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Georgia 2005

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Financial Sustainability Plan of the National Immunization Program of Georgia

TABLE OF CONTENTS Executive Summary............................................................................................................... i

A. Program objectives........................................................................................ i B. Economic and political context ..................................................................... i C. Program costs .............................................................................................. ii D. Funding gap ............................................................................................... iii E. Strategic priorities .......................................................................................iv

Section II Impact of country and health system context on immunization program costs, financing and financial management................................................................. 7 A. Political and socio-economic trends ............................................................. 7

A.1 Effect of civil service reforms or other initiatives on wages of health workers ...9 B. Country development objectives and health care....................................... 10 C. Government’s priorities in health............................................................... 11 D. Decentralization......................................................................................... 12

D.1 State Budget Development and Public Expenditure Management.................12 D.2 Budget Development and Execution for Immunization................................13 D.3 Functional Decentralization and Organizational Issues...............................14

Section III Immunization program characteristics, objectives and strategies ................... 17 A. National Program Review ........................................................................... 17 B. Key program objectives and strategies....................................................... 19

Section IV Past and current costs of the NIP .................................................................... 26 A. Overview .................................................................................................... 26 B. Notes on the methodology.......................................................................... 26 C. Description by cost categories ................................................................... 27

C.1 Vaccine costs ........................................................................................27 C.1.1 Routine vaccination....................................................................27 C.1.2 Supplemental immunization activities...........................................28

C.2 Personnel costs......................................................................................28 C.3 Other routine recurrent costs..................................................................29

D. Major trends .............................................................................................. 29 D.1 Costs....................................................................................................29 D.2 Financing..............................................................................................30

E. Implication on future resource requirements............................................. 31 Section V Future resource requirements and financing .................................................. 33

A. Overview .................................................................................................... 33 B. Baseline scenario....................................................................................... 34

B.1 Future resource requirements .................................................................34 B.2 Future financing and funding gap............................................................37

C. Alternative scenario ................................................................................... 38 C.1 Alternatives #1 and #3............................................................................38 C.2 Alternative #2........................................................................................39

Section VI Financial sustainability strategy and action plan ............................................ 40 A. Review of major findings – SWOT analysis................................................. 40 B. Strategy Option.......................................................................................... 41 C. Action plan and indicators......................................................................... 45

Section VII Stakeholder comments .................................................................................... 48 Section VIII Annexes........................................................................................................... 49

TABLE OF FIGURES Figure 1: Flow of resources, procurement and disbarment of vaccines.......................... 14 Figure 2: Functional decentralization within NIP............................................................ 15 Figure 3: Immunization Coverage per cent, 1993-2004.................................................. 18 Figure 4: Projected coverage rates for 9 antigens for 2004-2010 .................................... 20


Figure 5: Projected coverage rates at district levels for 2004-2010................................. 20 Figure 6: The NIP characteristics by objectives and strategies........................................ 22 Figure 7: Cost profile (share in %) – calculated in US$ ................................................... 27 Figure 8: Past cost of vaccines (routine) by antigens ...................................................... 28 Figure 9: Trends in past cost by category ....................................................................... 30 Figure 10: Financing profile (shares in %) ........................................................................ 30 Figure 11: Trends in past financing by sources................................................................ 31 Figure 12: Description of scenarios .................................................................................. 33 Figure 13: Comparison of future expenditures on vaccines by scenarios and years (in

millions)........................................................................................................... 34 Figure 14 Trend in the future resource requirements and share of vaccines (for routine

immunization and SIA) in million US$ ............................................................ 35 Figure 15: Projection of future resource needs (in Million US$)........................................ 36 Figure 16: Secure financing and funding gap ................................................................... 37 Figure 17: Secure + probable financing and funding gap ................................................. 37 Figure 18: Financial gaps ................................................................................................. 38 Figure 19: Summary of findings (SWOT)........................................................................... 40 Figure 20: Assessment of the strategy elements ............................................................... 42 Figure 21 Final financial sustainability strategy components/elements with

corresponding indicators and action plan ....................................................... 45 Figure 22: National Immunization Schedule 1994-2004 overview per antigens and source

of vaccine supply funding................................................................................ 51 Table 1: Major Socio-economic Indicators for Georgia, 1997-2003 ................................. 8 Table 2: Wastage regions by regions and antigens in 2003........................................... 21 Table 3: Main cost parameters of the NIP in the past.................................................... 26 Table 4 Personnel cost profile ...................................................................................... 28 Table 5: Real “other recurrent costs” in 2001-2003 ...................................................... 29 Table 6: Key cost and financing indicators.................................................................... 32 Table 7: Comparison of future resource requirements by scenarios and years ............. 33 Table 8: Resourced required to cover “other routine recurrent costs” in US$................ 36 Table 9: Funding gaps by alternative scenarios ............................................................ 38 Table 10: Past and current costs in US$......................................................................... 49 Table 11: Past and current costs in GEL......................................................................... 50 Table 12: UNICEF financing of past and current costs (with 2005 projections) by origin of

funds, cost categories and by years................................................................. 52 Table 13: Future resource requirements in US$ (baseline scenario) ............................... 53 Table 14: Future resource requirements in GEL (baseline scenario) ............................... 54

ACRONYMS – MORE ACRONYMS AD Auto-disable Syringes BCG Bacillus of Calmette and Guérin (anti-TB vaccine) CIF Curatio International Foundation CMSI Centre for Medical Statistics and Information CPH Centers of Public Health DPT Diphtheria-Pertussis-Tetanus Vaccine DT Diphtheria-Tetanus Vaccine EDPRP The Economic development and Poverty Reduction Program of Georgia EPI Expanded Programme on Immunization GAVI Global Alliance for Vaccines and Immunization GEL Georgian Lari GDP Gross Domestic Product GoG The Government of Georgia GSUSIF Georgia State United Social Insurance Fund HEP B Hepatitis B Vaccine


HCP Health Care Providers ICC Inter-Agency Coordinating Committee IDP Internally Displaced Person IEC Information, Education, Communication IT Information Technology M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Survey MIS Management Information System MLM Middle Level Management MMR Measles, Mumps and Rubella Vaccine MoLHSA Ministry of Labor, Health and Social Affairs MTEF Medium-Term Expenditure Framework NCDC National Centre for Disease Control & Medical Statistics NIDS National Immunization Days NIP National Immunization Programme OPV Oral Polio Vaccine PER Public Expenditure Review PHC Primary Health Care PHD Public Health Department SDS The State Department of Statistics SIAs Supplemental Immunization Activities UNICEF United Nations Children’s Fund USAID United State Agency for International Development USD United State’s Dollar VF Vaccine Fund VPD Vaccine Preventable Disease VRF Vishnevskaya-Rostropovich Foundation WHO World Health Organization

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A. Program objectives The main objectives of the national immunization program have been defined as follows in order of prioritization: 1. Improving the timely immunization coverage against all 9 antigens up to 90%

at the national level and at least to 80% at all district levels throughout the country;

2. Sustaining Polio free status and continuing accelerated disease control activities for Measles and Diphtheria;

3. Decreasing vaccine wastage rates; 4. Introduction of new vaccines based on epidemiological and cost-benefit

analysis; 5. Improving immunization coverage and program management capacities in

conflict affected zones. Having applied to the GAVI/Vaccine Fund Support in October 2001 the Government of Georgia (GoG) has received approval for all three sub-accounts of the application: 1. Financial assistance for Immunization Service Support (ISS) for 2002-06; 2. Vaccine and injection safety supplies for Hep B vaccination programme (3-dose) in 2002-06; and 3. Injection safety supplies for EPI in 2003-04, with cash disbursement in lieu of supplies procured for 2001 programme. The GAVI/VF support ends in 2006. The present document covers the period from 2001 to 2010 considering 2001 as pre-VF year, 2003 as VF year and 2006 as the last year of the GAVI support.

B. Economic and political context Though some level of macroeconomic stabilization was achieved by mid 1990s, entailed in growth of economic activity and GDP, Georgia is still far from reaching the pre-independence level of development – at present, 13 years after declaring independence, economic activity in the country is about 41% of its 1990 level. As per the current GDP level - 3.3 billion USD or 762 USD/per capita - Georgia is a developing country, while the Organization for Economic Co-operation and Development (OECD) considers it as a Least Developed Country (LDC).1 Georgia has been ranked the lowest by GDP growth from 1990 level amongst the former Soviet Union countries. The Human Development Report of 2004 ranks Georgia at the 97th place (vs.88th in 2003) out of 177 countries included in the Human Development Index (HDI).

