

0%

44%

0%

0%

0%

0%0%0%0%0%0%

Government Sub-national Gov. UNICEF WHO

DANIDA JICA GAVI Df ID

European Union MERCK Vaccines Local (Community) Clinton Foundation

Global Fund PEPFAR

9.4 Cost by immunization strategy

From Figure 6, dominant strategy of immunization in Kenya is fixed strategy. Although outreach strategy is projected

to pick up from 2008, it remained stable for the rest of the planned period of the cMYP. SIAs have also taken place in

the base year and are planned for the future but at a reduced rate as shown in Figure 4.

66

Figure 6: Costs by Strategy

Costs by Strategy

$0.0

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

$80.0

2006 2007 2008 2009 2010

Millions

Routine (Outreach Activities) Routine (Fixed Delivery)

Campaigns

9.5 Programme cost requirement for 2006-2010

The projected cost of the programme in the planning period (2006-2010) is $2467 million. The cost slowly increased

slight from 2006 to 20087 and then rapidly increased from 2008 t0 2009 and then decreased slightly from 2009 to

2010. In terms of costs driver, new vaccines continue to dominate all other costs of the immunization program in the

years of the cMYP. Within the immunization program, the costs are driven by activities related to the fixed site

delivery of services, as opposed to outreach activities, or campaign activities. This reflects the strategy adopted by the

country as shown in Figure 4 earlier.

67

Table 9.3: Programme costs and Future Resources Requirements

Expenditures Future Resource Requirements

Cost Category 2005 2006 2007 2008 2009 2010 Total 2006 - 2010

Routine Recurrent Cost US$ US$ US$ US$ US$ US$ US$ Vaccines (routine vaccines only)

Traditional vaccines $1,800,498 $2,475,546 $2,531,465 $2,697,694 $2,785,440 $2,875,764 $13,365,908

New and underused vaccines $14,360,298 $16,619,710 $17,122,119 $20,726,239 $49,887,305 $45,735,395 $150,090,768

Injection supplies $663,917 $1,507,808 $1,701,035 $2,006,611 $2,541,221 $2,741,779 $10,498,453

Personnel Salaries of full-time

NIP health workers (immunization specific) $188,004 $186,011 $189,732 $193,526 $197,397 $201,345 $968,010

Per-diems for outreach vaccinators/mobile teams/supervision $2,619,240 $3,933,618 $5,303,543 $5,654,116 $6,016,591 $6,391,303 $27,299,171

Transportation $40,845 $42,911 $45,083 $47,364 $49,760 $52,278 $237,397

Maintenance and overhead $613,906 $719,685 $951,050 $1,274,535 $1,326,448 $1,047,925 $5,319,644

Training $155,500 $791,416 $78,246 $115,185 $81,408 $83,036 $1,149,290

IEC/social mobilization $36,067 $73,437 $75,195 $76,699 $77,330 $78,877 $381,537

Disease surveillance $40,237 $91,959 $93,798 $95,674 $97,588 $99,540 $478,559

Programme management $334,465 $341,948 $349,827 $357,885 $375,867 $394,425 $1,819,952

Other $0 $0 $56,354 $0 $58,631 $0 $114,985

Subtotal Recurrent Costs $20,852,976 $26,784,050 $28,497,446 $33,245,528 $63,494,985 $59,701,666 $211,723,675

Routine Capital Cost

Vehicles $0 $0 $0 $0 $0 $153,344 $153,344

Cold chain equipment $0 $444,846 $1,895,708 $2,669,639 $27,386 $99,831 $5,137,409

Other capital equipment $2,400 $150,643 $97,223 $91,563 $93,394 $95,262 $528,086

Subtotal Capital Costs $2,400 $595,489 $1,992,931 $2,761,202 $120,780 $348,437 $5,818,839

Campaigns

Polio $1,018,896 $235,440 $778,394 $1,013,834

Measles $799,867 $6,032,752 $6,510,714 $12,543,467

Yellow Fever

MNT $0 $0 $0 $0 $0 $0 $0

Other campaigns $0 $7,060,395 $3,049,226 $3,181,355 $1,575,069 $14,866,045

Subtotal Campaign Costs $1,818,763 $13,328,588 $3,827,621 $3,181,355 $8,085,783 $28,423,346

GRAND TOTAL $22,6794,139 $40,708,127 $34,317,998 $39,188,084 $71,701,549 $60,050,103 $245,965,860

68

9.5.1 Projected Financing from all sources from 2006-2010. The financing trends for the years covered in the cMYP are further elaborated in Figures 7 & 8 and Table 9.4.

