policy advising in uganda reports/acvi meeting report.pdfprosperity and welfare for the people of...

Policy Advising in Uganda:

First Meeting Report

Establishing the Advisory Committee on Vaccines and Immunization

UGANDA NATIONAL ACADEMY OF SCIENCES

Uganda National Academy of SciencesA4 Lincoln House

Makerere UniversityPO Box 23911

KampalaUganda

Tel: +256-414-53 30 44Fax: +256-414-53 30 44E-mail: [email protected]

Website: www.ugandanationalacademy.org

© Uganda National Academy of Sciences, October 2012.

ISBN: 978-9970-424-03-0

Support for this work was provided by the African Science Academy Development Initiative (ASADI) of the U.S. National Academies, Washington, DC. The Ministry of Health in Uganda also supports the mandate of the Advisory Committee on Vaccines and Immunization (ACVI).

All rights reserved. Except as otherwise permitted by written agreement, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without the prior permission of the copyright owner, the Uganda National Academy of Sciences.

Establishing the advisory committee on vaccines and immunisation

iv Policy Advising in Uganda


The Uganda National Academy of Sciences (UNAS) works to achieve improved prosperity and welfare for the people of Uganda by generating, promoting, sharing, and using scientifi c knowledge and by giving evidence-based advice to government and civil society. UNAS was founded in 2000 and was granted a Charter by His Excellency the President of Uganda in 2009. It is an honorifi c and service-oriented organization founded on principles of objectivity, scientifi c rigor, transparency, mutual respect, linkages and partnerships, independence, and the celebration of excellence.

Council

Prof. Paul E. Mugambi PresidentProf. Elly N. Sabiiti Vice-PresidentProf. Edward K. Kirumira TreasurerProf. Justin Epelu-Opio Secretary GeneralDr. Ham-Mukasa Mulira MemberProf. William B. Banage MemberProf. Patrick R. Rubaihayo MemberProf. James P. M. Ntozi MemberProf. Nyeko Pen-Mogi MemberProf. Livingstone S. Luboobi MemberProf. Julius K. Zake Member

Staff

Franklin Nsubuga-Muyonjo Ag. Executive SecretaryHarriet Nanfuma Administrative AssistantPatrick Ochapet General Support Staff


iv Policy Advising in Uganda


The Uganda National Academy of Sciences (UNAS) works to achieve improved prosperity and welfare for the people of Uganda by generating, promoting, sharing, and using scientifi c knowledge and by giving evidence-based advice to government and civil society. UNAS was founded in 2000 and was granted a Charter by His Excellency the President of Uganda in 2009. It is an honorifi c and service-oriented organization founded on principles of objectivity, scientifi c rigor, transparency, mutual respect, linkages and partnerships, independence, and the celebration of excellence.

Council

Prof. Paul E. Mugambi PresidentProf. Elly N. Sabiiti Vice-PresidentProf. Edward K. Kirumira TreasurerProf. Justin Epelu-Opio Secretary GeneralDr. Ham-Mukasa Mulira MemberProf. William B. Banage MemberProf. Patrick R. Rubaihayo MemberProf. James P. M. Ntozi MemberProf. Nyeko Pen-Mogi MemberProf. Livingstone S. Luboobi MemberProf. Julius K. Zake Member

Staff

Franklin Nsubuga-Muyonjo Ag. Executive SecretaryHarriet Nanfuma Administrative AssistantPatrick Ochapet General Support Staff


vPolicy Advising in Uganda

ADVISORY COMMITTEE ON VACCINES AND IMMUNIZATION

Nelson Sewankambo (Chair), Professor and Principal, Makerere University College of Health Sciences, Kampala

George Barnabas Kirya, (Co-Chair), Chairman, African Medical and Research Foundation (AMREF) Uganda Advisory Council, Kampala

Jesca Nsungwa-Sabiiti, Assistant Commissioner, Child Health, Ministry of Health, Kampala

Patrick Y. Kadama, Director, Policy & Strategy, African Centre for Global Health and Social Transformation (ACHEST), Kampala

Peter Waiswa, Lecturer, Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala

Diana Kizza, Health Economist, Sabin Vaccine Institute, Kampala

Sabrina Bakeera-Kitaka, Senior Lecturer, Makerere University College of Health Sciences, Kampala

Sarah Kiguli, Associate Professor and Head of Department, Paediatrics, Makerere College of Health Sciences, Kampala

Jesca Lukanga Nakavuma, Senior Lecturer, Department of Biomolecular Resources and Biolab Sciences, College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, Kampala

Roy William Mayega, Lecturer, Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala

Benson Obua-Ogwal, Hon Member of Parliament, Parliament of Uganda, Kampala

Lawrence Kaggwa, Technical Resource Person, AMREF, Kampala


vi Policy Advising in Uganda

COMMITTEE ADVISORS

Francis Omaswa, Executive Director, African Centre for Global Health and Social Transformation (ACHEST), Kampala

Emmanuel Mugisha, Country Manager, Program for Appropriate Technology in Health (PATH), Uganda

Christian N. Acemah, ASADI Director for Strategy and Program Development, Board on African Science Academy Development, Institute of Medicine, U.S. National Academies, Washington, DC


vi Policy Advising in Uganda

COMMITTEE ADVISORS

Francis Omaswa, Executive Director, African Centre for Global Health and Social Transformation (ACHEST), Kampala

Emmanuel Mugisha, Country Manager, Program for Appropriate Technology in Health (PATH), Uganda

Christian N. Acemah, ASADI Director for Strategy and Program Development, Board on African Science Academy Development, Institute of Medicine, U.S. National Academies, Washington, DC


viiPolicy Advising in Uganda

REVIEWERS

This report was reviewed in draft form by independent reviewers chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the Uganda National Academy of Sciences (UNAS) Council. The purpose of this independent review is to provide candid and critical comments to assist UNAS in making the published report as sound as possible and to ensure that the report meets institutional standards, including those for objectivity and evidence. The review comments and draft manuscript remain confi dential to protect the integrity of the deliberative process.