Amongst the nine strategic priorities encompassing governance, macroeconomic stability, institutional environment, conflict affected zones, economy and natural environment, in regard to the social sector development the Economic Development and Poverty Reduction Program of Georgia (EDPRP) addresses: a) development of human capital and b) social risks management and social security. The strategy

1 Project of the Parliament of Georgia, Strengthening Effectiveness and Transparency of the Parliament

and Government of Georgia, UNDP Georgia, NCTeam, Tbilisi, February 2004.


ii

targets at improving the standard of living of individuals below the poverty line and reducing vulnerability level through improved management of social risks. The fact that the EDPRP measures success in terms of both of these indicators is notable.

In line with reform process in 1999 the Government of Georgia has endorsed the long-term strategic framework of the national health system development, outlined within the National Health Policy (1999-2010) and National Health Strategy. Stemming from the basic concepts of the fundamental human rights and social development targets, as well as the soundness of scientific based approach, the national health policy document has identified eight strategic priorities with the performance and outcome targets set by 2010. Following have been the priorities set out by the national health authorities in co-ordination and agreement with international development partners: • improvement of maternal and child health; • reduction of morbidity and mortality caused by cardiovascular diseases; • improvement of prevention, detection and treatment of oncological diseases; • reduction of traumatism; • reduction of communicable and socially dangerous diseases; • mental health; • establishment of healthy lifestyle, and • Provision of an environment safe for human health.

The Public Expenditure Management (PEM) cycle in Georgia is in the process of being reformed to introduce a Medium-Term Expenditure Framework (MTEF) approach. This process is led by the Ministry of Finance (MoF) that designed and started implementation in the fourth quarter of 2004.

The following issues related to the decentralization processes in Georgia potentially may have impact on the sustainability of the NIP: • Provider autonomization; • Decentralized management; • Weak human and institutional capacity, and • Lack of direct financial incentives.

C. Program costs Key parameters of the past and current project costs are presented below: 2001 2002 2003

Total program cost (in US$) 1,041,026 1,359,222 972,259

Total program cost as a share of total government health spending 4.2% 5.7% 3.3%

Total program cost as a share of total health expenditures 0.4% 0.6% 0.3%

Vaccine costs as a share of total routine costs 19% 27% 20%

Cost per fully-immunized child (US$) 23.03 24.32 21.58

Share of financing by government in total financing 73% 68% 79%

There was no significant difference between the pre-VF (2001) and VF (2003) years due to the SIAs carried out intensively in the past and the early introduction of Hep B vaccine in 2001 (before the GAVI/VF support).


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The share of government’s financing was 70-80% while donors (VRF, GAVI/VF and USAID/UNICEF) covered almost all program-specific costs.

D. Funding gap Four scenarios were elaborated to project the future resource requirements as presented below: Scenarios 2005 2006 2007 2008 2009 2010 Baseline

Vaccine costs $ 275,975 $ 285,550 $ 296,290 $ 309,088 $ 309,205 $ 309,216 Total costs $1,113,176 $1,229,622 $1,298,143 $1,308,247 $1,369,437 $1,434,707

Alternative 1 Vaccine costs $ 275,975 $ 285,550 $1,778,580 $1,873,785 $1,873,958 $1,874,025 Total costs $1,113,176 $1,229,622 $2,780,433 $2,872,944 $2,934,190 $2,999,516 Difference in % 114% 120% 114% 109%



There is no substantial financial gap in case of baseline scenario (if Heb B, MMR and traditional vaccines are purchased at UNICEF prices) considering both secure and probable financing as shown below:

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

2004 2005 2006 2007 2008 2009

Funding Gap

UNICEF/USAID

USAID

WHO

JICA

VRFUNICEF

GAVI - Vaccine Fund

Sub-national Gov.

National Government

However, the most probable scenario implies significant gap because the government has to continue the purchase of vaccines at market prices (if the financial sustainability strategy is not applied) as shown below:


iv

$-

$0.5

$1.0

$1.5

$2.0

$2.5

$3.0

$3.5

2005 2006 2007 2008 2009

Alternative 2Alternative 1Alternative 3Secure+probable funding 3.07 m

ln US$

1.57 mln U

S$

1.60 mln U

S$

E. Strategic priorities The following strategic priorities were identified with corresponding key progress indicators and actions to address the financial gap: Strategy component and elements Output indicators Actions

Responsible agency

Time frame

1. Resource Mobilization & Advocacy

• Share of actual domestic expenditures on recurrent costs of immunization program/amount budgeted for recurrent costs within the last fiscal year

• Well established Financial Planning process involving all financiers

1.1 Ensure purchase of vaccines by the state at prices close to UNICEF

• Purchase of quality vaccines with use of international procurement mechanism or direct procurement with price differential of less than ten percent from UNICEF prices

-1. To revise the legislation to enable state procurements directly from UNICEF

-2. To conduct market assessment to identify suppliers with the lowest prices (meeting quality standards)

-3. To strengthen state procurement capacity and transparency

• MoLHSA • Parliament • ICC

members

by the end of 2005

1.2 Obtain commitment from traditional donors

Donor expenditures and pledges: Donor actual expenditure in the past year

-1. To update the FSP (as an advocacy and planning tool) regularly together with ICC partners

-2. To conduct intensive

• MoLHSA • PHD • NCDC

Annually till 2010


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Strategy component and elements Output indicators Actions

Responsible agency

Time frame

expressed as a percentage of the gap between total costs estimated for the multi-year strategic plan (MYP) and expected national expenditures.

consultations with the ICC partners during the planning of their programming cycles

1.3 The NIP future resource requirements are incorporated in the MTEF

Existence of laws (budget law), statutes, regulations and/or official decrees specifying amounts or allocations to be dedicated to immunization programs

-1. To present the findings of the FSP to policy makers in the MoF and achieve consensus

-2. To hold working meetings with the policy makers and technical decision makers (in charge of MTEF) in the MoLHSA

• MoLHSA • PHD • NCDC • ICC

members

by the end of 2005

2. Efficiency & effectiveness

• Trends of vaccine stock-outs, by region #,%

• Trends in wastage rates over time, by antigen, particularly for vaccines subject to open vial policy regulations (DPT, DT, Td, OPV, HepB)

2.1 Stronger management capacity among immunization, cold chain, and supply manages

• Technical documents and training materials available

• Number of managers / professionals trained (or in % out of total)

-1. To prepare technical documents and training materials (Preparation, adaptation, translation, printing and distribution of technical documents and training materials, based on MLM and IIP modules)

-2. To train managers (conduct EPI Mid-Level Management (MLM) training course for region and district immunization managers)

-3. To translate and adopt the WHO-UNICEF Effective Vaccine Store Management (EVSM) Initiative

-4. To conduct vaccine store management and immunization safety training course - 12 regions and 66 districts for 2-3 days

• PHD • NCDC • ICC

members

2005-2008

2.2 Improve management information systems

• Existence of an accounting system for the immunization program or a broader

-1. To upgrade existing software for the MIS to meet more advanced (managerial) requirements

-2. To conduct a training course on EPI and standard used

•


vi

Strategy component and elements Output indicators Actions

Responsible agency

Time frame

accounting system where expenditures can be disaggregated by program

software for regional and district Public Health Centre (PHC)

2.3 Develop incentive system to motivate providers to increase coverage

• Reimbursement schemes of PHC providers consider appropriate incentives for immunization services

-1. To participate in the elaboration of the PHC provider reimbursement schemes

-2. To develop policy recommendations

-3. To conduct workshops & debates

• MoLHSA • PHD • ICC

members

annually till 2010

2.4 Consider the needs of the NIP in PHC reform

• Cold chain equipment at PHC level is incorporated in the standards of the primary health care facilities

• PHC medical personnel responsibilities are defined in the payment contracts and enforced

-1. To participate in the design of PHC facility standards (enforced by licensing or contracting mechanisms) and integrate the needs of the NIP

-2. To participate in the design of the functional plans and the scope of work of medical professionals of PHC institutions to integrate the needs of the NIP

-3. To participate in the human resource development planning and ensure that training (education) curriculum reflects immunization related topics

-4. To participate in the development of PHC provider contracts and suggest mechanism for their enforcement concerning the NIP objectives

• MoLHSA • PHD • ICC

members

2005-2006

Financial Sustainability Plan of the National Immunization Program of Georgia Section II

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A. Political and socio-economic trends Georgia obtained its independence from Soviet Union in 1991. The break-up was followed by intense civil conflicts and separatist pressures in autonomous regions (Ossetia and Abkhazia) and displacement of some 270 000 people in 1993. There was also a profound economic collapse, in part due to the civil disturbances and in part due to the unraveling of what had been a centrally planned economy directed from Moscow. The Soviet system did not encourage diversification within republican economies, leaving them vulnerable after independence. There was a large decline in output, a collapse of the system of payments, and thus trade between republics, and consequently a series of dramatic economic declines after 1992, which resulted in a sharp fall in the standard of living2.