Figure 7. Projection of Future Financing

Projection of Future Resource Requirements

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

$80.0

2006 2007 2008 2009 2010

Millions

Traditional Vaccines New and underused vaccinesInjection supplies PersonnelTransportation Other routine recurrent costsVehicles Cold chain equipmentOther capital equipment CampaignsShared Costs

69

9.5.2 Future Financing Table 9.4: Resource Requirements, Financing and Gaps*

Resource Requirements, Financing and Gaps*

2006 2007 2008 2009 2010 2006 – 2010

Total Resource Requirements $40,708,127 $34,317,998 $39,188,084 $71,701,549 $60,050,103 $245,965,860

Annual growth rate 44% -19% 12% 45% -19%

Total Resource Requirements (Routine only) $27,379,539 $30,490,377 $36,006,730 $63,615,765 $60,050,103 $217,542,514

per capita $0.8 $0.8 $1.0 $1.7 $1.5 $1.2

per DTP targeted child $22.4 $23.0 $26.4 $45.3 #DIV/0! $40.9

% Vaccines and supplies 75% 70% 71% 87% 86% 80%

Total Financing (Secured) $39,615,504 $10,925,223 $31,206,311 $9,049,580 $8,789,929 $99,586,547

Government $12,949,731 $7,169,367 $13,028,332 $8,951,992 $8,690,389 $50,789,811

Sub-national Gov. $0 $0 $0 $0 $0 $0

UNICEF $9,878,331 $3,349,226 $0 $0 $0 $13,227,557

WHO $1,417,732 $406,630 $95,674 $97,588 $99,540 $2,117,164

DANIDA $0 $0 $0 $0 $0 $0

JICA $0 $0 $0 $0 $0 $0

GAVI $15,369,710 $0 $18,082,305 $0 $0 $33,452,015

DfID $0 $0 $0 $0 $0 $0

Funding Gap $1,092,623 $23,392,775 $7,981,773 $62,651,968 $51,260,174 $146,379,313

% of Total Needs 3% 68% 20% 87% 85% 60%

Total Financing (Not Secured / Probable) $791,416 $21,318,478 $7,227,027 $62,149,006 $50,573,458 $142,059,386

Government $0 $5,368,113 $3,930,488 $8,974,548 $7,345,405 $25,618,555

Sub-national Gov. $0 $0 $0 $0 $0 $0

UNICEF $0 $0 $3,181,354 $4,505,767 $0 $7,687,121

WHO $0 $0 $0 $1,250,000 $0 $1,250,000

DANIDA $0 $0 $0 $0 $0 $0

JICA $0 $0 $0 $0 $0 $0

GAVI $0 $15,872,119 $0 $47,337,283 $43,145,017 $106,354,419

DfID $0 $0 $0 $0 $0 $0

European Union $0 $0 $0 $0 $0 $0

MERCK Vaccines $791,416 $78,246 $115,185 $81,408 $83,036 $1,149,291 Funding Gap $301,207 $2,074,297 $754,745 $502,963 $686,716 $4,319,927

% of Total Needs 1% 6% 2% 1% 1% 2%

70

Financing is either classified as secured, or probable. Secured funding refers to those funds already mobilised to

support the implementation of the cMYP. Probable funds are those potentially available but may require additional

efforts such as proposal development, negotiations, to secure them. From the total cost of $2467 million from 2006-

2010, only $10083 million was secured mainly from the GoK and other partners, thus leading to funding gap of

$14684 million (See Figure 8 and Table 9.4). The major providers of secured funding are GoK and GAVI. From the

above analysis, it would seem that secured financing represents a very small proportion of the total program costs.

However, this tends to grossly understate the amount of secured funding for the planned period. All funds mobilised

for the introduction of new vaccine (Pneumococcal, Yellow Fever and Pentavalent), some of which have already been

mobilised have been classified as probable. This is because the financing of Pneumococcal vaccine is dependent on the

approval of the proposal and so has been rightly classified as probable from both GAVI and GoK. This is more of the

problem of the costing tool which tends to lump the cost and financing of all new vaccines in one row.

