THE KINGDOM OF LESOTHO

MINISTRY OF HEALTH AND SOCIAL WELFARE

FINANCIAL SUSTAINABILITY PLAN

FOR

THE EXPANDED PROGRAMME ON IMMUNIZATION

December 2004

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CONTENTS Acknowledgements I Abbreviations and acronyms ii Executive summary iii Section 1: Impact of country and Health System context 1 1.1 Introduction 1 1.2 Economy 1 1.3 Health Sector Policy Framework 2 1.4 Health context 2 1.5 Financing Health Care 3 1.6 Future Prospects for Health Care Financing 3 1.7 Budgetary process and financial management 4 SECTION II: Programme characteristics, objectives and strategies 5 2.1 Programme characteristics 5 2.2 EPI coverage, 2001 – 2003 5 2.3 EPI Review 6 2.4 Multi year plan 8 2.5 Programme targets for future years 11 2.6 EPI programme financing 12 Section III: Pre Vaccine Fund and Vaccine fund year programme costing and financing 13 3.1 Pre-vaccine fund year (2001) and vaccine fund year (2003) expenditure 14 3.2 Pre vaccine fund year (2001) and vaccine fund year (2003) financing 15 Section IV: Future resource requirements, financing and funding gap analysis 17 Section V: Sustainable financing strategies, actions & indicators 24 5.1 Opportunities and challenges to financial sustainability in Lesotho 24

5.1.1 Opportunities 24 5.1.2 Challenges 24

5.2 Alternative policy scenarios 25 5.3 Strategies and actions for financial sustainability 28

5.3.1 Mobiliz ng additional resources 28 i5.3.2 Improving reliability of resources 28 5.3.3 Improving programme efficiency 29

5.4 Implementation and follow up of financial sustainability strategies 30

Section 6: Stakeholder comments 31

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TABLES AND ILLUSTRATIONS

Tables Table 1.1 Key health and demographic indicators for Lesotho Table 2.1: Immunization schedule in Lesotho Table 2.2: Coverage for routine vaccinations, 2001-3 Table 2.3 Key programme strategies, and inputs to implement the MYP Table 3.1: EPI expenditure by category in Lesotho, USD, and 2001 – 2003 Table 4.1: Programme costs by cost categories, 2004 – 2013 in USD Table 4.2: Secure, probable and funding gaps for the EPI programme, 2004 – 2013 Table 5.1: Cost, programmatic and disease burden implications of different

Policy options for Lesotho Table 5.2: Total programme costs, available resources, and

Funding gaps for the 2004 – 2013 period in Lesotho Table 5.3: Financial sustainability actions and monitoring indicators Figures Figure 2.1: Trends in EPI coverage from 1981 – 2003 Figure 3.1: Trends in past programme costs by cost category,

2001 – 2003 in USD millions Figure 3.2: Financing sources for immunization in USD, 2001 – 2003 Figure 3.3: Contribution to programme expenditure by partner for

Routine recurrent, capital and SIAs for Lesotho, Figure 4.1: Future programme costs by categories, USD millions Figure 4.2: Routine costs per DPT3 child for immunization in Lesotho,

USD millions 2001 – 2013 Figure 4.3: Secure/probable funding, and funding gaps for

Immunization in Lesotho, USD millions Figure 5.1: Impact of different policy alternatives on overall cost,

And funding gap for immunization, 2004 – 2013

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ACKNOWLEDGEMENTS The Ministry of Health & Social Welfare wishes to thank its partners including members of the Interagency Coordinating Committee for their inputs in the compilation of this document. Special mention goes to the Ministry of Finance & Development planning for their supportive role in facilitating the implementation of this Financial Sustainability Plan.

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ABBREVIATIONS AND ACRONYMS AD Auto Disable AEFI Adverse Events Following Immunization BCG Bacillus Calmette Guerine CBR Crude Birth Rate CDC Centre for Disease Control & Prevention CHAL Christian Health Association of Lesotho DCI Development Cooperation Ireland DT Diphtheria and Tetanus DPT Diphtheria, Pertussis and Tetanus DTP-HepB-Hib Pentavalent vaccine EPI Expanded Programme for Immunization FSP Financial Sustainability Plan GAVI Global Alliance for Vaccines and Immunizations GOL Government of Lesotho HC Health Center HepB Hepatitis B Hib Haemophilus influenzae type b HPSU Health Planning & Statistics Unit HSA Health Service Area ICC Interagency Coordinating Committee IMR Infant Mortality Rate ISS Immunizations Services Support JICA Japan International Corporation Agency LHWP Lesotho Highlands Water Project LRA Lesotho Revenue Authority MMR Maternal Mortality Rate MOFDP Ministry of Finance & Development Planning MOHSW Ministry of Health and Social Welfare MTEF Medium Term Expenditure Framework MYP Multi Year Plan NGO Non Governmental Organization OPV Oral Polio Virus PHC Primary Health Care PRSP Poverty Reduction Strategy Paper SACU South Africa Customs Union SIA Supplemental Immunization Activities USD United States Dollar UNICEF United Nations Children’s’ Fund VAT Value Added Tax VVM Vaccine Vial Monitor WHO World Health Organization