A new constitution was enacted in 1995 that declared president as a senior executive power, and separated legislative, executive and judicial functions. The new constitution has divided Georgia into 66 administrative-territorial units including: capital city of Tbilisi, sixty districts (rayons) and one autonomous republic of Adjara (in its turn comprised of 5 districts). These 65 districts are grouped into 11 historical-cultural regions, not defined by constitution and not having budgetary-fiscal system, thus3

Transition of the last decade subjected Georgia to fundamental political, economic and social transformation. Despite the visible political stabilization and governmental commitment towards restoring the macro-economic stability, the overall situation still remains fragile.

Since the collapse of the Soviet Union, Georgia has experienced dramatic economic downturn. With the steep drop of economic activity in early 1990s, government launched anti-crisis program for macroeconomic stabilization and systemic transformation. The main thrust of the reform was seen in the transformation of monetary policy and drastic fiscal adjustment, accelerated privatization, reforms of health care, education and social protection systems, liberalization of economic activity and trade, as well as price liberalization.

Though some improvements were achieved by mid 1990s, entailed in growth of economic activity and GDP, Georgia is still far from reaching the pre-independence level of development – at present, 13 years after declaring independence, economic activity in the country is about 41% of its 1990 level. As per the current GDP level - 3.3 billion USD or 762 USD/per capita - Georgia is a developing country, while the 2 A.Gamkrelidze, R.Atun, G.Gotsadze and L.MacLehose, 2002. Health Care Systems in Transition:

Georgia. European Observatory on Health Care Systems, WHO Regional Office for Europe. 3 The document hereinafter, when describing budgeting/financing and decentralization issues will

always relate to two levels: central/national and district (rayon).


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Organization for Economic Co-operation and Development (OECD) considers it as a Least Developed Country (LDC).4 The country as been ranked the lowest by GDP growth from 1990 level amongst the former Soviet Union republics. The Human Development Report of 2004 ranks Georgia at the 97th place (vs.88th in 2003) out of 177 countries included in the Human Development Index (HDI).

Armed conflicts erupted in South Ossetia and Abkhazia (autonomous republics of Georgia) in early 1990s, with influx of 270,000 IDPs, subjected the country with already plunging economy and collapsing infrastructure to additional social and economic challenges. Georgia’s government does not have effective control on the social and other service provision to the population in these territories, which influences functioning of the immunization program as well. Nevertheless, central source (NCDC) provides vaccines to the conflict affected zones and even managed to offer training to the immunization staff in these parts of the country.

The abandonment of the Soviet system of subsidies, transfers, and captured markets had a significant impact on living standards of the population, an impact that could not been reversed up to date. Georgia has been among the three poorest post-Soviet republics, with the population confronting severe social-economic hardship. In 2003, according to the State Department of Statistics (SDS), the proportion of people living below the poverty line was 55%. The proportion of the population in extreme poverty was 17%.5 Most commonly, poverty is manifested by low and unequal distribution of income, unemployment, and insufficient housing and labor migration. GINI coefficient (the measure of income inequality) has dropped from 37.1 in 2002 to 36.9 in 2004 after a slight increase to 38.9 in 2003.6

Table 1: Major Socio-economic Indicators for Georgia, 1997-2003 1997 1998 1999 2000 2001 2002 2003

Real GDP (change, %) 10.5 3.1 2.9 1.8 4.8 5.5 11.2 Consumer Price Index (change, %, prev. year) 7.1 3.6 19.2 4.0 4.7 5.6 4.8 Overall Tax Revenue (% of GDP) 15.4 14.8 14.6 15.0 15.6 15.1 14.8 Overall Public Expenditure (% of GDP) 20.5 20.3 21.0 18.7 18.6 18.8 17.6 Education (% of GDP) 2.0 2.1 2.1 2.1 2.0 1.8 1.6 Health Care (% of GDP) 1.1 0.7 0.6 0.9 0.8 0.8 0.7 Social Protection (% of GDP) 4.2 4.4 4.7 4.3 3.8 4.0 4.0 Housing and Municipal Services (% of GDP) - 0.1 0.1 0.1 0.1 0.1 - Overall Budget Deficit (% of GDP) 4.6 4.9 5.5 3.4 2.3 3.4 2.3 External Debt (US $ million) 1,412 1,627 1,635 1,556 1,602 1,753 1,853 Poverty incidence (according to Official Subsistence Minimum) 46.2 50.2 51.8 51.8 51.1 52.1 54.5

Extreme poverty incidence (according to Alternative poverty line) 9.9 13.8 15.2 14.3 13.8 15.1 16.6

Unemployment rate (official) 7.5 12.3 12.7 10.3 11.1 12.3 11.5 Source: State Department of Statistics of Georgia

In 2003, Georgia's total foreign debt was US $1,853 million, or 53% of GDP. The country borrows to a great extent to finance consumption. The existing policy with

4 Project of the Parliament of Georgia, Strengthening Effectiveness and Transparency of the Parliament

and Government of Georgia, UNDP Georgia, NCTeam, Tbilisi, February 2004. 5 Millennium Development Goals in Georgia, 2004. 6 Human Development Reports 2002, 2003, 2004


9

the full knowledge of multilateral financial organizations, bears high risk in view of non-trivial debt burden of Georgia, a burden that authoritative sources have assessed as “unsustainable” unless a serious debt restructuring takes place.7

The public health system of Georgia as part of the highly centralized Soviet model was ensuring comprehensive service coverage through integrated infrastructure of service providers. However, the inefficient administrative and financial management system was collapsed within the transition period as a result of economic crisis. The impact of transition reflected in extremely scarce budget allotments for basic social services, and health care in particular subjected the sectors to substantially declining performance. From 4% of GDP (1991) the state health allocations fell to < 1% in 1998, yielding USD 4-5 per capita. Public expenditures on health sector, as share of GDP, at its peak investment in 2001 comprised 1.3 percent only. Share of Health expenditures within the consolidated budget in 2002 comprised as low as 7% of the total public expenditure.

A.1 Effect of civil service reforms or other initiatives on wages of health workers

The change of leadership through the 2003 Rose Revolution enabled the establishment of a new framework for the consolidation of national identity. However the new authorities have received a government structure characterized by crippling corruption levels. Mismanagement by the previous government resulted in a low tax collection rates which contributed to growing pension and salary arrears. The new government also inherited widespread poverty, as well as the unresolved conflicts with Abkhazia and South Ossetia.

The government prioritized decreasing debts in pension and salary arrears throughout the year 2004 as well as gradual increase of the wages of public sector employees. During 2004 as a first step toward creating a professional civil service, the new government of Georgia reduced public employment by some 30,000 positions and used salary savings to increase remuneration of remaining personnel. However these changes have not yet affected all sectors – i.e. wages for the education sector employees had grown gradually, while changes have not yet affected health sector employees8. The wages of medical professionals are not paid directly from the state budget. They are employed by medical organizations that legally are subject to private low (incorporated as Limited Liability Companies or Joint Stock Companies). Therefore, the GoG can not directly increase the wages of medical personnel even if a significant portion of their salaries are paid from the state health programs (if the medical organization is contracted by the Georgia State United Social Insurance Fund). Anyway if the new Government decides to increase wages for the health sector staff it will require amendment of the financial projections for NIP to account for the increased resource requirement.