UNAS thanks the following individuals for their participation in the review process:

Jesca Lukanga Nakavuma, College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, Kampala, Uganda

Patrick Kelley, Institute of Medicine (IOM), U.S. National Academies, Washington, DC

Oyewale Tomori, Nigerian Academy of Science (NAS), Lagos, Nigeria

Anne Schuchat, U.S. Centers for Disease Control and Prevention (CDC)

Christian N. Acemah, Institute of Medicine, U.S. National Academies, Washington, DC


viii Policy Advising in Uganda

Preface

The vision of the Uganda National Academy of Sciences (UNAS) is improved prosperity and welfare for the people of Uganda through science. The mission of UNAS is to generate, promote, share, and use scientifi c knowledge and to give evidence-based advice to government and civil society. Fulfi llment of this mission is intended to advance Uganda’s ability to address its national development challenges by:

• engaging in a series of scientifi c activities designed to elucidate potential evidence-based solutions to pressing national and regional development-related concerns;

• enhancing the capacity of UNAS to provide relevant and useful scientifi c policy advice; and

• building Uganda’s appreciation of and demand for advice from UNAS.

UNAS is an autonomous body that brings together a diverse group of experts from all scientifi c fi elds who work together in an inter- and transdisciplinary manner to achieve their main goal of promoting excellence in science and offering independent, evidence-based advice for the prosperity of Uganda. To fulfi ll its mission, UNAS has, since its founding in 2000, used a number of advisory models that have included both convening and consensus activities to (1) highlight and elucidate issues and (2) provide recommendations for addressing these issues. The former activities have involved mainly conducting workshops where experts speak authoritatively on issues of concern, while the latter have entailed primarily convening expert committees to undertake consensus studies. A more recent model at UNAS has involved forming advisory committees, starting with the Malaria Vaccine Committee (MVC) in 2011 and then the Advisory Committee on Vaccines and Immunization (ACVI) in 2012.

The idea of convening the ACVI was fi rst discussed with diverse stakeholders in Uganda (both individuals and organizations), including the Ministry of Health; all expressed unqualifi ed support for the project. Indeed, the Ministry of Health has already written formally to UNAS to, among other things, express its support and readiness to work with the Academy on the project. This report summarizes the proceedings of the fi rst meeting of the ACVI.


viii Policy Advising in Uganda

Preface

The vision of the Uganda National Academy of Sciences (UNAS) is improved prosperity and welfare for the people of Uganda through science. The mission of UNAS is to generate, promote, share, and use scientifi c knowledge and to give evidence-based advice to government and civil society. Fulfi llment of this mission is intended to advance Uganda’s ability to address its national development challenges by:

• engaging in a series of scientifi c activities designed to elucidate potential evidence-based solutions to pressing national and regional development-related concerns;

• enhancing the capacity of UNAS to provide relevant and useful scientifi c policy advice; and

• building Uganda’s appreciation of and demand for advice from UNAS.

UNAS is an autonomous body that brings together a diverse group of experts from all scientifi c fi elds who work together in an inter- and transdisciplinary manner to achieve their main goal of promoting excellence in science and offering independent, evidence-based advice for the prosperity of Uganda. To fulfi ll its mission, UNAS has, since its founding in 2000, used a number of advisory models that have included both convening and consensus activities to (1) highlight and elucidate issues and (2) provide recommendations for addressing these issues. The former activities have involved mainly conducting workshops where experts speak authoritatively on issues of concern, while the latter have entailed primarily convening expert committees to undertake consensus studies. A more recent model at UNAS has involved forming advisory committees, starting with the Malaria Vaccine Committee (MVC) in 2011 and then the Advisory Committee on Vaccines and Immunization (ACVI) in 2012.

The idea of convening the ACVI was fi rst discussed with diverse stakeholders in Uganda (both individuals and organizations), including the Ministry of Health; all expressed unqualifi ed support for the project. Indeed, the Ministry of Health has already written formally to UNAS to, among other things, express its support and readiness to work with the Academy on the project. This report summarizes the proceedings of the fi rst meeting of the ACVI.


ixPolicy Advising in Uganda

Acknowledgments

The Uganda National Academy of Sciences (UNAS) and the Advisory Committee on Vaccines and Immunization wish to express their warmest appreciation to the individuals and organizations that contributed in various ways to the realization of the committee’s fi rst meeting.

The committee is indebted to the African Science Academy Development Initiative (ASADI) of the U.S. National Academies for providing the funding for the initial 6 months of the committee’s work. The committee also thanks UNAS staff members for their support, especially in the planning and organization of the fi rst meeting. The team that produced the draft report (Anne Muwumba and Jonathan Reich, guided by Franklin Muyonjo) is also acknowledged. Finally, special thanks go to the reviewers who volunteered their time to provide candid and critical comments to ensure that this report would be accurate, effective, and credible.

Prof. Nelson SewankamboChair, Advisory Committee on Vaccines and Immunization

Prof. Paul Edward MugambiPresident, Uganda National Academy of Sciences


x Policy Advising in Uganda

Contents

Summary…………………………………………………………………………... .............1

Committee Objectives ............................................................................................1

Key Issues in Immunization Policy .........................................................................1

Path Forward..........................................................................................................2

1 Introduction ............................................................................................................3

2 Formation of the Committee...................................................................................3

3 The Committee’s First Meeting ..............................................................................4

4 Committee Objectives ............................................................................................4

5 The Immunization Vision for Uganda .....................................................................5

6 Key Challenges in Immunization ............................................................................5

Coverage and Immunization Performance.............................................................5

Governance of Vaccines and Immunization Practice .............................................7

Budgeting and Financing .......................................................................................9

7 Path Forward........................................................................................................10

References ................................................................................................................11

Annex 1: List of Participants .....................................................................................12

Annex 2: Meeting Agenda ........................................................................................13

Annex 3: Uganda Immunization Schedule ..............................................................15


x Policy Advising in Uganda

Contents

Summary…………………………………………………………………………... .............1

Committee Objectives ............................................................................................1

Key Issues in Immunization Policy .........................................................................1

Path Forward..........................................................................................................2

1 Introduction ............................................................................................................3

2 Formation of the Committee...................................................................................3

3 The Committee’s First Meeting ..............................................................................4

4 Committee Objectives ............................................................................................4

5 The Immunization Vision for Uganda .....................................................................5

6 Key Challenges in Immunization ............................................................................5

Coverage and Immunization Performance.............................................................5

Governance of Vaccines and Immunization Practice .............................................7

Budgeting and Financing .......................................................................................9

7 Path Forward........................................................................................................10

References ................................................................................................................11