Figure 8: Future Secure Financing and Gaps

Future Secure Financing and Gaps

$0.0

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

$80.0

2006 2007 2008 2009 2010

Millions

Government Sub-national Gov. UNICEF WHO

DANIDA JICA GAVI Df ID

European Union MERCK Vaccines Local (Community) Clinton Foundation

Global Fund PEPFAR

FUNDING GAP

When both secured and probable funding was taken into account, the funding gap reduced to approximately $45

million for the five years of the life of the cMYP (2006-2010). The bulk of the fund is expected from GoK and GAVI.

The GoK expenditure is mainly in relation to co-payment for the three new vaccines while those from GAVI, as

71

explained consist of any potential funding for Pneumococcal vaccine and the continuous support for existing Yellow

Fever and Pentavalent vaccines. Therefore, all funding towards new vaccines from GoK and GAVI will be secured as

soon as approval is granted for Pneumococcal vaccine for reasons explained in the final sustainability section.

The WHO and UNICEF funding is not expected to rapidly increase over the planned period. However, in order to turn

such probable funds to secure will require engaging well in advance of the implementation of the activities concerned.

This is ideal at the time of their respective programme development period.

Figure 9: Future Secure + Probable Financing and Gaps

Future Secure + Probable Financing and Gaps

$0.0

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

$80.0

2006 2007 2008 2009 2010

Millions

Government European Union Sub-national Gov. UNICEF

Local (Community) WHO Clinton Foundation DANIDA

JICA GAVI Df ID

MERCK Vaccines Global Fund PEPFAR

FUNDING GAP

72

9.6 Financial sustainability strategies, actions and indicators

9.6.1 Financial sustainability strategies, actions and indicators

The financial challenges of the EPI in Kenya have been highlighted in section 9.5. From the analysis of costs and

available funding, it is clear that additional resources are needed by the programme to ensure smooth implementation

of the stated objectives of the cMYP. The main objection of this sub-section is to move the agenda further by coming

up with strategies to tackle the financial challenges thereby providing a smooth environment for the implementation of

the cMYP within the planned timeframe. This is done by first taking into consideration the opportunities and threats

the programme faces. Since mobilisation of most of the financial resources required to implement the entire plan is a

prerequisite for a successful outcome. In light of that, the Government of Kenya through DVI and Ministry of Health

has devised a number of strategies in not only mobilising the much needed additional resources, but improving the

reliability of funding and improving the efficiency of the implementation of the programme.

This section of the cMYP looks at the opportunities and threats to the EPI in the Kenya at alternative policy

scenario for financial sustainability, formulates strategies for financial sustainability and finally outlines the

monitoring of the financial sustainability strategies.

Opportunities

There is strong political and financial support by the GoK for EPI in Kenya demonstrated by the 56% funding of

baseline cost in 2005. This commitment is likely to continue due to the positive economic growth forecast of 4% for

the rest of the year 2008 and 7% growth thereafter up to 2010. Kenya has MTEF for the next three years (2006-2010),

which guarantee EPI funding at the same level at least in the medium-term. Kenya has budget line for vaccines was

established which tends to “ring-fenced” any funding allocated to the programme. Kenya has enjoyed a positive

economic growth of 8% on annual basis for the past few years. Although the growth forecast for 2008 has been

reduced to only 4% in 2008 due to the political problem, the forecast is enough for the GoK to honour its commitments

to the introduction of Pneumococcal and other new vaccine while at the same time maintain the operations of the EPI

programme.

Threats

Despite the opportunities in Kenya for improved EPI financing and efficient service delivery, there are some threats to

overcome for better mobilisation of resources for immunization financing and successful implementation of the cMYP.

The recent proliferation of Global Health Initiatives that target specific interventions outside of immunization limits

government’s ability to secure budgetary support from many traditional donors which would otherwise prefer to

channel their funds through these initiatives. There are a number of cost-effective health and other social interventions

competing with immunization for the limited government and donor resources such as HIV/Aids, Tuberculosis,

Malaria, Reproductive health. Kenya experienced a political instability immediately after the election in December that

73

is affecting the economy in terms of revenue generation and donor assistance. Although per capita income in Kenya is

an average of $534, the distribution of income is skewed against the majority of the people, thus limiting the ability to

mobilise resources domestically. Finally, the health system on which EPI operates is generally weak despite efforts by

GAVI and other partners to strengthen it through health systems strengthening.