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Preamble This Financial Sustainability Planning document was developed based on targets and known activities for the years 2005-2013. Ideally the plan should have been developed in unison with the multi year plan for the coming years in order to ensure that all planned activities are accounted for and captured in the costs. It is possible that the costs presented here will change as planning for the future is further developed. The FSP is intended as interactive document that should be revisited and revised periodically.

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EXECUTIVE SUMMARY Increasing poverty, declining public health expenditure and the AIDS pandemic are currently the greatest threats to the survival of children in Lesotho. Vaccine preventable diseases, including tuberculosis, malnutrition, diarrhoea, acute respiratory infections, pregnancy related complications and AIDS continue to contribute significantly to the disease burden in children. As one of the key social sectors, the health sector assumes high priority in the government fiscal policy with the total health budget ranging between 7% and 7.5% of total government expenditure. On average, the total health expenditure in the country represents 6.1% of GDP, with over 50% of the health expenditure coming from Government. One of the key government priorities in the next three years is to reduce the debt burden. This focus limits the potential for allocating additional funds to the social sector including health and therefore immunization initiatives. Though immunization has been identified as a priority area for intervention, competition for resources with other priorities will remain a reality. The Expanded Programme on Immunization in Lesotho was established in 1979. The programme aims to ensure that vaccines are available to the population for the traditional six preventable diseases of Tuberculosis, Diphtheria, Whooping Cough, Tetanus, Polio and Measles, including Hepatitis B, introduced into the programme in 2003 with GAVI support. Although reported vaccine-preventable disease morbidity and mortality is currently low in Lesotho, there are challenges in assessing the true impact of the National EPI. A programme multi year plan (MYP) was developed in 2001 for the period of 2001 – 2006. The key objectives of the plan include:

a) To achieve increased immunization coverage to at least 80% immunization coverage for all antigens by 2005.

b) Introduction of Auto-Disable syringes (AD) in routine immunization services c) Detect one case of Acute Flaccid Paralysis (AFP) per 100,000 population of <15

years age in each HSA per year until the country is certified Polio free d) Collect blood specimens from all suspected Measles cases for laboratory

confirmation e) Reduce the number of Neonatal Tetanus cases to less than one case per 1,000

live births in each district As of December 2004 some of these objectives have been met. The AD syringes are now in use for all vaccines provided through the EPI programme. AFP surveillance is of certification level. Blood specimens for measles cases are being collected and sent to the lab for confirmation. Number of neonatal tetanus cases is below one case per 1,000 live births, although it is not clear if this is due to absence of disease or insufficient surveillance. Other objectives have not yet been met. Routine immunization coverage is still below the objective of 80% for all antigens. Vaccine management is still very weak. Transportation and supportive supervision of HSAs and health facilities is still inadequate.

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Future programme targe s and new activities tThe target coverage for BCG and DPT3 for the years 2006-13 is 86%, and the target coverage for measles for the same years is 90%. The wastage targets for 2006-13 are 40% wastage for BCG by the year 2008, 30% for measles by the year 2006, and 20% for OPV and Pentavalent (DTP-HepB-Hib) by the year 2006. The programme also intends to introduce Hib vaccine in combination with DPT and HepB in 2006. This new vaccine will significantly increase the cost of the EPI programme, as the vaccine is many times more costly than the traditional vaccines. For the years 2006 to 2011, GAVI will support the costs of the new vaccine after which time the government will assume responsibility for those costs. Finally, nationwide measles follow up campaigns are planned for 2007 and 2011. These campaigns require intense inputs in terms of planning, human resources, and funds. Programme financing In 2001 the programme required approximately USD 1 million to operate. This increased to USD 1.8 million in 2003, the first year of GAVI support. This near doubling in expenses is primarily due to the nationwide measles campaign that was carried out in 2003. The increased strength of the local currency, from 10.4 Maloti: USD1 in 2002 to 7.6 Maloti: USD1 in 2003 also led to an apparent increase in costs of some cost categories particularly the personnel costs. Financing for these programme expenditures came from a series of sources as illustrated below. Financing sources for immunization in USD, 2001 - 2003 $1.

6 $1.