Annex 1: List of Participants .....................................................................................12

Annex 2: Meeting Agenda ........................................................................................13

Annex 3: Uganda Immunization Schedule ..............................................................15


xiPolicy Advising in Uganda

List of Boxes and Figures

BOX 1 Vaccine-Preventable Diseases ................................................................5

FIGURE 1 Immunization Coverage Trend in Uganda between 2000 and 2010 .......6

FIGURE 2 Government and Partnership Coordination of Health Service Delivery

for the Immunization Programme in Uganda ..........................................8

FIGURE 3 Concept of a Co-fi nancing Programmme ................................................9


xii Policy Advising in Uganda

List of Acronyms

ACVI Advisory Committee on Vaccines and Immunization

ASADI African Science Academy Development Initiative

DTP3 Diphtheria-Tetanus-Pertussis (vaccine)

EPI Expanded Programme on Immunization

GAVI Global Alliance for Vaccines and Immunization

HPV Human Papilloma Virus

IOM Institute of Medicine

IPD Invasive Pneumococcal Disease

MCV Measles Childhood Vaccine

MVC Malaria Vaccines Committee

MDG Millennium Development Goal

NAS Nigerian Academy of Science

NITAG National Immunization Technical Advisory Group

OPV3 Oral Poliovirus Vaccine

PATH Program for Appropriate Technology in Health

PCV Pneumococcal Conjugate Vaccine PHC Primary Health Care

TT2 Tetanus Toxoid (vaccine)

UNAS Uganda National Academy of Sciences

UNEPI Uganda National Expanded Programme on Immunization

UNICEF United Nations Children’s Fund

WHO World Health Organisation

WHO-AFRO World Health Organisation Regional Offi ce for Africa


xii Policy Advising in Uganda

List of Acronyms

ACVI Advisory Committee on Vaccines and Immunization

ASADI African Science Academy Development Initiative

DTP3 Diphtheria-Tetanus-Pertussis (vaccine)

EPI Expanded Programme on Immunization

GAVI Global Alliance for Vaccines and Immunization

HPV Human Papilloma Virus

IOM Institute of Medicine

IPD Invasive Pneumococcal Disease

MCV Measles Childhood Vaccine

MVC Malaria Vaccines Committee

MDG Millennium Development Goal

NAS Nigerian Academy of Science

NITAG National Immunization Technical Advisory Group

OPV3 Oral Poliovirus Vaccine

PATH Program for Appropriate Technology in Health

PCV Pneumococcal Conjugate Vaccine PHC Primary Health Care

TT2 Tetanus Toxoid (vaccine)

UNAS Uganda National Academy of Sciences

UNEPI Uganda National Expanded Programme on Immunization

UNICEF United Nations Children’s Fund

WHO World Health Organisation

WHO-AFRO World Health Organisation Regional Offi ce for Africa


1Policy Advising in Uganda

Summary

In order to ensure evidence-based advice on routine immunization and in order to facilitate the effi cient introduction of new vaccines (such as those for malaria, pneumococcal disease, and rotavirus) in Uganda, the Ministry of Health and Uganda National Academy of Sciences (UNAS) agreed on the need to establish an independent advisory committee that would make evidence-based policy recommendations on these issues to the ministry. To this end, the Advisory Committee on Vaccines and Immunization (ACVI), comprising 12 nonpartisan experts, was formed. Its main goal is to advise on routine immunization and the introduction of new and underutilized vaccines. The committee held its fi rst meeting on 11 July 2012 to discuss its objectives and plan its future work.

COMMITTEE OBJECTIVES

The ACVI has three main objectives:

• Policy guidance: Provide the Ministry of Health with apolitical policy advice based on credible scientifi c evidence.

• Context-specifi c prioritization: Provide the Ministry of Health with recommendations on vaccine priorities, including new and underutilized vaccines.

• Forward thinking: Track the progress of vaccines and immunization practice throughout Uganda and internationally to better advise on planning for Uganda’s future needs.

KEY ISSUES IN IMMUNIZATION POLICY

The committee identifi ed several important issues that must be addressed in the development of a good vaccine and immunization policy for Uganda:

• Coverage: Are the vaccines routine, new, or underutilized? What training and/or infrastructure is required to administer the vaccines?

• Governance: Which authority or authorities will create and oversee immunization programs?

• Financing: How will the vaccine and immunization programs be fi nanced?


2 Policy Advising in Uganda

PATH FORWARD

The committee recognized and agreed that a more comprehensive understanding of the vaccine and immunization status of Uganda was necessary before it could formulate policy advice. Accordingly, it was decided that the UNAS Secretariat would enlist the help of a consultant to provide in-depth reviews in the following areas:

• current governance arrangements, policies, and strategies for vaccines and immunizations in Uganda;

• coverage trends of routine immunization in Uganda;

• fi nancing options; and

• the country’s management capacity for immunization programs.



PATH FORWARD

The committee recognized and agreed that a more comprehensive understanding of the vaccine and immunization status of Uganda was necessary before it could formulate policy advice. Accordingly, it was decided that the UNAS Secretariat would enlist the help of a consultant to provide in-depth reviews in the following areas:

• current governance arrangements, policies, and strategies for vaccines and immunizations in Uganda;

• coverage trends of routine immunization in Uganda;

• fi nancing options; and

• the country’s management capacity for immunization programs.



1. INTRODUCTION

With support from the Malaria Vaccine Initiative (MVI) of the Program for Appropriate Technology in Health (PATH), the Uganda National Academy of Sciences (UNAS) formed its multidisciplinary, independent Malaria Vaccines Committee in April 2011 to provide evidence-based policy advice to the government and the public on how best to plan for the possible introduction of a malaria vaccine in Uganda. The committee’s work is focused on decreasing the time between licensure and introduction of a vaccine and having effective (human) programs effi ciently delivered throughout the country.

Because the introduction of new vaccines (such as those for malaria, pneumococcal disease, and rotavirus) depends on having policies, strategies, and plans in place for vaccines and immunization practices, UNAS and the Ministry of Health agreed on the need to establish an independent Advisory Committee on Vaccines and Immunization (ACVI). This committee would provide evidence-based advice on vaccines and immunization practices in Uganda. The committee’s main goal is to advise on routine immunization and the introduction and delivery of new and underutilized vaccines. The initial focus will, however, be on routine immunization since the introduction of new and underutilized vaccines depends on the strength of the existing policies, governance, processes, procedures, and fi nancing issues related to routine immunization. The decision to form this committee should be viewed in the context of the fi rst strategic objective of the Global Vaccine Action Plan, which calls for the establishment of national immunization technical advisory groups (NITAGs) to reduce dependence on external bodies for policy guidance (WHO, 2012b).