9.6.2 Alternative policy scenarios for financial sustainability

The Government of Kenya will explore all possible options to maintain and improve its EPI programme. To achieve

that, the various options of financial sustainability will be assessed in terms of programmatic implications, disease

burden, poverty reduction, and towards the achievement of Millennium Development Goal (MDG) 4. The following

alternative scenarios are explored with a view to assessing their effects on programme costs:

(i) Stop the introduction of Pneumococcal vaccines

(ii) Cancel some or all the planned SIAs

Failure to go ahead with the introduction of pneumococcal vaccines in the short run will save the programme an

average of $750,000 per annum. However, the downside of this strategy is that, the country has to bear the full disease

burden of diseases prevented by Pneumococcal vaccine in Kenya as demonstrated by several studies within and outside

the country. The detailed burden of Pneumococcal diseases has been outlined in the earlier sections of this cMYP.

Although, non-introduction of Pneumococcal vaccine in short-term will save the GoK from the co-paying for the

vaccine, the long-terms costs are higher in terms of cost of morbidity and mortality as well as cost of treatment.

Furthermore, it will deny the country the support provided by GAVI. GAVI support will help the country put in place

both financial and operational strategies for the full takeover of the cost of Pneumococcal vaccine. Therefore, loosing it

will be a lost opportunity and should the country decide to introduce later when one may not sure of the availability of

the support at the same level.

Although cancellation of well-spaced SIAs will reduce costs, the programmatic implication of this choice is costly.

This is especially true for Kenya that shares border with six countries. In 2005, Kenya’s Polio Certification Document

Report was presented to and accepted by the Africa Regional Certification Committee (ARCC). Kenya’s status remains

the same importation of Wild Polio Virus (WPV) through one of its porous borders. This is because there were no

confirmed cases of wild polio virus circulation and surveillance indicators remained satisfactory.. Cancellation of SIAs

will further open up the country to potential importation. Furthermore, SIAs represent progress towards achieving a

global goal, which Kenya will not meet. Resources for measles and polio SIAs are easily mobilised from Measles

Partnership and other donors than those for routine programme. Therefore, investments in SIAs could support capital

investment, training, logistics in the routine programme. Therefore, lack of SIAs would therefore affect the availability

of such funds and all the benefits that come with them.

74

In light of the above, the preferred option is to keep SIAs as these impact most on the disease burden and on the

government’s developmental objectives. Both routine and SIAs are required in their correct mix to maintain the

programme objectives while fitting within the global goals and financial realities of the country. In summary, the above

options will lead to cost reductions but will at the same likely lead to increase disease burden and non-fulfilment of

some international goals. Since the above two options are not feasible, specific strategies are required for the financial

sustainability of the programme.

5.6.3 Strategies and actions for financial sustainability

Given the opportunities and threats outlined earlier, the three main strategies the GoK intends to pursue to improve the

financial sustainability of the EPI include:

(i) Mobilising additional resources

(ii) Improving resource reliability

(iii) Improving programme efficiency

Mobilising additional resources

The resources required for the co-payment for Pneumococcal vaccines has already been planned in the government

budget, because the allocation has already been made in the MTEF. These earmarked funds also include payment for

other new vaccines such as Yellow Fever and Pentavalent. Since Kenya is one of the few countries that have paid

above their own shares of GAVI co-payment in the past, the trend is likely to continue. Therefore, the MoH is not

required to submit any new request to the Ministry of Health (MoH) for additional allocation. In addition, adequate

resources have been mobilised to further strengthen the cold chain of the country. In 2007/2008 alone, five cold rooms

of 12 cubic metres and refrigerators have been purchased and plans are on to purchase additional cold rooms and

refrigerators for the various levels of the cold chain system.

The small gap realised in resources shall be sought through mobilisation of additional resources from traditional bi-

lateral and multi-lateral partners for the EPI programme. There shall be targeted resource mobilisation from specific

partners based on the respective cost category for which funds are required. For example, the funding gaps relating to

SIAs shall be discussed with partners through Child Health ICC. The programme shall encourage ICC to hold

discussions with partners that could support specific interventions of the plan. The programme shall engage the

traditional SIA partners such as Rotary International, Measles Partnership, UNICEF and WHO for funds at least 1 year

prior to the planned polio and measles SIAs in 2008 and 2010. Furthermore, availability of other donors in country

such as USAID, JICA, DFID and DANIDA in the country provides the opportunity for mobilisation of more resources

domestically. Some of these donors have supported routine and supplementary immunization activities (SIAs), cold

chain, training etc.