4

CHAL $1.2 CDC $1.0 JICA thru UNICEF

$0.8 Development Cooperation Ireland

UNICEF $0.6 WHO

GAVI - Vaccine Fund $0.4 Sub-national Gov. $0.2 National Government

$- 200

1 2002

2003

The Government provides the bulk of the programme expenditure. This represents the large impact of expenditure due to shared inputs (shared personnel, transport and buildings), and personnel costs for the programme. When shared costs such as personnel and building overhead are excluded, the percentage of the programme costs covered by government reduces to about 25% in 2003. Future cost projections Estimates of future programme costs were derived for the planned activities and recurrent costs of the programme

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Future programme costs by categories, USD millions

$-

$1.0

$2.0

$3.0

$4.0

$5.0

$6.0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Other opt ional informat ion

Other SIAs

M easles Campaigns

Polio Campaigns

Other capital costs

Cold chain equipment

Vehicles

Other rout ine recurrent costs

Transportat ion

Personnel

Inject ion supplies

New and underused vaccines

Tradit ional Vaccines

In 2004, the high programme costs are maintained as in 2003, at approximately USD 2 million due to additional SIAs. In 2005, the costs will reduce, but increase again in 2006 to over USD 2.5 million due to the planned introduction of the Pentavalent vaccine. Costs further increase in 2007 due to the measles campaign that will be carried out then, before settling back at approximately USD 2.5 million. Significant increases in costs are again seen in 2011, corresponding to the next measles SIA. Funding gaps begin to become significant in 2006, increasing dramatically in 2007, and remain high. Dramatic increase in the funding gap is seen again in 2011. Secure/probable funding and funding gaps for immunization in Lesotho, USD millions

$-

$1.0

$2.0

$3.0

$4.0

$5.0

$6.0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Funding Gap

0

0

0

CHAL

CDC

JICA thru UNICEF

Ireland Aid

UNICEF

WHO

GAVI - Vaccine Fund

Sub-nat ional Gov.

Nat ional Government

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Strategies to cover programme costs in the years, 2004-13 Three strategies were explored in order to cover the funding gap in future years: Mobilizing additional resources; Improving the reliability of its resources; Improving programme efficiency. In addition, different programme scenarios which would reduce immediate programme cost were also explored, including their possible implications on programme effectiveness. Mobiliz ng additional resources iThe programme shall seek additional resources from Government, by ensuring its costing and financing information is included in the new MTEF. In addition, the programme shall seek additional resources from its partners. There shall be targeted resource mobilization form specific partners, based on the respective cost category for which funds are required, and the priorities of the partner. The publicity of the programme shall be increased among potential funders, with the programme achievements and financial situation elaborated. Improving reliability of resources As mentioned above, the programme shall ensure its requirements are included in the Government’s/health sectors MTEF estimates. This provides a sectoral framework into which costing and financing estimates are elaborated on a 3 year rolling framework. In addition, the programme shall seek to ensure its partners (including Government) are always aware of how the resources are utilized in the programme, and avoid situations where funds are not committed because previous ones were not appropriately accounted for. Improving programme efficiency The programme shall seek to ensure the finances it has, or is able to mobilize, are utilized in the most efficient manner, with the best possible outputs derived from these funds. As mentioned in the beginning of this section, there are a number of issues that lead to inefficiencies, both within the wider Ministry of Health (such as inadequate transport facilities, or low numbers and skills of health workers), or in the EPI programme (such as vaccine wastage, and poor maintenance of equipment). Implementation and follow up A series of actions and indicators were developed for monitoring implementation of the financial sustainability strategies. The Ministry of Health, through the ICC shall be responsible for implementation and follow up. A technical sub working group (FSP team) shall follow up on a regular basis, on behalf of the ICC, the implementation of the actions required to attain financial sustainability. An action plan shall be elaborated by this team. On an annual basis, the ICC and other stakeholders shall meet to review progress based on the indicators used and actions expected, and adapt the financial sustainability strategies and actions for the coming year based on the issues in the previous year. Outputs from this meeting shall form the basis for the reporting mechanism to GAVI on progress on financial sustainability (required with the Annual Performance Report)