The UNAS ACVI, chaired by Professor Nelson Sewankambo, Fellow of UNAS, has the mandate of advising the Government of Uganda and the general public on the following: (1) the effective use of vaccines to control vaccine-preventable diseases, (2) the introduction of vaccines, (3) means of strengthening Uganda’s health system to better deliver life-saving vaccines, and (4) any other issues related to immunization.

2. FORMATION OF THE COMMITTEE

Before convening the ACVI for its fi rst meeting, UNAS developed a proposed slate of committee members indicating areas of expertise that were critical to the committee’s viability and suitability and to the execution of its mandate. Individuals in these areas were then identifi ed as potential committee members. Before the committee’s formal establishment and launch, these potential members underwent a bias and confl ict-of-interest review by UNAS. This review was intended to ensure that no one on the committee would have intractable biases or stand to benefi t fi nancially or otherwise from the committee’s future recommendations. This process is crucial for the creation of a balanced, impartial academic committee, especially if the committee is meant to generate objective policy recommendations.

Before the committee could initiate its work, therefore, potential members were asked to disclose any biases or declare any potential confl icts of interest. They were then informed that they had been identifi ed and elected because of their individual expertise and merit and that they would serve as individuals, not as representatives of the institutions with which they were affi liated. They would also serve on a voluntary basis.



3. THE COMMITTEE’S FIRST MEETING

At the committee’s fi rst meeting, it was deemed necessary for the members to be briefed on the current state of vaccines and immunization in Uganda before deciding on a path forward. To this end, the committee heard the following presentations and key points:

• Committee Considerations—Global/Regional (African Union [AU])/National) (Sabrina Bakeera Kitaka, Christian N. Acemah): This is the decade of vaccines, and Uganda needs to own the Global Vaccine Action Plan. The launch of the ACVI is therefore timely.

• Status of Vaccines and Immunization in Uganda (Jesca Nsungwa-Sabiiti): Vaccine and immunization coverage in Uganda has declined. Funding for immunization programmes needs to be increased and sustained, and immunization data management needs to improve.

• Role of International Organizations (Diana K. Mugenzi): International organizations are supporting developing countries by fi nancing vaccine and immunization programmes and providing recommendations on policy and regulations on the use of vaccines.

• Current Hot Topics in Immunization (Patrick Y. Kadama, Francis Omaswa): While Uganda has a clear governance and coordination structure for health service delivery, performance on routine immunization has declined. In this context, it is necessary to have a sustainable immunization fi nancing system, strengthen health systems, and restart dialogue on the country’s vaccine and immunization policy.

4. COMMITTEE OBJECTIVES

The following are the ACVI’s specifi c objectives:

• Policy guidance: The committee will provide independent, evidence-based advice to the Ministry of Health and the nation by conducting both convening and consensus activities. Examples of the former activities include policy makers’ dialogues, media roundtables, and workshops, while examples of the latter include closed committee meetings to analyze evidence as the basis for formulating policy recommendations. These activities will support Uganda in adopting apolitical, trustworthy, scientifi cally rigorous policies on vaccines and immunization based on credible evidence and on the consensus of a multidisciplinary expert committee.

• Context-specifi c prioritization: The committee will analyze the evidence with respect to routine vaccination as the basis for its recommendations on Uganda’s vaccine utilization priorities. While the focus will be on routine vaccination, the committee will also consider new and underutilized vaccines.

• Forward thinking: By tracking national, regional, and international innovations in vaccines and immunization practice, the committee will help ensure that the immunization program in Uganda is effective and effi cient for decades into the future. These innovations will be adapted to suit the Ugandan context.



3. THE COMMITTEE’S FIRST MEETING

At the committee’s fi rst meeting, it was deemed necessary for the members to be briefed on the current state of vaccines and immunization in Uganda before deciding on a path forward. To this end, the committee heard the following presentations and key points:

• Committee Considerations—Global/Regional (African Union [AU])/National) (Sabrina Bakeera Kitaka, Christian N. Acemah): This is the decade of vaccines, and Uganda needs to own the Global Vaccine Action Plan. The launch of the ACVI is therefore timely.

• Status of Vaccines and Immunization in Uganda (Jesca Nsungwa-Sabiiti): Vaccine and immunization coverage in Uganda has declined. Funding for immunization programmes needs to be increased and sustained, and immunization data management needs to improve.

• Role of International Organizations (Diana K. Mugenzi): International organizations are supporting developing countries by fi nancing vaccine and immunization programmes and providing recommendations on policy and regulations on the use of vaccines.

• Current Hot Topics in Immunization (Patrick Y. Kadama, Francis Omaswa): While Uganda has a clear governance and coordination structure for health service delivery, performance on routine immunization has declined. In this context, it is necessary to have a sustainable immunization fi nancing system, strengthen health systems, and restart dialogue on the country’s vaccine and immunization policy.

4. COMMITTEE OBJECTIVES

The following are the ACVI’s specifi c objectives:

• Policy guidance: The committee will provide independent, evidence-based advice to the Ministry of Health and the nation by conducting both convening and consensus activities. Examples of the former activities include policy makers’ dialogues, media roundtables, and workshops, while examples of the latter include closed committee meetings to analyze evidence as the basis for formulating policy recommendations. These activities will support Uganda in adopting apolitical, trustworthy, scientifi cally rigorous policies on vaccines and immunization based on credible evidence and on the consensus of a multidisciplinary expert committee.

• Context-specifi c prioritization: The committee will analyze the evidence with respect to routine vaccination as the basis for its recommendations on Uganda’s vaccine utilization priorities. While the focus will be on routine vaccination, the committee will also consider new and underutilized vaccines.

• Forward thinking: By tracking national, regional, and international innovations in vaccines and immunization practice, the committee will help ensure that the immunization program in Uganda is effective and effi cient for decades into the future. These innovations will be adapted to suit the Ugandan context.