7 “Georgia. "Public Expenditure Review”. Report No 22913-GE. World Bank. Washington DC. 8 During elections to secure sufficient electoral votes opposition (current government) promised health

sector employees to protect their jobs and not to allow closing of hospitals or health facilities. Due to this reason plans to rationalize supply side of the health sector proposed by the previous government were criticized by the political opponents.


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B. Country development objectives and health care The government committed itself to restore territorial integrity and to launch reforms within the priority areas of economy, business, social security, governance and environmental protection. Ensuring universal access to basic healthcare has been one of the nine strategic targets within the reform processes.

The existing social-economic challenges have guided development of Economic Development and Poverty Reduction Program (EDPRP) in 2003. EDPRP has been an comprehensive, overarching strategic framework and planning document targeting at “raising the welfare of the population through improvement of the quality of life of each person along the sustainable socio-economic development of the country.”

The EDPRP sets forth two main strategic objectives: • Fast and sustainable economic development: Average growth rate of real

GDP at 5-8 percent per annum, which should ensure two- to three-fold growth of real GDP by 2015 vs. 2001; and

• Reduction of poverty: Reduction of extreme poverty (in relation to the “Alternative Minimum Poverty Line”) from 14 percent to 4-5 percent, and reduction of poverty in relation to the “Official Poverty Line” (or subsistence minimum) from 52 percent to 20-25 percent by 2015.8

Amongst the nine strategic priorities encompassing governance, macroeconomic stability, institutional environment, conflict affected zones, economy and natural environment, in regard to the social sector development EDPRP addresses: a) development of human capital and b) social risks management and social security. The strategy targets at improving the standard of living of individuals below the poverty line and reducing vulnerability level through improved management of social risks. The fact that the EDPRP measures success in terms of both of these indicators is notable. Recent experience in Georgia demonstrates that economic growth may not translate into increased levels of population welfare. For Georgia, it will probably define whether the public embraces the EDPRP as a program of its own. First, to translate economic growth into increased incomes of the poor requires policies that favor growth in sectors that the poor can reach. Second, to translate increased levels of economic activity into increased State revenues requires a functioning and transparent tax revenue service, a goal that has proven elusive so far. However, the progress of the new government in raising tax revenues as a share of GDP has been impressive during 2004. Rapid gains in tax collections were achieved thanks to a drive to curb tax evasion and corruption, together with a one-off surge in non-tax revenue (partly stemming from monies collected from former government officials suspected of corruption), this has permitted a faster-than-expected clearance of domestic wage and pension arrears10. However, new streamlined/liberalized tax code was passed by the parliament at the end of 2004, which reduced the number of taxes from 21 to 8, cutting the VAT rate, abolishing

8 The “Alternative Minimum Poverty Line” is a very low poverty line with a value of approximately 52

GEL a month. The “Official Poverty Line” is based on the cost of the Official Minimal Food Basket (2,500 Kcal/day) and is in the vicinity of 115 GEL/month. See the National Human Development Report 2001-2002 for a discussion on poverty lines in Georgia (available at www.undp.org.ge).

10 IMF Country report No.05/1, January 2005. Georgia: First Review under the Three-Year Arrangement under the Poverty Reduction and Growth Facility. p7.

http://www.undp.org.ge)


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earmarked payroll health (3+1) tax that formed the part of social tax and decreasing the social tax rate from 33 to 20 percent; setting a flat 12 percent personal income tax instead of income-dependant tax in a range of 12-20 percent. Time is needed to see actual impact of these changes on the tax rates and overall resource availability from the national budget. It is yet impossible to estimate direct impact of these changes on the NIP.

C. Government’s priorities in health The Georgia Health Care Reform (Reform I) aiming to ensure universal access to basic health services for the country population was launched in 1995. The reorientation process struggling with the heritage of inefficient and collapsing centralized fiscal and management system, insufficiency of both institutional (e.g. outdated facilities and under-equipped services) and human resources (e.g. under-trained professionals and overstaffing of the system) envisaged optimization of the health infrastructure (decentralization & privatization), introduction of new health care financing systems and reorganization of the network of health care providers. In brief, the reforms to the health care system focused on reducing overcapacity, allowing the private sector to occupy a greater role in the provision of medical services, establishing a system of medical insurance, and strengthening the provision of primary and preventive health care services. A major outcome of the reform was introduction of the state medical insurance system ensuring access of the general population to basic health services within the Basic Benefit Package. However the rights of the population to equal and accessible health care services committed within the restructured systems could hardly be realized due to insufficiency of the financial management systems. Chronic under-funding and instability of financial resources persisting throughout the reform process has affected functioning of all levels of health care system and reasoned substantial shift of expenditures to the out-of-pocket payment systems (out-of-pocket payments ranging from 66 to 87% of total health expenditures)9.

In line with reform process in 1999 the Government of Georgia has endorsed the long-term strategic framework of the national health system development, outlined within the National Health Policy (1999-2010) and National Health Strategy. Stemming from the basic concepts of the fundamental human rights and social development targets, as well as the soundness of scientific based approach, the national health policy document has identified eight strategic priorities with the performance and outcome targets set by 2010. Following have been the priorities set out by the national health authorities in co-ordination and agreement with international development partners: • improvement of maternal and child health; • reduction of morbidity and mortality caused by cardiovascular diseases; • improvement of prevention, detection and treatment of oncological diseases; • reduction of traumatism; • reduction of communicable and socially dangerous diseases; • mental health;

9 The World Bank, 2003. Report No 22913-GE. Georgia. Public Expenditure Review”. Washington DC.


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• establishment of healthy lifestyle; and • Provision of an environment safe for human health.

At the end of 2000, the government of Georgia adopted a concept of PHC development that envisages the formation of a health care model that effectively and reliably provides the entire population of the country with high quality yet cost effective medical services and is physically available and affordable (Reform II). This effort will be implemented over five years (2003-2008) with the support of PHC Reform partners - World Bank, EU and DfID.

The key components of this program include a) the construction/reconstruction of the PHC facilities in the selected regions; b) the provision of essential equipment in selected regions; c) the development of a national policy to support this initiative; d) the development of an improved national health care financing system that will provide sustainability for the PHC; e) the establishment of a health management information system that will meet the priority needs of the PHC and also contributing to the long term information needs of the sector.

The national immunization program remains a top priority amongst the key policy and strategic frameworks of the national health care system in Georgia. Among the targets endorsed within 1999-2010 National Health Policy Document are: maintainance of the Polio free certificate and neonatal tetanus elimination status, elimination of measles and CRS, reduction of HepB incidence by 80% by 2010 and reduction of diphtheria, mumps and pertusis prevalance to


13

President with the Cabinet of Ministers is responsible to revise the policies in accordance to the internal and foreign policy of the state. The revisions to the policy are subject to approval by the Parliament.

The Ministry of Finance (MoF) considers that a systematic policy review framework is not yet developed in Georgia11. Developing a process and framework for policy review is one of the objectives of the public expenditure management reforms led by the Ministry of Finance that will begin in 2005. Policy review informs the next stage of the PEM process – strategic planning. The two stages are closely linked12. Provided FSP document offers step forward towards policy review and target setting within PEM process.

The strategic planning stage of the PEM cycle includes the preparation and update of national and sector strategy documents and the preparation of Sector Expenditure Frameworks and the Medium Term Expenditure Framework.13 Strategic planning is a key step in ensuring that budgets are linked to policies.

The Budget Preparation process begins with the preparation of documents on “Basic Data and Directions”, which is based on the a) Medium-Term Macroeconomic Framework; b) Medium –Term Fiscal Forecasts; and c) Basic Directions for Budget and Tax Policy. Based on this document MoF provides planned expenditure ceilings to different ministries and spending agencies. Spending agencies elaborate their relevant budgets within planned expenditure ceilings and submit to MoF for discussion within the government. After government approval president submits draft budget law to the parliament for the approval.