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Section 1: Impact of country and Health System context 1.1 Introduction The Kingdom of Lesotho is a small mountainous country of 30,355 square km totally enclosed by the Republic of South Africa. The country has had a stable government since independence in 1966. Topographically the country is divided into 4 zones: Lowlands comprising areas below 2,000 m altitude; Foothills which lies between 2,000 and 2,300 m altitude; Mountains where altitude exceeds 2,300 m; Senqu River Valley. A large percentage of the country population is located in the highlands, and foothills. The country enjoys a temperate climate with 4 distinct seasons. The annual rain fall ranges from 50cm to 150cm with the exposed mountain slope receiving most of the rain. The rainy season commences on October and ends in April although some rain and snow may occasionally fall in winter (June- August) period. The winter temperatures fall below the freezing point, whereas summer temperatures may exceed 30°c in summer especially the lowlands. 1.2 Economy Lesotho’s currency, the Maloti, is linked to the South African Rand on a one to one ratio i.e. one Maloti is equal to one South African Rand. In 2002, the Maloti was valued at 10.4 to 1 USD. This reduced to 8.4 Maloti to 1USD in 2003 and further reduced to 6.5Maloti to 1USD in 2004. Lesotho’s economic growth rate has been relatively strong in recent years, estimated at 3.5% in 2002. Several factors however have negatively affected the economy in recent years. The Lesotho Highlands Water Project (LHWP) created a great deal of employment in the construction sector, and the completion of this project in 2002 led to a decline in construction jobs. There has also been a reduction in miners’ remittances and South African Customs Union (SACU) revenue. Other factors impeding economic growth include political upheavals in 1998, decreased volumes of external assistance, restructuring of key government institutions, repayment of the commercial loans for LHWP, and recent government spending on famine. While industry is a well developed sector in Lesotho, much of the population relies on subsistence farming for its survival. Challenged with sustaining this favorable economic growth rate, Lesotho explored alternative sources of revenue collection, and has recently exploited strategies for improving revenue collection through implementation of the Revenue Policy by the Lesotho Revenue Authority and introducing the Value Added Tax (VAT). The government also intends to increase national productivity, generate job opportunities and implement prudent fiscal strategies for good financial management and maintenance of sustainable fiscal balances.

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1.3 Health Sector Policy Framework The health sector policy derives directly from the broad government objectives outlined in the Vision 2020 and PRSP. The priority areas for the Health Sector include child survival, which incorporates immunization, nutrition, as well as reproductive and maternal health. Other factors that impact on child survival include access to clean water and sanitation, increased employment opportunities and increased literacy/education. As part of an effort to promote efficiency, the Ministry of Health & Social Welfare (MOHSW) embarked on a Health Sector Reform programme in 2001. The reform initiative is geared towards rationalizing existing management systems and implementing effective guidelines and protocols so that basic service delivery standards are met efficiently. Health sector reform incorporates restructuring of all the elements of the sector including those related to control and management of pharmaceuticals, human resources, infrastructure development and institutional management capacity for the health sector. Primary Health Care remains the cornerstone of service delivery therefore the Ministry has also undertaken to define the essential services package, which incorporates all the elements of PHC. Hence immunization coverage remains one of the crucial indicators for effectiveness of the health sector. The MOHSW has commenced piloting a decentralization programme as a priority within the ongoing Health Sector Reform programme. This initiative will be piloted in three of the ten administrative districts of Lesotho. It is anticipated that with a more decentralized planning and budget systems the resources for the Expanded Programme on Immunization (EPI) will be distributed more timely and be controlled at implementation level. Health service delivery is provided through geographically demarcated 18 Health Service Areas (HSAs) of which a hospital is the focal point. Another important initiative being undertaken is the development of a Medium Term Expenditure Framework (MTEF), which facilitates the important link between priorities and the budget. The MTEF utilizes a three year budgeting approach and is intended to simplify and improve allocation and spending of the budget. The processes for institutionalising a three-year MTEF started in 2001 but it is expected that this process will become fully effective starting FY 2005/06. The EPI is currently budgeted for under the MOHSW Family Health Division cost centre thus resources allocated to this programme are submerged into the Family Health Division budget. 1.4 Health context Increasing poverty, declining public health expenditure in real terms, and the AIDS pandemic are currently the greatest threats to the survival of children in Lesotho. Infant and under five mortality rates have increased by 33 percent and 38 percent respectively to 80/1000 and 113/1000 live births over the past 5 years. Disease conditions such as tuberculosis, malnutrition, diarrhoea, acute respiratory infections, pregnancy related complications and AIDS, continue to contribute significantly to the morbidity and mortality patterns in children. Although vaccine preventable diseases such as measles, diphtheria, tetanus, peruses and polio have been contained due to sustained high immunization coverage of the early 1980s, there is a threat of these diseases re-emerging in epidemic proportions due to the declining coverage witnessed in the 1990s.