5. THE IMMUNIZATION VISION FOR UGANDA

Immunization is crucial for the strengthening of any country’s health system, as well as for attaining the Millennium Development Goals (MDGs), particularly those related to health (MDGs 4, 5, and 6) (WHO, 2005). In line with the global Decade of Vaccines vision, the committee believes Uganda’s goal should be for every child, adolescent, and adult to have equal and equitable access to vaccines and immunization services (Decade of Vaccines Collaboration, 2012). Equal and equitable access will ensure that more people are protected against more vaccine-preventable diseases (see Box 1) and that vaccines are put to their best use in improving health (GAVI, 2011).

BOX 1Vaccine-Preventable Diseases

• Anthrax• Cholera• Diphtheria• Hepatitis A• Hepatitis B• Hepatitis E• Haemophilus infl uenza type b• Human papillomavirus• Japanese encephalitis

• Measles• Meningococcal disease• Mumps• Pertussis• Pneumococcal disease• Poliomyelitis• Rabies• Rotavirus gastroenteritis

• Rubella• Infl uenza• Tetanus• Tuberculosis• Typhoid fever• Tick-born encephalitis• Varicella and herpes

zoster (shingles)• Yellow fever

SOURCE: Decade of Vaccines Collaboration, 2012.

To achieve this goal, the immunization program in Uganda needs to have three major areas of focus: (1) strengthening routine immunization, (2) conducting supplemental immunization activities, and (3) sustaining a sensitive disease surveillance system (WHO-UNICEF, 2011a).

6. KEY CHALLENGES IN IMMUNIZATION

Key challenges in immunization in Uganda include inadequate coverage and immunization performance, governance of vaccines and immunization practice, and budgeting and fi nancing.

Coverage and Immunization Performance

Population coverage for immunization against vaccine-preventable diseases falls into three categories: (1) traditional or routine vaccines, (2) new and underutilized vaccines, and (3) future vaccines. Between 2009 and 2010, Uganda’s immunization performance showed a decline (see Figure 1), which led to an increasing number of under- and unimmunized children. Immunization performance in Uganda varies among districts, and the proportion of districts achieving the set targets for routine immunization and surveillance has not reached required certifi cation levels (WHO-UNICEF, 2011b).



FIGURE 1 Immunization coverage trend in Uganda between 2000 and 2010. NOTE: The bright red line represents the target coverage percentage (80 percent) for the diphtheria-tetanus-pertussis (DPT3), polio 3, measles, and tetanus toxoid (TT2)+pregnant immunizations. Note the decline in coverage of all four vaccines between 2009 and 2010. SOURCE: WHO-UNICEF, 2011b.

Routine Immunization

Routine immunization is the basis of the immunization program in Uganda. The aim is to attain 80 percent diphtheria-tetanus-pertussis (DTP3) coverage, eliminate measles by maintaining measles childhood vaccine (MCV) coverage at 95 percent, and eliminate polio through four oral poliovirus vaccine types (OPV0, OPV1, OPV2, and OPV3). According to the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO), however, in 2010 Uganda was among the lowest-ranked African countries in coverage of these three vaccines, at 60 percent for DTP3 and 55 percent for both MCV and the third dose of poliovirus vaccine (WHO-UNICEF, 2012).

• Measles: Uganda has a high burden of disease due to measles. The recent outbreak of measles highlights the urgency of securing the crucial political support and dedicated funding needed to improve routine immunization coverage with two doses of measles vaccine, carry out supplementary immunization activities, and maintain high-quality laboratory-supported surveillance (WHO, 2010).



FIGURE 1 Immunization coverage trend in Uganda between 2000 and 2010. NOTE: The bright red line represents the target coverage percentage (80 percent) for the diphtheria-tetanus-pertussis (DPT3), polio 3, measles, and tetanus toxoid (TT2)+pregnant immunizations. Note the decline in coverage of all four vaccines between 2009 and 2010. SOURCE: WHO-UNICEF, 2011b.

Routine Immunization

Routine immunization is the basis of the immunization program in Uganda. The aim is to attain 80 percent diphtheria-tetanus-pertussis (DTP3) coverage, eliminate measles by maintaining measles childhood vaccine (MCV) coverage at 95 percent, and eliminate polio through four oral poliovirus vaccine types (OPV0, OPV1, OPV2, and OPV3). According to the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO), however, in 2010 Uganda was among the lowest-ranked African countries in coverage of these three vaccines, at 60 percent for DTP3 and 55 percent for both MCV and the third dose of poliovirus vaccine (WHO-UNICEF, 2012).

• Measles: Uganda has a high burden of disease due to measles. The recent outbreak of measles highlights the urgency of securing the crucial political support and dedicated funding needed to improve routine immunization coverage with two doses of measles vaccine, carry out supplementary immunization activities, and maintain high-quality laboratory-supported surveillance (WHO, 2010).



• Polio: The wild poliovirus outbreaks of 2009 and 2010 were a clear indication of a gap in population immunity due to under- and unimmunized children (WHO-UNICEF, 2011b). Among African countries, Uganda has the highest number of children that have not received their fi rst dose of oral poliovirus vaccine, and 43 percent of districts have an OPV3 coverage of less than 80 percent (WHO, 2012c).

As a result, immunization is high on the agenda of the Parliament of Uganda, which is in the process of forming a Uganda Parliamentary Forum on Immunization (McQuestion, 2012).

Introduction of New Vaccines

Currently, Uganda is facing a high disease burden as a result of invasive pneumococcal disease and severe diarrheal disease due to rotavirus, as well as high associated medical costs (WHO-UNICEF, 2011b). The Global Alliance for Vaccines and Immunization (GAVI) is supporting the introduction of three new vaccines in Uganda: the pneumococcal vaccine (PCV), the rotavirus vaccine, and the human papillomavirus (HPV) vaccine. With approval from GAVI, Uganda will be introducing the pneumococcal vaccine to the public in 2013 (GAVI Alliance, 2012b).

Governance of Vaccines and Immunization Practice

At the global level, the decisions made on what vaccines Uganda administers are based on advice from the WHO Executive Board and the World Health Assembly. At the regional level, the WHO Regional Offi ce for Africa (WHO-AFRO) advises on these decisions. At the country level, there is a clear government and partnership coordinating body on the governance of vaccines and immunization practice in Uganda (see Figure 2).