D.2 Budget Development and Execution for Immunization For the budget development purposes PHD, NCDC and MoLHSA conduct negotiations based on the PHD and NCDC estimates to secure adequate financing within health sector budget. Budget estimates are based on the historical costs adjusted for inflation and planned targets and activities under the immunization program for the next year. The data availability for budget estimation on a sub-national and national level has been improving gradually and effectively utilized in the budgeting process, though further advances for data quality and breadth is still required. FSP document in the hands of NCDC and PHD is seen as an essential instrument in the process of health sector budget negotiations with MoLHSA to secure adequate financing within the national health sector budget. It is critical to highlight that central financing is essential for NIP as it provides resources for the most part of immunization program (see Figure 1) with the exception of shared human resource costs of providers and for the transportation costs of vaccines from district Centers of Public Health (CPH) to providers.

Local authorities are expected to contribute running costs of the PHC facilities and district CPH. Also in 2004 responsibility to finance Vaccine Preventable Disease

11 Ministry of Finance (2004) MTEF Design and Implementation Plan. 12 S.Stone, 2004. Georgia: Primary Health Care Reform Support Project Budget Management for

Health Care. Oxford Policy Management. Tbilisi. 13 The Sector Expenditure Framework and the Medium Term Expenditure Framework are new and

will be introduced formally from 2005 to cover the years 2006-2008.


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(VPD) surveillance were partially shifted to district budgets. However, due to the extremely limited, irregular and unequal (among districts) nature of local financing for the health sector, financial sustainability of VPD surveillance is put at serious risk.

Figure 114: Flow of resources, procurement and disbursement of vaccines

Medical service

providers

Medical Medical service service

providersproviders


providersproviders

785 785 Medical Medical service service

providersproviders

Medical service

providers


providersproviders


providersproviders


providersproviders

Public Health Department

(PHD)

Public Health Public Health Department Department

(PHD)(PHD)

NCDCNCDCNCDC

66 District PHD66 District PHD

Medical service

providers


providersproviders


providersproviders


providers providers TbilisiTbilisi

Medical service

providers


providersproviders


providersproviders


providers providers TbilisiTbilisi

12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD12 Regional PHD

Georgia State United

Social Insurance

Fund

Georgia State United

Social Insurance

Fund

Local Local GovernmentsGovernments

State BudgetState Budget

Retrospective payment for

medical services –per unit of service

(vaccination) –covers all costs but vaccines, syringes

and donations(will be abolished

from 2005)

Payment (performance based) for the transportation

of vaccines and monitoring and

evaluation of the implementation of the

state immunization programme

Financing of fixed and running costs such as utilities, maintenance

of equipment (cold chain)

Financing of the agency running and capital costs (including immunization)

Vaccines and syringes procured

and delivered to the NCDC

Funds from the State Immunization program

given to the GSUSIF for the procurement

Financing of the State Immunization programme minus cost for vaccines & syringes

Financial flows

Flow of vaccines

Funding for cold chain maintenance and custom clearance of vaccines

Retrospective payment –global budget to outpatient clinics under State Ambulatory Care program

D.3 Functional Decentralization and Organizational Issues General decentralization drive within the health sector affected the NIP by separating responsibilities between central and district levels. Figure 2 (on page 15) provides details of the responsibilities between the levels as a result of this decentralization. However, functional decentralization has not been followed by implementation of an effective management structures and/or instruments to provide successful stewardship from a central level.

The following issues potentially may have impact on the sustainability of the NIP:

Provider autonomization – Initiated in 1995 health sector reform created totally autonomous health service providers, who are being licensed by the state to provide

14 The chart is limited to flow of financial/supplies recourses within state funded NIP components and

implementing/coordinating institutions. Resources provided by donor agencies (UNICEF, WHO, VRF, GAVI) basically follow the existing financial and supply disbursement flow. Vaccines/injection and technical (cold-chain, IT) supplies procured through external donations are received/disbursed through NCDC, while financial assistance issued for programme management (i.e. capacity building, M&E) are managed through PHD network and/or NCDC.


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certain types of services. Providers in the county are not subordinated and/or effectively contracted by the local health care administrations. As a result, the providers have been totally de-linked from the local health care managers. At the same time the central contracting/financing agencies are much remote to effectively manage providers through direct contracts. Both central agencies - PHD and NCDC - can not set direct contracts with providers, and thus lack effective means to enforce national NIP regulations and standards.

Decentralized management – Establishment of district Centers of Public Health (CPH) shifted management function from central level to districts. Existing overall legal environment in the country does not provide sufficient power to the CPHs while charging them with responsibilities that are impossible to perform considering limitations in granted powers. Thus, overall management/stewardship ability of the central and local levels of the health sector in general has been weakened, which particularly affected NIP. Currently, efforts are being made to address these problems, though yet solutions are not readily available for a given complex environment and further work is required.

Weak human and institutional capacity – Lack of sufficient human and institutional capacity further aggravates the problem of decentralized and devolved responsibilities. Shortage in funds for conducting trainings and for strengthening institutional capacity still remains a major challenge for the government.

There is a lack of direct financial incentives for the PHC staff to further increase immunization coverage rates in their respective communities. Up until 2003 GoG provided output based reimbursement to the providers based on a vaccinated child. In 2003 payment method for PHC providers has changed to per capita form and financial incentives for vaccination were removed. It is strongly believed among stakeholders that restoring direct financial incentives for vaccinations is critical for NIP performance improvement.

Figure 2: Functional decentralization within NIP FUNCTION CENTRAL LEVEL LOCAL LEVEL

Planning & Forecasting • NCDC consolidates district specific plans into the national plan

• Solicitation with ICC partners • Budget development for National

Program

District CPH develops district specific programmatic projections/targets

Procurement • SISUF Procures vaccines and supplies from national budget

• NCDC receives and stores donated and procured supplies

Distribution • NCDC distributes vaccines to district CPH

District CPH supply providers with vaccines

Reporting • NCDC consolidates district-specific reports into the national

• NCDC reports to the national authorities and international organizations

District CPH consolidates facility level reports and submits to the NCDC


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FUNCTION CENTRAL LEVEL LOCAL LEVEL

M&E • NCDC consolidates district-specific monitoring and evaluation reports

• Conduct routine and outreach program monitoring

• Coordinates and/or carries out studies and evaluations

Conducts routine monitoring of providers (immunization performance, cold-chain, supply/logistics, injection safety and reporting) Carries out VPD surveillance Conduct situation analysis on a district level

Training • Serves as a national resource centre for all trainings related to NIP

Facilitates trainings for district providers

Policy development and standard setting

• PHD in collaboration with ICC develops and revises policies for the approval of the MoLHSA

• NCDC proposes standards for approval to the MoLHSA

All of the above factors impinge on effectiveness of the health sector performance in general including implementation of the NIP. Solutions to the stated obstacles are not easy and require exploration and creative thinking on the part of the Government and significant investments that have yet to come.

Financial Sustainability Plan of the National Immunization Program of Georgia Section III

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SSeeccttiioonn IIIIII IImmmmuunniizzaattiioonn pprrooggrraamm cchhaarraacctteerriissttiiccss,, oobbjjeeccttiivveess aanndd ssttrraatteeggiieess

A. National Program Review The socio-economic and political turmoil in Georgia during the early 1990s led to a marked deterioration of the health care system and a subsequent disruption of vaccine provision services. Institutional and management capacities were affected, and routine EPI coverage declined to as low as 30 per cent in 1993-1994. Support provided by international partners (UNICEF, WHO, USAID, Japan Government, UK) over the last decade has been critical for revitalization of the state immunization program and improvement of the service performance.

The long-standing partnership has envisaged support for supply procurement and logistics, policy and strategy development, institutional and human capacity building, establishment of outreach services and support to NIP studies and evaluations.

Major Achievements in the National Immunization Program are the following: • Vaccine Security ensured through continuous and non-interrupted provision

of vaccine/syringe supplies for routine EPI and Supplemental immunization activities through UNICEF-USAID support (i.e. Polio NIDs in 2002, Measles SIAs in 2004, etc.);

• Expansion of the NIP schedule through leveraging resources from GAVI/VF for Hep B and VRF for MMR.

• Improved and sustained government commitment for the NIP self-sustainability – in 2003 and 2004 GoG procured 20% and 30% of under-2 EPI supplies, respectively as well as 100% of DT, OPV and Td vaccination supplies for 5 and 14 year age groups.