75

The cMYP has already been presented to some of the partners through Child Health ICC (CH ICC). This is likely to

continue by mainly targeting non-traditional EPI partners. The publicity and advocacy of the programme shall be

intensified among these potential donors with the programme achievements and financial situation elaborated. This

shall ensure that a wider group of partners is aware of the cMYP objectives, strategies, costs and financing gaps to

make informed decision on support. Plans are also on to increase domestic resources for health through SWAP and

MTEF.

Improving reliability of resources

About 56% of EPI funds came from the GoK budget.. Therefore, the reliability of funding from the GoK is assured.

However, the main challenge, in terms of reliability with respect to funds from partners is, they are often not

committed beyond one year. In addition to mobilising resources, the programme shall also seek to have its resources

available in a more reliable manner. At present, the programme is only aware of its financing for not more than one

year except from those coming from GAVI. This reliance on ad hoc operational activities in line with the availability of

funds makes long term planning difficult. The first step towards achieving reliability of funding is to ensure that

budgetary requirements for EPI are included in the national health strategic plan and budget.

The cMYP has been discussed and will be further discussed at the Child Health ICC as well as with individual donors

to improve the awareness of the programme and its financing situation in the medium term, thereby giving partners

better time to plan their resource commitments for the future. Advocacy meetings will be held with the MTEF and

where possible, with the SWAP team earlier enough for them to include EPI funding priorities in their subsequent

cycle of funding. The programme shall have improved accounting and reporting mechanisms to ensure that GoK and

partners are always informed as to how the resources they donate to the EPI are utilised. This will lead to transparency

and improved donor confidence.

Improving programme efficiency

There are a number of areas where the programme shall work to ensure efficiency. The EPI programme started

integrating some of its activities with other Child Health Initiatives so as to take advantage of any synergy. One such

example is that, instead of having ICC for EPI alone, Kenya has Child Health ICC that also oversees the

implementation of other child survival initiatives. This potentially saves both financial and human resources which

could have been invested in each ICC. High vaccine wastage and poor maintenance of cold chain equipment also lead

to poor utilisation of limited resources. Therefore, putting in place strategies to work towards limiting these

inefficiencies shall free such resources and be a strong advocacy tool to attract additional resources. The present

wastage rates shall be reduced through better vaccine management, cold chain improvement and proper monitoring and

supervision. Plans will be put in place to reduce wastage at the various levels of the EPI delivery system. Although the

national wastage rate is not significantly different from international benchmarks, some facilities tend to waste a lot of

vaccines. For example, a wastage rate of 50% for a two vial pentavalent is too high. Though much of the vaccine

76

wastage is due to vaccination services being offered for five days in a week, the DVI recognizes that other factors

contribute to the wastage. Contribution of these factors will be reduced through to improved monitoring and

supervision. Special accounts for donor funds has already been opened for ease of transfer and use of such funds while

at the same time maintain stringent accountability process in place. The cohort approach of programming adopted by

the MoH is likely to improve efficiency in programme planning and management. Furthermore, combing efforts and

resources will further maintain efficiency.

The cold chain inventory will be updated and detailed maintenance plan implemented. There is also a plan to

standardise the cold chain equipment at the various levels of the EPI delivery system. Solar refrigerators that are

deemed more expensive than electrical/gas ones are gradually being replaced. In addition to improving the efficiency

of the equipment, staff will be trained at the various levels with a view to improving their efficiencies.

9.7 Implementation and follow-up of financial sustainability strategies

This section presents the plan of action for the implementation of the financial sustainability activities outlined in the

previous sections. The activities, persons or organisations responsible, and monitoring indicators for the different

strategies of achieving financial sustainability are outlined in the Table 9.5. The responsibility for monitoring the

implementation rests with DVI through Child Health ICC. A technical sub-working group shall follow-up on regular

basis, on behalf of the ICC, the implementation of the plan. This shall include representation from the EPI (EPI

Manager), and other members to be chosen by the ICC. The working group will select a focal point to oversee the

implementation of the plan and coordinate the membership.