Guidance on coordination and governance is provided through three structures: the management structure, which guides the internal coordination for the Ministry of Health; the governance structure, which works to defi ne the guiding strategic direction and follows up on the operation of interventions; and the partnership structure, which guides external coordination of service delivery by all stakeholders at the respective levels of care (Uganda Ministry of Health, 2010).



FIGURE 2 Government and partnership coordination of health service delivery for the immunization programme in Uganda. NOTES: Note the presence of the Health Policy Advisory Committee (HPAC), the main body involved in coordinating the health sector. Specifi cally, HPAC is a donor/stakeholder coordination mechanism that works through established technical working groups; provides a forum for sharing information and experience; and approves the work plans, budget, and other project expenditures for the health sector.CSO = civil society organisation; DGHS = Director General of Health Services; DHMT = District Health Management Team; HDP = health development partner; HSD = Health Subdistrict; LG = local government; MoH = Ministry of Health; OPM = Offi ce of the Prime Minister; PS = Permanent Secretary; S/C = subcounty; VHT = village health team.SOURCE: Uganda Ministry of Health, 2010.

Ê

7Ê

ÊÊÊÊ

Ê

Ê

FIGURE 2 Government and partnership coordination of health service delivery for the immunization programme in Uganda. NOTES: Note the presence of the Health Policy Advisory Committee (HPAC), the main body involved in coordinating the health sector. Specifically, HPAC is a donor/stakeholder coordination mechanism that works through established technical working groups; provides a forum for sharing information and experience; and approves the work plans, budget, and other project expenditures for the health sector. CSO = civil society organisation; DGHS = Director General of Health Services; DHMT = District Health Management Team; HDP = health development partner; HSD = Health Subdistrict; LG = local government; MoH = Ministry of Health; OPM = Office of the Prime Minister; PS = Permanent Secretary; S/C = subcounty; VHT = village health team. SOURCE: Uganda Ministry of Health, 2010.

1. Strategic policy direction

2. Operational policy direction

3. Technical direction

4. Regional coordination

5. District coordination

6. HSD coordination

7. Facility coordination

8. Community coordination

Roles Structure Members (Government and Partners)

Cabinet/Parliament

Top Management Committee

Health Policy Advisory Committee

Senior Management Committee

Regional Stakeholders Fora

District Stakeholders Fora

Health Subdistrict Stakeholders Fora

Subcounty Stakeholders Fora

Technical Working Groups (TWGs)

Village Health Teams

OPM, Minister of Health, Ministers of State and PS of Health,

Parliamentary Committees

PS’s and DGHS Office (Chair), Directorates and Departments

PS’s (Chair), Directorate and Department Heads,

HDP Representatives, Private-Sector and CSO Representatives

DGHS (Chair) Heads of Departments and Divisions

MoH Departments, HDP Representatives, Private-Sector and

CSO Representatives

LG Public and Non-Public-Sector Representatives

DHMT, HSD, S/C Representatives

S/C and Parish RepresentativesÊ

VHTs

HSD and S/C RepresentativesÊ



FIGURE 2 Government and partnership coordination of health service delivery for the immunization programme in Uganda. NOTES: Note the presence of the Health Policy Advisory Committee (HPAC), the main body involved in coordinating the health sector. Specifi cally, HPAC is a donor/stakeholder coordination mechanism that works through established technical working groups; provides a forum for sharing information and experience; and approves the work plans, budget, and other project expenditures for the health sector.CSO = civil society organisation; DGHS = Director General of Health Services; DHMT = District Health Management Team; HDP = health development partner; HSD = Health Subdistrict; LG = local government; MoH = Ministry of Health; OPM = Offi ce of the Prime Minister; PS = Permanent Secretary; S/C = subcounty; VHT = village health team.SOURCE: Uganda Ministry of Health, 2010.

Ê

7Ê

ÊÊÊÊ

Ê

Ê

FIGURE 2 Government and partnership coordination of health service delivery for the immunization programme in Uganda. NOTES: Note the presence of the Health Policy Advisory Committee (HPAC), the main body involved in coordinating the health sector. Specifically, HPAC is a donor/stakeholder coordination mechanism that works through established technical working groups; provides a forum for sharing information and experience; and approves the work plans, budget, and other project expenditures for the health sector. CSO = civil society organisation; DGHS = Director General of Health Services; DHMT = District Health Management Team; HDP = health development partner; HSD = Health Subdistrict; LG = local government; MoH = Ministry of Health; OPM = Office of the Prime Minister; PS = Permanent Secretary; S/C = subcounty; VHT = village health team. SOURCE: Uganda Ministry of Health, 2010.

1. Strategic policy direction

2. Operational policy direction

3. Technical direction

4. Regional coordination

5. District coordination

6. HSD coordination

7. Facility coordination

8. Community coordination

Roles Structure Members (Government and Partners)

Cabinet/Parliament

Top Management Committee

Health Policy Advisory Committee

Senior Management Committee

Regional Stakeholders Fora

District Stakeholders Fora

Health Subdistrict Stakeholders Fora

Subcounty Stakeholders Fora

Technical Working Groups (TWGs)

Village Health Teams

OPM, Minister of Health, Ministers of State and PS of Health,

Parliamentary Committees

PS’s and DGHS Office (Chair), Directorates and Departments

PS’s (Chair), Directorate and Department Heads,

HDP Representatives, Private-Sector and CSO Representatives

DGHS (Chair) Heads of Departments and Divisions

MoH Departments, HDP Representatives, Private-Sector and

CSO Representatives

LG Public and Non-Public-Sector Representatives

DHMT, HSD, S/C Representatives

S/C and Parish RepresentativesÊ

VHTs

HSD and S/C RepresentativesÊ



Budgeting and Financing

Immunization fi nancing in Uganda depends on external donations (WHO-UNICEF, 2011b). In the past, Uganda had a national fund for vaccines and immunization, but that fund is now defunct. According to fi nancial projections, Uganda may need at least US$100 million by 2014 to sustain its immunization program (GAVI Alliance, 2012a).

Financing for vaccines and immunization in Uganda could be provided by public-private partnerships through such organisations as GAVI. GAVI offers co-fi nancing programs whereby the governments of developing countries are required to contribute a certain fraction of the cost of vaccines or immunizations, and GAVI covers the rest of the cost (see Figure 3).