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Table 1.1 Key health and demographic indicators for Lesotho

Indicator

Value Source

Population 2,333,846 Population data sheet: 2002 Infant mortality rate 80/1000 Population data sheet: 2002 Maternal mortality rate 419/100,000 LDS,2001:Vol 1 Crude birth rate 30/1000 1996 Census Life expectancy Females : 40.8* 56.3

Males : 39.1* 48.7 Population data sheet: 2002

Access to health Urban : 35% Rural : 11%

CWIQ 2002

* includes the estimated impact of HIV/AIDS 1.5 Financing Health Care As one of the key social sectors the health sector assumes high priority in the government fiscal policy with the total health budget ranging between 7% and 7.5% of total government expenditure. On average, 82% of the total Health & Social Welfare budget comes from the government while the other 18% is from external sources. The average per capita government expenditure on health is USD 26.50 while as a percentage of GDP total health expenditure is on average 6.11%. In 2003 total health expenditures represent 6.4% of the GDP of the country. Of these health expenditures, 57% was from the Government of Lesotho (GOL), with the remainder from partners, and households. Government tax funding plays a significant part in the financing of service delivery. Patient user fees are the most prominent form of health financing but this revenue is reverted to the Central Treasury at the Ministry of Finance & Development Planning and thus does not add direct value to the Health Sector. Non-for-profit health providers are an exception to this procedure. Although a patient user fee exemption system is in place, the systems for this are still underdeveloped. Exemptions are granted on the basis of socio-economic status, type of illness as well as patient demographic details. Existing budgeting systems do not provide sufficient detail to allow for a precise analysis on how the resources allocated to the health sector are used to fund the EPI. 1.6 Future Prospects for Health Care Financing One of the key government priorities in the next three years is to reduce the debt burden, which currently rests at 3%. This focus limits the potential for allocating additional funds to the social sector including health and therefore immunization initiatives. The expectation is that over the period 2005/08, public expenditure will be targeted at high priority activities as identified in the Poverty Reduction Strategy Paper (PRSP) and enhancing operational efficiency. Though immunization has been identified as a priority area for intervention, competition with other priorities such as HIV/AIDS and the treatment of the related opportunistic infections will remain a reality. The implication is that to ensure sustainable provision of immunisation services great effort has to go into ensuring efficient use of scarce resources by adopting the most cost effective strategies and the health sector will need to undertake aggressive resource mobilisation strategies for the EPI programme.

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1.7 Budgetary process and financial management The GOL budget cycle runs from April to March of the following year. The MOHSW at present enjoys a budget outturn of 101% (MOFDP data for 2003/04) for the recurrent budget and on average 70% for the capital budget. This disparity between approved budget and actual expenditure is mainly due to inefficient financial management systems where financial reporting is not adequately linked to physical progress reports. Moreover disbursement mechanisms tend to be very long and tedious such that at a particular point in time it is difficult to say exactly how much has been spent or committed. The end result of this is that by end of year the MOHSW still has some outstanding debts, which have to be financed through the new budget, because of the cash accounting approach used by government. These factors impact greatly on resources actually available for use in a given year and on how these resources are used. The capital budget is prone to under-spending. The reason for this is that much of what is termed capital budget is in fact recurrent in nature but is called capital because it is donor funded and this includes some of the funding for EPI. The main reason for under-expenditure of the capital budget is the lack of absorptive capacity which can be attributed partly to the vertical administrative planning of programmes such as EPI. In this vertical system, planning and budgeting for all programmes (EPI, Reproductive Health, Disease Control, etc.) takes place at the central headquarters level for the district level. The lack of capacity to coordinate and manage planning processes and implementation of these plans and budgets mean that even when resources are available, more often than not they do not reach the intended beneficiaries at the district level. In fact, budgets often get as far as the central programme and have to be returned at the end of the financial year as they have not been spent. The current initiatives towards decentralisation and rationalisation of role and responsibilities between the central and district level should go a long way in improving this situation.

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SECTION II: Programme characteristics, objectives and strategies 2.1 Programme characteristics The Expanded Programme on Immunization (EPI) in Lesotho was established in 1979. It is placed at the central MOHSWSW headquarters level, within the Family Health Division. The EPI aims to ensure that vaccines are available for the population for the traditional six preventable diseases of Tuberculosis, Diphtheria, Whooping Cough, Tetanus, Polio and Measles, as well as Hepatitis B. The six traditional vaccines have been provided by the programme since its inception in 1979, while Hepatitis B was commenced in 2003 with the support of GAVI/vaccine fund. The Hepatitis B vaccine is presently provided as a monovalent vaccine. The immunization schedule in the country is illustrated in Table 2.1 below:

Table 2.1: Immunization schedule in Lesotho

Period

Vaccine Doses per Antigen

At birth

BCG, OPV 0

1

6 weeks

DPT1, HepB 1, OPV1

1

10 weeks

DPT2, HepB2, OPV2

1

14 weeks

DPT3, HepB3, OPV3

1

9 months

Measles

1

18 months

DT& Measles booster dose

1

The schedule includes booster doses for Diphtheria, and Tetanus vaccines provided as a DT vaccine. To be able to ensure provision of these antigens, EPI utilizes the MOHSW organizational structures. Health workers, especially those at the health facilities, ensure services are adequately provided to the population. At present, the coverage achieved for the respective antigens, with wastage rates over the past few years is illustrated below.