A detail Plan of Action (POA) guiding the work of the group shall be drawn. A report should be submitted to the ICC

on regular basis. The ICC shall review and monitor progress regularly (every quarter) and plan for the following

quarter. The cMYP team shall meet semi-annually to review progress on expected activities and plan for upcoming

tasks.

On an annual basis, the ICC and other stakeholders shall meet to review progress on financial sustainability indicators

and plan or fine-tune the financial sustainability strategies and actions for the following year. Outputs from this annual

meeting shall form the basis for reporting progress.

77

Table 9.5: Activities and indicators for follow up of financial sustainability strategies

Target Activity for which resources needed

Person/

Organisation for

follow -up

Indicators for follow-up

Indicator Frequency of follow-up

Value

Baseline Target

Mobilise additional resources for EPI

Increase GoK EPI expenditure through MTEF from the current level through inter-ministerial discussions

DVI % of government expenditure on EPI

Annually 56% 70%

EPI expenditure as proportion of total health expenditure

Annually - 8%

Target additional support for EPI from MTEF and when possibly SWAP

HP/DVI

% of EPI funds funded from MTEF and where possible SWAP

Annually - 80%

Conduct target resource mobilisation from local corporations, individuals and communities

CH ICC Number of local corporations and individuals presented with the cMYP for funding

Bi-Annually - 50%

Present the contents of the cMYP to traditional and non-traditional partners such as UNICEF, WHO, JICA, DFID, USAID as an advocacy tool for resource mobilisation.

CH ICC Number of forums utilised to present the cMYP

Bi-Annually 1 (ICC) 5

Improve Reliability of resources

Negotiations with specific partners such as WHO, UNICEF and JICA for funding pledges beyond one year for routine and SIAs

CH ICC Proportion of funds mobilised for one year prior to any SIA

Annually 33% 80%

Include EPI priorities in the next MTEF well in advance

DVI/HP

EPI needs included in the MTEF Every 3 years - By end 2009

Improve Programme efficiency*

Improve the capacity of the health and EPI staff at facility level for efficient management and delivery of immunization services

MoH/EPI

% of health facility trained in various aspects of immunization delivery

Quarterly ? 75%

Increase the capacity to monitor vaccine wastage rate every level

DVI/Provinces/District/Health facilities

Wastage data available at each facility

monthly Districts & HFs only

DVI, Province, Districts and HFs

78

Improve monitoring and evaluation of the programme

DVI Number of Health facilities with monitoring and evaluation in place

Quarterly - 100%

Update cMYP EPI Manager

Annual update of cMYP annual plan

Annually 0 1 annually

*This is costly and has not been financed consistently. Funding has been pegged to specific activities or regions.