• Overall immunization coverage for the 6 major antigens (BCG, DPT, OPV, measles) improved from 30-50% to >80-90%. HepB vaccine coverage remains modest due to recent introduction of the antigen (2001);

• Vaccine Preventable Disease (VPD) incidence reduced - Diphtheria - from 5.5/100,000 children in 1997 to 0.6 in 2003; Zero reporting for Polio and MNT maintained; Measles morbidity - 6.4/100,000 in 1997 to 4.9 in 2003, though the disease incidence started to increase in late 2003. Introduction of MMR vaccines in 2004 through financial support from Vishnevskaya-Rostropovich Foundation and joint coordination of national ICC partners is an unprecedented opportunity for Georgia to ensure effective management of Measles and Congenital Rubella Syndrome prevention activities.

• Polio Free Certification achieved in July 2002 among other countries of the European region;

• A strong policy and strategy framework established for quality assurance of NIP management and performance;

• Functional Inter-Agency Coordination Committee (ICC) established, serving as a forum for overall coordination, planning, and M&E of NIP related issues;

• Capacities of institutional and human resources strengthened through establishment of adequate cold-chain capacities and skills-building training for national & mid-level managers and health care providers;


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• Health Information System project launched in 2002 with improvement of management and reporting systems within NIP and VPD surveillance

Figure 3: Immunization Coverage per cent, 1993-2004 Vaccine 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003* 2004***

BCG 30.3 30.0 31.8 70.0 75.8 94.2 95.2 95.0 90.9 91.2 85.3 85.1

DPT3 54.3 58.0 54.3 91.6 92.0 89.2 98.0 98.0 87.2 85.7 74.8 71.9

OPV3 81.5 82.0 81.5 93.5 98.4 95.0 98.0 98.0 82.7 90.3** 74.3 63.4

Measles 61.1 63.0 61.1 88.0 95.0 90.0 97.0 97.0 57.2 65.9 79.9 82.3

HepB 3 - - - - - - - 51.2 62.0 51.1 47.8 59.6 Source: NCDC data Dec 2004 * Since 2003 by introducing new reporting forms (timely vs. overall) GoG is reporting timely age-appropriate coverage rates, thus reduced coverage is by no means reflecting deterioration of the program performance. ** High OPV3 coverage in 2002 related to implementation of Polio NIDs. *** 2004 Data covering January - November period, 11 month performance

Comment that the data do not comply to JRF – late availability of admin data on denominator…

Since 1994 up to 2001 UNICEF through USAID and UK Natcom financial assistance has been the major donor for EPI vaccine and injection safety device procurement. NIP schedule initially funded through single-source donation from UNICEF has been expanded and gained multi-lateral contributions from the national government, global public-private partnership and an international NGO. Please refer to NIP schedule evolvement over the last decade, with introduction of new vaccines, changes to the schedule as well as source of funding per specific NIP antigens (Figure 22 on page 51).

Starting from 2002 with approval of GAVI/VF support to the country, the country has been receiving 5 year supply of Hepatitis B vaccine and matching quantities of injection safety equipment, as well as injection safety devices for routine EPI program (within the scope of new and under-used vaccines and injection safety components of the GAVI/VF support). A total amount of Heb B vaccine doses requested by the Government of Georgia was 782,960. The GAVI committed 600,500 US$ for 5 years to meet the country needs in Heb B vaccine (at average cost of 0.77 US$ per dose).

In 2002 GoG has successfully launched the first installment for contributing state budget resources towards the Vaccine Independent Initiative (VII), thereby establishing the very first grounds for self-sustainability of NIP. Starting with procurement of DT, OPV 5 and Td vaccines for 5 and 14 year age group as well as mumps (non-routine) vaccines for 12 month aged infants, the Ministry of Labor, Health and Social Affairs through the State Insurance Fund has been successful in gradual expansion of the government share in procurement of the routine EPI vaccines. In 2002, GoG has ensured procurement of the 20% share of the EPI vaccine supplies for under-2 child population, followed by increased contribution to VII up to 30% in 2003.

Further to demonstrating the steadily increasing governmental commitment to NIP, in 2004 a new partner agency – Vishnevskaya-Rostropovich Foundation joined the


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ICC network. The contribution provided by VRF has been substantial in terms of 3-year commitment (2004-06 years) for provision of MMR vaccine for 1,5 and 13 age groups (including 14 age group for FY2004) and supporting existing national responses towards measles morbidity reduction and congenital rubella syndrome prevention strategies.

Within the present FSP GoG is expressing commitment for stepwise phasing out from donor agencies support for routine immunization supplies from 2006 as well as replacement of new vaccines (HepB & MMR) starting from 2007.

B. Key program objectives and strategies The main objectives∗ of the national immunization program have been defined as follows in order of prioritization: 1. Improving the timely immunization coverage against all 9 antigens up to 90% at

the national levels and at least to 80% at all district levels throughout the country;

2. Sustaining Polio free status and continuing accelerated disease control activities for Measles and Diphtheria;

3. Decreasing vaccine wastage rates; 4. Introduction of new vaccines based on epidemiological and cost-benefit analysis 5. Improving immunization coverage and program management capacities in

conflict affected zones.

Following are the strategies identified by national ICC partners for attainment of the defined NIP objectives.

Objective 1: Improving the timely immunization coverage against all 9 antigens up to 90% at the national levels and at least to 80% at all district levels throughout the country by 2010.

Please refer to Figure 4 (on page 20) and Figure 5 (on page 20) for the projected coverage targets for YY 2004-2010)

Suggested strategies: 6. Vaccine security: The national partners target at maintenance of the existing

NIP schedule (9 EPI and non-routine antigens) through securing national or external budgetary resources for sustainability of the NIP supply component (vaccines, syringes, safety boxes). Please refer to Figure 22 on page 51 for evolution of the NIP schedule per source of vaccines for YY 1994-2004. The

∗ It has to be stressed that proposed strategies have limitations. Higher (than shown in tables 2.2 and

2.3) increase of the coverage rates is conditional upon deeper structural reforms in health care system and administrative/governance setup of the country. Therefore, the proposed strategies can produce much higher coverage rates if the necessary reforms beyond the scope of the NIP and health system are implemented successfully.


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integration and management of the procurement systems has to be refined for prevention of the vaccine stock-outs and non-interruption of the NIP delivery services.

Program management: Improvement of the program management capacities through institutional (cold-chain and IT/MIS) and human (policy guidance and in-service staff training) capacity building activities. Focus should be shifted towards district performance-based analysis and improvement of the management capacities at sub-national levels through locally tailored approaches. Reducing missed-opportunities through improving national staff capacities in enforcement of the existing policy on contraindications. Immunization safety: Safety of immunization services to be ensured through putting in place quality assurance systems for NIP supply procurement, continuous support for effective operation of the cold-chain equipment at all levels of the service delivery and logistics support, improvement of injection safety and waste management practices and enforcement of the national policy on AEFI surveillance. Advocacy and program communication: Accelerating advocacy and social mobilization efforts for renewing and improving public trust to the child vaccination program. Development and implementation of IEC campaigns for improving public awareness on benefits of child vaccination and the importance of timely, age-appropriate immunization. Advocacy efforts will be also directed towards partners mobilization and exploring financial and technical resources for filling-up the defined gaps per specific program scenarios. Innovative approaches: 1. Introduction of effective mechanisms to create incentives among primary health care providers; 2. Defining scope and implementing outreach services for reaching the child population within remote and difficult to reach geographic settings. Reporting, M&E and supervision: 1. Data quality assurance through scaling up the NIP HIS system at all districts; 2. Supporting continuity of the routine monitoring systems and improving mechanisms for supervision and feedback; 3. Supporting implementation of the NIP related studies and evaluations (EPI evaluations, data quality assessment, EPI coverage surveys, etc.)

Figure 4: Projected coverage rates for 9 antigens for 2004-2010 Type of Vaccine 2004 2005 2006 2007 2008 2009 2010 BCG 90% 92% 95% 95% 95% 95% 95% DTP(1) 90% 93% 95% 95% 95% 95% 95% DTP(3) 85% 87% 89% 92% 95% 95% 95% OPV(1) 90% 93% 95% 95% 95% 95% 95% DT 80% 85% 87% 90% 93% 95% 95% Hep B(1) 78% 81% 85% 90% 95% 95% 95% MMR 80% 83% 86% 90% 95% 95% 95%

Figure 5: Projected coverage rates at district levels for 2004-2010 Programme Indicator Baseline 2003 2005 2006 2007 2008 2009 2010

(%) (%) (%) (%) (%) (%) (%) % of districts with > 80% DPT 3 coverage 56 60 65 70 75 85 > 95%


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Objective 2: Sustaining Polio free status and continuing ADC activities for Measles & Diphtheria

Suggested strategies: Sustained coverage: Maintaining high coverage rates for polio, measles and diphtheria vaccines (ref.: objective 1); VPD surveillance: Improving VPD surveillance and reporting through appliance of the HIS systems at all sub-national levels, and Lab based surveillance: Continuing lab-based diseases surveillance and assuring compliance of the existing institutional and human capacities for effective VPD lab-diagnostics.