FIGURE 3 Concept of a co-fi nancing program. NOTE: An organization such as the Global Alliance for Vaccines and Immunization (GAVI) could pilot an International Finance Facility Fund, which would raise funds from government and private donors. These funds would then be distributed to help developing countries pay for vaccines and immunizations. SOURCE: Center for Global Development, 2005.

Poliovirus vaccine stockpile

Health systems strengthening

Advance contracts for new vaccines available soon (for example, rotavirus and

pneumococcal disease)

Advance contracts to buy new vaccines (for example, HIV, malaria, tuberculosis)

International Finance Facility

Fund

Capital markets

Donor Donor



Funding from the Government of Uganda for the Uganda National Expanded Programme on Immunization has remained static for the past 5 years, and primary health care (PHC) funding is inadequate and irregular (WHO-UNICEF, 2011b). Routine funding for immunization is available through PHC conditional grants to the districts, but this funding is often delayed, which affects the implementation of activities (WHO-UNICEF, 2011b).

7. PATH FORWARDAfter listening to the expert testimony summarized above, the committee was

concerned about the current state of Uganda’s immunization system. Members agreed that they needed more information before developing policy suggestions, and therefore decided to hire a consultant to undertake a quick but systematic review of the current status of vaccines and immunization practice in Uganda. The consultant’s main role will be to gather data that the committee will then analyze and synthesize to arrive at an evidence-based position. The UNAS Secretariat will develop the terms of reference for the consultant, and was also asked to formulate a work plan for the committee in close collaboration with the committee chair.

Finally, the committee decided that for its work to have impact, the following will be necessary:

• The Ministry of Health should be given regular updates on the committee’s work.• The committee should work with greater determination and focus on ensuring that

rigorous academy processes are followed.• Committee reports should be disseminated widely (to ministries, Parliament,

development partners, district medical offi cers, and professional associations).• The committee should encourage renewal of the process of public discussion and

decision making on vaccines and immunization in Uganda by hosting focused media roundtables and policy dialogues.



Funding from the Government of Uganda for the Uganda National Expanded Programme on Immunization has remained static for the past 5 years, and primary health care (PHC) funding is inadequate and irregular (WHO-UNICEF, 2011b). Routine funding for immunization is available through PHC conditional grants to the districts, but this funding is often delayed, which affects the implementation of activities (WHO-UNICEF, 2011b).

7. PATH FORWARDAfter listening to the expert testimony summarized above, the committee was

concerned about the current state of Uganda’s immunization system. Members agreed that they needed more information before developing policy suggestions, and therefore decided to hire a consultant to undertake a quick but systematic review of the current status of vaccines and immunization practice in Uganda. The consultant’s main role will be to gather data that the committee will then analyze and synthesize to arrive at an evidence-based position. The UNAS Secretariat will develop the terms of reference for the consultant, and was also asked to formulate a work plan for the committee in close collaboration with the committee chair.

Finally, the committee decided that for its work to have impact, the following will be necessary:

• The Ministry of Health should be given regular updates on the committee’s work.• The committee should work with greater determination and focus on ensuring that

rigorous academy processes are followed.• Committee reports should be disseminated widely (to ministries, Parliament,

development partners, district medical offi cers, and professional associations).• The committee should encourage renewal of the process of public discussion and

decision making on vaccines and immunization in Uganda by hosting focused media roundtables and policy dialogues.



REFERENCES

Center for Global Development. 2005. Making markets for vaccines: Ideas to action. http://www.cgdev.org/doc/books/vaccine/MakingMarkets-complete.pdf (accessed September 14, 2012).

Decade of Vaccines Collaboration. 2012. Draft 4 of the Global Vaccination Action Plan. http://www.who.int/immunization/sage/meetings/2012/february/GVAP_Draft_March_2012.pdf (accessed September 14, 2012).

GAVI (Global Alliance for Vaccines and Immunization. 2011. Gender and immunization factsheet. http://www.gavialliance.org/about/mission/gender/ (accessed September 14, 2012).

GAVI Alliance. 2012a. Guidelines for applications: New and underused vaccines support. http://www.gavialliance.org/support/nvs/ (accessed September 14, 2012).

GAVI Alliance. 2012b. Report to the GAVI Alliance Board (June 12-13). http://www.gavialliance.org/about/governance/gavi-board/minutes/2012/12-june/ (accessed September 14, 2012).

McQuestion, M. 2012. Uganda Parliament Forms Core Immunization Group. http://www.sabin.org/blog/uganda-parliament-forms-core-immunization-group (accessed September 14, 2012).Uganda Ministry of Health. 2010. Health sector strategic & investment plan (2010/11–2014/15). http://www.kampala.cooperazione.esteri.it/utlkampala/Download/HSSIP%20Final.pdf (accessed September 14, 2012).

WHO (World Health Organization). (2005). Health and the millennium development goals. www.who.int/hdp/publications/mdg_en.pdf (accessed September 14, 2012).

WHO. 2010. Global immunization vision and strategy. http://apps.who.int/gb/ebwha/pdf_fi les/EB128/B128_9-en.pdf (accessed September 14, 2012).

WHO. 2012a. Strengthening routine immunization in Uganda. Global Immunization News.

WHO. 2012b. Global vaccine action plan. http://apps.who.int/gb/ebwha/pdf_fi les/WHA65/A65_22-en.pdf (accessed September 14, 2012).

WHO. 2012c. Immunization profi le—Uganda. http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofi leresult.cfm?C=uga (accessed September 14, 2012).

WHO-UNICEF (United Nations Children’s Fund). 2011a. Uganda national expanded programme on immunization multi year plan 2010-2014. ftp://iff-immunisation.org/Monitoring%20IRC%20July%202012/IRC%20review%20docs/UGA/APR%20&%20background%20documents/new%20cMYP%20APR%202011%20-%201%20-%20EN.pdf (accessed September 14, 2012).

WHO-UNICEF. 2011b. Uganda national expanded programme on immunization multi year plan 2012-2016. ftp://iff-immunisation.org/Monitoring%20IRC%20July%202012/IRC%20review%20docs/UGA/APR%20&%20background%20documents/Other%20-%20UGANDA%20EPI%20cMYP%202012-2016%20-%201%20-%20EN.pdf (accessed September 14, 2012).

WHO-UNICEF. 2012. Immunization summary: A statistical reference containing data through 2010. http://www.childinfo.org/fi les/immunization_summary_en.pdf (accessed September 14, 2012).