79

10.0 DVI Annual Work plan for 2008

Key Activities 2008 Costs Funder Responsible

person

Service Delivery

1. Intensify & sustain outreach services X

2. Conduct supplementary SNIDs X

3. Develop facilitative supervision schedules X

4. Screen all children <5years who present to the health facility to reduce missed opportunities X

5. Open more SDPs in far to reach population X

6. Conduct daily maintenance of cold chain X

7. Maintain vaccine potency at all levels X

8. Distribute vaccines and other supplies to SDPs on monthly basis. X

9. Involve facilities in the EPI planning processes X

10. Replace the un-serviceable refrigerators X

13. Hold meetings with school management to develop schedule for school health programmes (TT) X

14. Conduct the school health programmes (TT) X

16. Conduct TT SIAs for child bearing women in high risk districts (14 districts) X

17. Conduct routine immunization as per schedule (TT) X

18. Screen mothers (CBAW) to reduce missed opportunities X

19. Motivate clients to return for immunization by providing services & information for the need to

complete schedule

X

20. Provide quality EPI services (SOPs) X

21. Provide home visiting tools for CORPs X

22. Liaise with community leaders and FBO leaders – Drop out rates X

25. Motivate CORPs X

80


person

27. Conduct catch up campaigns for integrated measles in 2008 X

28. Conduct outreach/mobile clinics X

29. Provide & sustain transport for districts hard to reach X

VACCINE SUPPLY, QUALITY AND LOGISTICS

3. Forecast Vaccines at facility, district, province and national levels X

4. Distribute vaccines and other supplies to SDPs on monthly basis X

7. Computerize vaccine management system X

8. Regularly monitor vaccine wastage at all levels X

9. Support Pharmacy and Poisons Board to establish a system for vaccines quality checks X

12. Regularly monitor adherence to guidelines X

14. Replace non CFC free and un-serviceable cold chain equipment X

15. Procure and distribute cold chain equipment to new SDPs X

16. Support KEMSA to stock cold chain spare parts at regional KEMSA stores X

20. Avail AD syringes and safety boxes to all immunization service points X

22. Support districts to construct incinerators at district and sub-district levels X

23. Support immunizing facilities to burn and bury waste for those with no incinerators X

SURVEILLANCE

1. Conduct quarterly progress meetings between KEPI, PHMTs, DHMTs and Partners X

6. Establish links for surveillance reports at district level X

7. Provide financial support to district level regularly for AFP/measles/MNT surveillance X

8. Provide funds for maintenance of transport for DDSCs, PDSCs and NDSOs X

9. Provide funds for communication for DDSCs, PDSCs, NDSOs X

10. Provide funds for WHO surveillance officers, NDSCs, PDSCs, NPCC, NPEC and NTF X

11. Provide funds for Hib, MNT, Measles and Rotavirus surveillance X

81


person

13. Support procurement of laboratory supplies and equipment in liaison with IDSR Unit X

14. Create/enhance local laboratory networks X

15. Provide all levels with adequate reporting tools X

16. Train DDSCs to analyze and use data at their level X

17. Provide and maintain computers and accessories for all levels X

18. Conduct annual cross border meetings with inter-country surveillance officer X

19. Conduct field visits at all levels and give written feedback: National-quarterly; Prov.- Monthly;

District – daily/monthly

X

20. Provide instant, monthly, & quarterly feedback (verbal & written) X

ADVOCACY AND COMMUNICATION

3. Distribute as brochures, leaflets etc to community members, schools, popular meeting spots X

5. Develop radio, TV, Internet and other media spot messages for Routine Immunization. X

7. Develop and distribute newsletters on immunization information on a quarterly basis X

10. Develop joint work plans X

11. Shoot 4 video productions X

12. Record 4 audio tape messages X

13. Disseminate and Distribute copies of (1) and (2) above X

14. Advocate for increased and sustained allocation in the national budget for advocacy and

communication

X

15. Encourage business partners to support advocacy of particular immunization events X

16. Attend annual district planning workshop and ensure EPI communication plan is integrated into

district plans

X

19. Monitor communication activities at all levels and provide feedback X

20. Develop an integrated reporting tool X

21. Hold feedback meetings X

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23. Prepare messages for broadcasting and for feedback meetings X

MANAGEMENT

1. Rational re-distribution of available h/workers within the districts and the country as whole

2. Motivate H/workers and CORPs by recognition, appraisals and allowances X

4. Draw and implement a training plan in all the districts X

6. Annual review of the KEPI organogram to fit the demand of the future X

7. Develop annual plans at all levels X

8. Hold quarterly review meetings at the Districts with stakeholders involvement X

9. Provide logistical and financial support to districts X

10. Develop and disseminate timely Annual Operation Plans X

11. Carryout and implement a study on fleet management system for PHC services X

12. Provide appropriate serviceable transport X

15. Construct new, and rehabilitate existing cold rooms and stores in the regions and districts X

16. Construct incinerators in 40% of all health facilities X

17. Carry out assessment of cold chain inventory X

18. Replace 90% of old fridges with CFC free fridges X

19. Procure CFC free fridges for new facilities X

20. Procure assorted cold chain spare parts X

21. Provide appropriate source of energy to support cold chain X

22. Avail AD syringes and safety boxes to all SDPs X

23. Mobilize locally available resources to avail documentation tools and consumables X

24. Set up national immunization resource mobilization steering committee

25. Joint biannual meeting of ICC, MOH and treasury staff to mobilize GOK resources for

immunization

X

27. Organize meeting with potential private sector partners/ donors X

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28. Contract an organization to coordinate resource mobilization X

29. Re-establishment of regular outreach services X

30. Supportive supervision: on-site training community links with service delivery X

31. Monitoring and use of data for action X

32. Better planning and management of human and financial resources X

33. Reduce the number of immunization dropout through micro planning at the district or local level X

34. Strengthen managerial skills of immunization providers at all levels X

35. Provide timely funding, logistic support and supplies in every district X

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