Objective 3: Decreasing vaccine wastage rates

Suggested strategies: Vaccine procurement: Optimization of NIP procurement through introduction of cost-effective vial presentations based on needs forecasting per national & sub-national levels per service delivery settings. Open Vial Policy: enforcement and monitoring of OVP implementation. Table 2: Wastage regions by regions and antigens in 2003

DPT OPV Measles Hepatitis B Region wastage

rate range wastage

rate range wastage

rate range wastage

rate range

Adjara 1.42 1.38 1.86 1.69 1.45 2.96 1.85 1.30 3.13 1.30 1.17 1.86 Kakheti 1.53 1.32 1.89 1.62 1.43 2.06 2.00 1.52 2.98 1.39 1.13 1.57 Imereti 1.48 1.25 2.20 1.72 1.32 2.47 1.76 1.39 2.85 1.35 1.22 1.70 Samegerelo 1.79 1.38 2.03 2.09 1.57 2.71 2.43 1.53 3.32 2.01 1.57 2.40 Shida Kartli 1.40 1.32 1.52 1.54 1.42 1.71 1.86 1.48 2.53 1.24 1.17 1.23 Kvemo Kartli 1.46 1.04 2.11 1.61 1.38 2.17 2.01 1.52 3.25 1.33 1.19 1.48 Guria 1.74 1.53 2.18 1.53 1.42 1.77 1.93 1.87 2.06 1.37 1.34 1.75 Tbilisi 1.29 1.24 1.40 1.43 1.40 1.57 1.55 1.49 1.81 1.21 1.14 1.44 Samtskhe-Javakheti 1.87 1.58 2.53 1.82 1.40 3.14 2.57 1.48 3.90 2.01 1.60 3.39 Mtskheta-Mtianeti 2.00 1.65 2.77 1.88 1.76 2.27 2.45 1.25 3.75 1.62 1.34 2.25 Racha-Lechkhumi 2.41 1.42 3.06 2.57 1.98 3.31 4.14 2.79 5.70 3.28 1.77 4.18 Poti 1.23 1.17 1.35 1.35 1.25 1.74 1.77 1.57 1.92 1.60 1.44 1.97 Country Average 1.48 1.63 1.89 1.38

Objective 4: Introduction of new vaccines based on epidemiological and cost-benefit analysis

Suggested strategies: Feasibility assessment: Supporting implementation of the disease burden and cost-benefit analysis for introduction of the specific new vaccine antigens into NIP Resource mobilization: Based on disease burden and cost-benefit analysis, perform advocacy for resource mobilization to introduce and ensure sustainable inclusion of new vaccine antigens into NIP.


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Objective 5: Improving immunization coverage and program management capacities in conflict affected zones

Suggested strategies: NIP supply security: continuing procurement and delivery of NIP supplies (vaccines, injection safety supplies) for conflict affected zones – Abkhazia and South Ossetia with estimated birth cohort of 4,200. Co-ordination: improving co-ordination and inter-agency partnership for planning, implementation & M&E of the child vaccination programs in the conflict affected areas; Program management: Improvement of the program management capacities through institutional (cold-chain replenishments) and human (policy guidance and in-service staff training) capacity building activities. Research, M&E and reporting: 1. Supporting baseline NIP evaluation in conflict affected zones; 2. Improvement of routine M&E systems through engagement of international partners within the conflict affected areas; 3. Improvement of reporting systems on EPI coverage and program need forecasts to the national government agencies.

Figure 6: The NIP characteristics by objectives and strategies PROGRAM OBJECTIVES &

STRATEGIES EXISTING INPUTS FOR STRATEGY IMPLEMENTATION

ADDITIONAL INPUT REQUIREMENTS & PROJECTIONS

Objective 1: Improving timely immunization coverage against all 9 antigens up to 90% at the national levels and at least to 80% at all district levels throughout the country

1.1 Vaccine security • Government resources for procurement of the 40% of routine immunization supplies for 2005.

• Government commitment for sustaining financing for NIP supply component and optimization of the supply procurement systems.

• UNICEF/USAID commitment to cover 60% of routine immunization supplies for 2005.

• GAVI/VF commitment to cover Hep B vaccine and IS supplies up to 2006.

• VRF commitment to cover MMR vaccine and IS supplies up to 2006 (with probable extension to 2007).

• Securing government funds for step-wise phasing out from donor assistance in procurement of all routine antigens from 2006 and new vaccines – Hep B and MMR starting from 2007

• Technical assistance (TA) for assessment and optimization of the NIP supply procurement systems.

1.2 Program Management Capacities

• NIP policy framework brought in compliance with updated international guidance and standards.

• Unified protocols put in place at all levels of NIP implementation.

• Cold-chain equipment available at all national and sub-national levels, needs for additional cold-chain inputs identified through 2004 inventory updated per district and PHC facility levels.

• IT equipment available at all 66 district management levels for NIP/VPD surveillance. Scaling up of HIS system implementation at all district levels underway.

• Procurement of additional cold-chain equipment & supplies based on existing gaps.

• Replacement of existing cold-chain per defined annual projections for equipment devaluation.

• Continuation of the national staff training activities in policy and program administration, with focus on enforcement of policy on contraindications.

• Supporting implementation of HIS system at district management levels through CPH staff –training.


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PROGRAM OBJECTIVES & STRATEGIES

EXISTING INPUTS FOR STRATEGY IMPLEMENTATION


• Staff requirements for NIP implementation met at all levels of the program implementation.

• Staff trained in updated policy and protocol application.

1.3 Immunization Safety • QA systems in place for donor-agency procured supplies.

• GoG starting implementation of the QA systems for state funded NIP supplies in 2004.

• SIP in place, staff at all levels trained in injection safety.

• Injection safety supplies (ADs, reconstitution syringes and safety boxes) procured and distributed “bundled” to vaccines supplies to all levels of logistics management and service provision.

• Waste management practices limited to open surface burning and burial. Action plan on waste management available based on 2004 assessment.

• AEFI surveillance system in place, staff trained in the policy and system appliance.

• TA for assessment of NIP supply procurement mechanisms.

• Continuing procurement and distribution of injection safety supplies (ADs, reconstitution syringes and safety boxes) “bundled” to vaccine supplies as per annual need forecasts.

• Enforcement of ISP through staff training and improved monitoring & supervision.

• Procurement of waste management equipment (small-capacity incinerators for major cities) and putting in place cost-effective, locally tailored strategies for NIP waste management.

• Enforcement of AEFI policy through staff training and improved monitoring and surveillance.

1.4 Advocacy and communication

• High government commitment for supporting advocacy and social mobilization efforts for child immunization.

• National capacities in program communication at central and facility levels enhanced, though room for further improvement exists.

• IEC activities implemented through media campaigns and distribution of printed materials. Comprehensive communication strategy needs to be developed and implemented.

• Strong inter-agency co-ordination mechanism (ICC) established and functional since 2000 with capacity for further resource and partner mobilization for NIP.

• Securing allocation of national and external financial resources for implementation of comprehensive, target oriented IEC campaigns on annual basis

• Continuous inter-agency co-ordination and advocacy for exploring new NIP partners.

1.5 Innovative approaches • The transition of the fee-for-service based payment system (up to 2003) to baseline salary scales within PHC system has affected the staff motivation at service delivery level.

• Outreach immunization teams established in 2000 for reaching children in 25 most vulnerable districts of 7 (out of 12) regions. Outreach services were operating in 2001-2003. Following reform of PHC infrastructure set-up, outreach services discontinued work, though need for re-establishment and further expansion is evident.