Annex 1List of Participants

MEETING OF THE ADVISORY COMMITTEE ON VACCINES AND IMMUNIZATION(11 JULY 2012)

Nelson K. SewankamboCollege of Health SciencesMakerere UniversityPaul E. MugambiUganda National Academy of SciencesJ. Epelu-OpioUganda National Academy of SciencesSabrina B. KitakaCollege of Health SciencesMakerere UniversityGeorge B. KiryaAdvocates for Professionalism and Quality in Health (APROQUAH)Jesca Nsungwa-SabiitiMinistry of Health, Kampala Peter WaiswaSchool of Public HealthMakerere UniversityRoy William MayegaSchool of Public HealthMakerere UniversityDiana K. MugenziSabin Vaccine InstituteSarah KiguliCollege of Health SciencesMakerere UniversityLawrence KaggwaAfrican Medical and Research Foundation, KampalaJesca L. NakavumaCollege of Veterinary MedicineMakerere University, Kampala Benson Obua-OgwalParliament of UgandaPatrick KadamaAfrican Centre for Global Health and Social Transformation, KampalaFrancis OmaswaAfrican Centre for Global Health and Social Transformation, Kampala Christian N. AcemahInstitute of Medicine, U.S. National AcademiesFranklin Nsubuga-MuyonjoUganda National Academy of SciencesPatrick OchapetUganda National Academy of Sciences



Annex 1List of Participants

MEETING OF THE ADVISORY COMMITTEE ON VACCINES AND IMMUNIZATION(11 JULY 2012)

Nelson K. SewankamboCollege of Health SciencesMakerere UniversityPaul E. MugambiUganda National Academy of SciencesJ. Epelu-OpioUganda National Academy of SciencesSabrina B. KitakaCollege of Health SciencesMakerere UniversityGeorge B. KiryaAdvocates for Professionalism and Quality in Health (APROQUAH)Jesca Nsungwa-SabiitiMinistry of Health, Kampala Peter WaiswaSchool of Public HealthMakerere UniversityRoy William MayegaSchool of Public HealthMakerere UniversityDiana K. MugenziSabin Vaccine InstituteSarah KiguliCollege of Health SciencesMakerere UniversityLawrence KaggwaAfrican Medical and Research Foundation, KampalaJesca L. NakavumaCollege of Veterinary MedicineMakerere University, Kampala Benson Obua-OgwalParliament of UgandaPatrick KadamaAfrican Centre for Global Health and Social Transformation, KampalaFrancis OmaswaAfrican Centre for Global Health and Social Transformation, Kampala Christian N. AcemahInstitute of Medicine, U.S. National AcademiesFranklin Nsubuga-MuyonjoUganda National Academy of SciencesPatrick OchapetUganda National Academy of Sciences



Annex 2Meeting Agenda


Meeting Agenda 11 July 2012

ADVISORY COMMITTEE ON VACCINES AND IMMUNIZATION

First Meeting

Kabira Country Club, Kampala

AGENDA

Opening: J. Epelu-Opio (Uganda National Academy of Sciences [UNAS]) and Nelson Sewankambo (UNAS)

SESSION 1: OPEN

08H30–09H00: Registration

09H00–09H05: Self-Introductions

09H05–09H10: Opening Remarks PE Mugambi, PresidentUNAS

09H10–09H30: The Role of Science Academies: An Overview Franklin Muyonjo

UNAS

09H30 -09H50: The Nature of Advisory CommitteesChristian N. AcemahInstitute of Medicine, U.S. National Academies

09H50–10H00: DISCUSSION

10H00–10H30: TEA/COFFEE BREAK



SESSION 2: CLOSED

10H30–11H0O: Rationale for the Committee

Nelson Sewankambo, Chair

Advisory Committee on Vaccines and Immunization (ACVI)

Fellow of UNAS

11H00–11H30: Bias and Confl ict of Interest Discussion

Franklin Muyonjo

UNAS

11H30-12H00: Committee Considerations (Global/Regional [African Union]/National)

Sabrina Bakeera-Kitaka

College of Health Sciences

Christian N. Acemah

Institute of Medicine, U.S. National Academies

12H00–12H30: The Status of Vaccines and Immunization in UgandaJesca Nsungwa-Sabiiti

Ministry of Health

12H30–13H00: The Role of International OrganizationsDiana KizzaSabin Vaccine Institute

13H00–14H00: LUNCH BREAK

14h00–14H30: Current Hot Topics in ImmunizationFrancis OmaswaPatrick Kadama African Centre for Global Health and Social

Transformation (ACHEST)

14H30–15H00: Proposed Work Plan for the CommitteeNelson SewankamboUNAS

15H00–15H30: Path Forward Nelson SewankamboUNAS

15H30–16H00: TEA/COFFEE BREAKDeparture at Leisure



SESSION 2: CLOSED

10H30–11H0O: Rationale for the Committee

Nelson Sewankambo, Chair

Advisory Committee on Vaccines and Immunization (ACVI)

Fellow of UNAS

11H00–11H30: Bias and Confl ict of Interest Discussion

Franklin Muyonjo

UNAS

11H30-12H00: Committee Considerations (Global/Regional [African Union]/National)

Sabrina Bakeera-Kitaka

College of Health Sciences

Christian N. Acemah

Institute of Medicine, U.S. National Academies

12H00–12H30: The Status of Vaccines and Immunization in UgandaJesca Nsungwa-Sabiiti

Ministry of Health

12H30–13H00: The Role of International OrganizationsDiana KizzaSabin Vaccine Institute

13H00–14H00: LUNCH BREAK

14h00–14H30: Current Hot Topics in ImmunizationFrancis OmaswaPatrick Kadama African Centre for Global Health and Social

Transformation (ACHEST)

14H30–15H00: Proposed Work Plan for the CommitteeNelson SewankamboUNAS

15H00–15H30: Path Forward Nelson SewankamboUNAS

15H30–16H00: TEA/COFFEE BREAKDeparture at Leisure



Annex 3Uganda Immunization Schedule

NOTE: This schedule will be updated with the introduction of new vaccines.

9 7 8 9 9 7 0 4 2 4 0 3 0

policy advising in uganda reports/acvi meeting report.pdfprosperity and welfare for the people of...

Documents