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2.2 EPI programme coverage and wastage, 2001 – 2003 Figure 2.1 shows the trends in coverage as derived from administrative data

Figure 2.1: Trends in EPI coverage from 1981 – 2003

EPI coverage from 1981 to 2003

0102030405060708090

100

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

BCGOPV3DPT3Measles

Table 2.2: Coverage and for routine vaccinations, 2001-3

Coverage Antigen 2001 2002 2003

BCG 70% 73% 79% DPT 3 65% 73% 83% Tetanus (TT) N/A* N/A N/A Measles 56% 66% 73% Polio 3 (OPV) 64% 70% 83% HepB 3 N/A N/A 17%

DT N/A N/A N/A *N/A – Not applicable

The EPI coverage estimates, based on the Ministry of Health annual report data, is high, with the decline observed during the 1990’s having been reversed at present. It has been acknowledged that there is high antigen wastage. However, there are limitations to quantifying the extent as a result of limited resources for data collection and analysis. In 2003, it was found that 3000 doses of Measles antigen had expired. Furthermore, the standard 20-dose BCG vial is rarely utilized optimally as very few of the health care delivery facilities will have more than 20 births a day. Instances of antigen expiry as a result of a short shelf life have been attributed to distribution logistics of the vaccines to Lesotho. Stock outs due to administrative restructuring within procurement units also occurred. Since 1996 no case of acute poliomyelitis has been reported. Neonatal tetanus has been kept below 1 per 1000 births, but there are sporadic cases of measles.

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2.3 EPI Review 2001 To review challenges facing the programme in its activities, an EPI review was carried out in 2001. Field visits conducted during this 2001 review revealed a general picture of an overall decline in the quality of EPI management, such that the considerable potential among junior staff is being undermined by the failure by senior staff to set rational priorities and act upon them. On the one hand, Health Centres have been supplied with high-quality vaccination and cold chain equipment, and the high quality of nurses’ basic training ensures that their vaccination technique is generally good. Furthermore, sufficient vaccines are donated annually to fully vaccinate every Basotho infant and woman of child-bearing age. However, Health Centre staffs are losing motivation due to lack of support and feedback from their HSA Primary Health Care (PHC) teams and, in some areas, frequent rotation of posts. Supervisory visits are increasingly rare and lack technical depth, such that staffs feel neglected. Outreach visits to remote villages are increasingly being cancelled, in part due to lack of transport as a result of poor logistical management and unclear priorities, but also due to the absence of support from HSA PHC teams. In several cases, Nursing Assistants are staffing Health Centres alone. The review noted that there had been a high quality of vaccines and injection equipment delivered consistently over the 3 years prior to the review. However, it also highlighted the following key issues that are hindering achievement of the programme objectives:

1. General decline in the quality of EPI management 2. Rational priorities not being established and followed through 3. Lack of motivation of peripheral level staff and little support including supervision

from the central level. 4. Cancellation of outreach visits due to lack of transport and/or staff. 5. No updated EPI policies on new innovations or initiatives. 6. Health centre staffs have not received any training in vaccine management,

setting targets, monitoring of immunization drop outs and on injection safety. Recommendations from the review included:

1. The national EPI policy should be revised with the inclusion of modern EPI theory and practice.

2. Include modern theory and practice of cold chain and operations management, EPI service delivery, monitoring and evaluation of routine vaccination coverage, and EPI disease surveillance in basic training curricula for nurses and, where appropriate, for environmental health officers.

3. Comprehensive, high-quality in-service training, supervision and monitoring of EPI activities at all levels should be carefully designed at national level and implemented at HSA and health facility levels.

4. Implement the WHO multi dose policy in order to reduce vaccine wastage. 5. The refrigerated vaccine delivery vehicle should be utilised more effectively.

Routine orders for vaccines should be delivered to each of the HSAs regularly. This will eliminate the need for the HSAs to rely on ambulances to fulfill this function when the latter are traveling to Maseru.

6. Training at all levels of the cold chain and vaccine management is a priority. This should include, among other things, the VVMs, the “shake test” for toxoids, and overall vaccine management through the use of stock cards and order forms that make provision for the supply of correct diluents with the relevant vaccines.