• Piloting different models of NIP staff reimbursement and incentive mechanisms at PHC levels for comparative assessment of impact of payment/incentive mechanisms on the program performance.

• Advocate for resource allotment and integration of the recommended model within PHC system based on the pilot results.

• Expansion of outreach immunization services to all 12 regions and districts with special vulnerability.


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ADDITIONAL INPUT REQUIREMENTS & PROJECTIONS • Need for allocation of national

or external resources to cover operational costs of outreach services with assurance of sustainability through state program funding.

1.6 Reporting, M&E and supervision

• Quality of admin data improved with introduction of unified reporting system for NIP and VPD surveillance since 2003 (all recurrent costs currently funded through donor agency up to 2006).

• Routine monitoring and supervision system in place at central and sub-national levels.

• NIP studies and survey data available from EPI evaluations (1999), MICS (1999), injection safety (2002) & waste management assessment (2004) and cold-chain assessment (2004) reports.

• Starting from 2006 allocate state resources for sustainability of the existing HIS system for NIP and VPD surveillance (i.e. printing of recording forms & protocols, maintenance of the IT equipment).

• Continuity of monitoring and supervision systems at all levels through improving system of supervision and feedback.

• Supplementing national administrative data with findings from studies and surveys: EPI evaluation (2005-06), MICS (2005), cold-chain assessment (2008).

Objective 2: Sustaining Polio free status and continuing accelerated disease control activities for Measles, Rubella and Diphtheria

2.1 Sustained coverage • Ref.: Objective 1 • Resources secured for

implementation of SIAs activities for MMR among 13 age group in 2005-06

• Resources secured for implementing Polio SIAs among districts with


25




supervision mechanisms. Objective 4: Introduction of new vaccines based on epidemiological and economic analysis 4.1 Feasibility

assessment • No disease burden or feasibility

study undertaken for introduction of new vaccines.

• Securing financial resources and TA for feasibility study

4.2 Resource mobilization • N/A • Resource mobilization for new antigen introduction into NIP.

Objective 5: Improving immunization coverage and program management capacities in conflict affected zones

5.1 NIP supply procurement • GoG forecasts and procured NIP supplies including needs for conflict affected zones. Vaccine delivery managed through international liaison agencies.

• Securing government and external donor funding for National immunization program supplies, including forecasts for conflicted affected zones.

5.2 Co-ordination • Co-ordination with de facto authorities still limited.

• More advocacy and partners mobilization for improving liaison with de facto authorities.

5.3 Program Management Capacities

• Basic cold-chain equipment provided by GoG and donor agencies.

• Institutional and human capacities are still inadequate needing expansion of capacity building opportunities.

• Provision of additional cold-chain equipment based on the baseline evaluation data.

• Supporting local staff and management training through external TA.

5.4 Research, M&E and reporting

• No comprehensive baseline data available on NIP management capacities and performance within the conflict affected areas.

• First performance reports from conflict zones became available in 2004, though provided info is very limited and non-reliable.

• Financial and technical support for implementing EPI evaluation in Abkhazia and SO (2005).

• Inter-agency support and technical assistance for improvement of reporting and M&E systems.

Financial Sustainability Plan of the National Immunization Program of Georgia Section IV

26

SSeeccttiioonn IIVV PPaasstt and current ccoossttss ooff tthhee NNIIPP

A. Overview Having applied to the GAVI/Vaccine Fund Support in October 2001 the Government of Georgia (GoG) has received approval for all three sub-accounts of the application: 1. Financial assistance for Immunization Service Support (ISS) for 2002-06; 2. Vaccine and injection safety supplies for Hepatitis B vaccination programme (3-dose) in 2002-06, and 3. Injection safety supplies for EPI in 2003-04, with cash disbursement in lieu of supplies procured for 2001 programme. Therefore the year 2001 was considered as pre-VF year and 2003 – as VF year. The GAVI support ends in 2006.

The total cost of immunization maintained almost at the same level in the past: it was 1.04 million US$ (2.16 million GEL) in pre-VF year and it decreased slightly to 0.97 million US$ (2.09 million GEL) in 2003. The cost of routine (fixed delivery) changed even less being in a range of 0.97-0.99 million US$ (1.67-1.69 million GEL) (see Table 3 below). Detailed break down of past and current costs by categories is given in Annexes, see Table 10 (on page 49) and Table 11 (on page 50).

Table 3: Main cost parameters of the NIP in the past 2001 2002 2003 2001 2002 2003 Costs

In UD$ In GEL

Vaccines (routine) 189,194 276,10415 196,131 392,445 605,910 420,878

Routine delivery 989,858 1,034,377 972,259 1,673,856 1,882,791 1,691,321

Vaccines as % of routine 19% 27% 20% 23% 32% 25%

Total costs 1,041,026 1,359,222 972,259 2,159,400 2,982,813 2,086,371

Change in % from previous year 31% -28% 38% -30%

The cost of vaccines was almost the same in pre-VF and VF years and there share was one fifth of the total routine (fix) delivery costs (in US$) as shown in Table 3 above. The share of vaccines in the total routine cost was higher when expressed in GEL due to two facts: a) fluctuations in the exchange rate and b) all expenditures but vaccines and injection were calculated (and paid) in GEL.

B. Notes on the methodology It was difficult to fit antigens in the limited list of vaccines in data input worksheet (both for routine and SIA vaccination). ICC members encountered technical problems in entering routine mumps vaccination data into “other new/under-used vaccines” raw of the FSP tools. As the national immunization schedule does not cover Tetanus (TT) vaccination, mumps related data were entered along TT vaccine cells. There was no room to add HepB mopping up campaigns in 2001 and 2003; therefore the data was entered in route vaccination.

15 In reality it was 196 thousand US$, see explanation in Notes on the methodology and C.1.2

Supplemental immunization activities


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The past expenditures under the cost category “Other recurrent costs” determine future resource requirements. Because of that costs indicated as “other recurrent costs” in the past don’t indicate to reality – higher values were entered in the tool in purpose to produce required projected expenditures in future.

C. Description by cost categories Share of different cost categories in the past and current costs is shown in Figure 7 below. Four cost categories – vaccines, personnel (direct and shared), other routine costs and SIAs had the highest share and will be described in details below.

Figure 7: Cost profile (share in %) – calculated in US$

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2001 2002 2003

Other optional informationOther SIAsMeasles CampaignsPolio CampaignsOther capital costsCold chain equipmentVehiclesOther routine recurrent costsTransportationPersonnelInjection suppliesNew and underused vaccinesTraditional Vaccines

C.1 Vaccine costs

C.1.1 Routine vaccination

Two antigens: Hep B and Polio (OPV) accounted for more than half of the total costs on vaccines as shown in Figure 8 on page 28. However the cost profile of vaccines should be treated with caution because of factoring SIAs for Hep B in routine costs (see “Notes on the methodology” above) in 2002.


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Figure 8: Past cost of vaccines (routine) by antigens

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

Td $3,385 $2,995 $3,783

DT $4,093 $6,234 $1,656

Polio (OPV) $39,854 $50,459 $35,559

Measles $15,667 $35,142 $20,908

Mumps $- $36,894 $46,805

DTP $27,357 $31,283 $22,710

BCG $9,787 $15,699 $10,068

Hep B $89,051 $97,399 $54,642

2001 2002 2003

Mumps and measles mono vaccines together constituted one third of costs in pre-VF and VF years.

C.1.2 Supplemental immunization activities

Three antigens were used in SIAs (so called mopping up campaigns) in 2001 and 2002. The Polio and Mumps campaigns started in 2001 and ended in 2002, however the cost of Polio was entered in the latter. It would be more correct to say that the total expenditures of vaccines for Polio campaign were 150 thousand US$ and for Mumps campaign – 218 thousand US$ in years 2001-2.

As to the Hep B campaign in 2002, it is not visible in the tool (see Notes on the methodology above). Vaccines supplied by GAVI were used for routine immunization and the cost of Hep B vaccines used for the campaign was approximately 80 thousand US$ (therefore the past cost of vaccines for routine immunization in 2002 has to be adjusted by subtracting 80 thousand from 276 thousand US$ that equals to 196 thousand US$).

C.2 Personnel costs The share of personnel costs was approximately one third of the total cost of the NIP in pre-VF and VF years as shown in Table 4 below.

Table 4 Personnel cost profile 20

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