7. Training of health workers should be intensified at both HSA and facility levels on national EPI goals, basic data management, including how to calculate and

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monitor routine vaccination coverage and dropout rates, and EPI disease surveillance, including how to detect, investigate and report suspected cases of vaccine-preventable diseases, collect specimens for laboratory confirmation, and respond to outbreaks.

8. HSA PHC teams should revise and disseminate maps and age-specific catchment population profiles, to permit effective monitoring of vaccine coverage, dropouts and disease trends at health facility and HSA levels.

9. Community Health Workers’ village health registers should be used by all health facilities for estimating their catchment population, tracing defaulters and monitoring coverage.

10. The Health Education Programme in the MOHSW should develop a national health education policy.

11. Health workers should be trained in the use of EPI education materials and how to explain them clearly to community members.

12. All information, education and communication (IEC) materials, both visual and audiovisual, including those that are self-generated, should be developed according to the needs of target groups in the community and should be pre-tested.

The programme is, as part of its future activities, aiming to ensure these issues are appropriately addressed in order to meet the programme goals and mandate. 2.4 Multi Year Plan A programme multi year plan (MYP) was developed in 2001 for the period of 2001 – 2006, and highlights the key programme objectives as to: a) Strengthen immunization systems b) Increase immunization coverage in the kingdom of Lesotho by 5-10% point over the next five years so that at least 80% immunization coverage for all antigens achieved by 2005 as set by WHO African Regional Office (WHO-AFRO) c) Improve transport situation in all HSAs and national level (procurement of EPI vehicles) d) Introduction of Auto-Disable syringes (AD) in routine immunization services e) Institute the system of reporting all serious adverse events following immunizations (incorporate AEFI into routine reporting system) f) Detect one case of AFP per 100,000 population of <15 years age in each district (HSAs) per year until the country is certified Polio free g) Collect blood specimens from all suspected Measles cases for laboratory confirmation h) Reduce the number of Neonatal Tetanus cases to less than one case per 1,000 live births in each district i) Increase awareness and build ownership of the programme that will positively bring the desired impact

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The respective strategies to ensure these objectives are implemented, together with required inputs are outlined in the Table 2.3 below. A new multi year plan for the years 2006 to 2011 will be developed in 2005. Table 2.3 Key programme strategies, and inputs to implement the 2001-2006 MYP

OBJECTIVES

STRATEGIES INPUTS REQUIRED TO IMPLEMENT STRATEGIES

Strengthen immunization systems

• Training of health workers and supervisors on managerial skills in EPI at both HSA and facility levels

• Strengthening and inclusion of current EPI policies and practices in pre-service institutions

• Timely ordering of adequate vaccines, cold chain equipment and other supplies in collaboration with potential partners and donors

• Development of the national health education policy and publication of improved EPI promotional materials

• Trainers, training manuals and materials

• Printing and distribution

of EPI Policies

• Training on logistics management

• Adequate advocacy and

communication about EPI in all levels

Increase immunization coverage in the kingdom of Lesotho by 5-10% point over the next five years so that at least 80% immunization coverage for all antigens achieved by 2005 as set by WHO-AFRO

• Solicit adequate funding from collaborating partners and donors for procurement of vaccines

• Enlist government commitment on contribution towards procurement of vaccines

• Train health workers on Multi-Dose Vial Policy(MVDP) and interpretation of vaccine vial monitor

• Training on financial management

• Quarterly review on the

status of the funds and feed back on expenditure to the partners

• Additional personnel at

central and HSA level Improve transport situation in all HSAs and national level (procurement of EPI vehicles)

• Solicit funding from collaborating partners and donors

• Enlist support from government and ICC

• Ensure annual plan of action includes transport requirement over the next 5 year period

Introduction of Auto-Disable syringes (AD) in routine immunization services

• Solicit adequate funding from collaborating partners and donors

• Enlist government support for sustainable procurement of AD syringes

• Train health workers on safe injection practices

Annual requirement of AD syringes for 5 year period

Institute the system of reporting all serious adverse events following immunizations (incorporate AEFI into routine reporting system)

• Absence of circulation of indigenous wild Polio virus for at least a three year period during which surveillance activities have been maintained at the level of performance needed for certification

• National certification committee in each country has validated and submitted the documentation required by the regional certification commission

• Appropriate measures are in place to detect and respond to importation of wild Polio virus

• Weekly active search of suspected AFP cases

• Identification and • training of the NTF

• Quarterly review

meetings with focal points

9

Table 2.3 (continued) Key programme strategies, and inputs to implement the MYP

OBJECTIVE STRATEGIES INPUTS REQUIRED TO IMPLEMENT STRATEGIES

Detect one case of AFP per 100,000 population of <15 years age in each district (HSAs) per year until the country is certified Polio free

• Train one Disease Surveillance Focal Point in each admitting hospital

• Improve knowledge and skills of health workers in surveillance activities through trainings, refresher courses and meetings

• Institute aggressive AFP surveillance with involvement of all health workers and communities aimed at detecting all cases of AFP and perform adequate clinical and epidemiological investigation.

• Intensify active search for AFP cases in all admitting hospitals and other health facilities by reviewing their records for the following: Poliomyelitis, Acute flaccid paralysis, transverse myelitis, Gullain-Barre syndrome, paraplegia, quadriplegia, Encephalitis and non bacterial meningitis

• Rapid and active response to potential outbreaks • through investigation ,proper reporting and

documentation of all AFP cases • Review of all AFP cases at 60 days with only one

stool specimen collected or whose stool specimens were taken after 14 days of onset of paralysis

• Identification of focal people at all HSAs

• Active response team

Collect blood specimens from all suspected Measles cases for laboratory confirmation

• Train one Disease Surveillance focal point in each admitting hospital

• Improve knowledge and skills of health workers in surveillance activities through trainings, refresher courses and meetings

• Map and line-list measles cases at all levels for easy identification of high risk areas

• Use available data of monthly suspected measles cases to identify areas that have circulation of Measles virus

• Intensify laboratory diagnosis of suspected Measles cases

• Conduct outbreak response immediately after laboratory confirmation

• Intensify active search for all suspected Measles cases in all admitting health facilities by reviewing their records

Funds to conduct trainings on reporting electronically for HSAs as well as funding to procure electronically communication Printing of guide lines manuals

Reduce the number of Neonatal Tetanus cases to less than one case per 1,000 live births in each district

Intensify immunization of all child bearing age group (15-49 years) with Tetanus Toxoid

Active social mobilization team

10

As of December 2004 some of these objectives have been met, and some are still outstanding. The AD syringes are now is use for all vaccines provided through the EPI programme. AFP surveillance is of certification standard. The 2002 implementation of the WHO-AFRO Integrated Disease Surveillance & Response (IDSR) strategy has been instrumental in addressing AFP and Measles surveillance objectives. Blood specimens for measles cases are being collected and sent to the lab for confirmation. Number of neonatal tetanus cases is below one case per 1,000 live births, although it is not clear if this is due to absence of disease or insufficient surveillance. Other objectives have not yet been met. Routine immunization coverage is below the objective of 80% for all antigens. Vaccine management is restricted. Transportation and supportive supervision of HSAs and health facilities is still inadequate. 2.5 Programme targets for future years The programme has set ambitious goals of increasing routine coverage and reducing vaccine wastage in the coming years. According to the 2001-6 multi year plan, coverage for all antigens should be at least 80% by the year 2005. Further improvements beyond this are expected. The target coverage for BCG and DPT3 for the years 2006-13 is 86%, and the target coverage for measles for the same years is 90%. The targets for wastage also call for marked improvements. The targets for 2006-13 call for a reduction of wastage to 40% for BCG by the year 2008, 30% for measles by the year 2006, and 20% for OPV and Pentavalent by the year 2006. These goals will require a significant improvement in vaccine management in the short term. In addition to these targets for coverage and wastage, the programme also intends to introduce Hib vaccine in combination with DPT and HepB in 2006. This new vaccine will significantly increase the cost of the EPI programme, as the vaccine is many times more costly than the traditional vaccines. For the years 2006 to 2011, GAVI will support the costs of the new vaccine (Hib portion of the Pentavalent vaccine), after which time the government will assume responsibility for those costs. Effective introduction of the new vaccine will also require concerted efforts in training, surveillance, and assessment. Finally, nationwide measles follow up campaigns are planned for 2007 and 2011. These campaigns require intense inputs in terms of planning, human resources, and funds. In order to meet the coverage and wastage targets for the coming years, successfully introduce the Pentavalent vaccine in 2006, and implement the planned measles SIAs, the EPI programme will require significant improvements in staff capacity, planning, training, and supervision at the national, district, health service area, and health facility level. It is quite likely that these improvements will require additional funds.

11

2.6 EPI programme financing The EPI works with the following service delivery partners, all of whom have been supporting the programme for more than five years:

1. Christian Health Association of Lesotho (CHAL) 2. NGO Red Cross 3. Maseru City Council 4. Maseru Private Hospital 5. Military Hospital 6. Government Hospitals

Other partners are providing financial and technical support to the EPI programme. These include:

1. GAVI 2. Development Cooperation Ireland (DCI) 3. JICA 4. UNICEF 5. WHO

The support from these partners shall be elaborated in the coming section.

12

Section III: Pre Vaccine Fund and Vaccine fund year programme costing and financing We present a review of the costing and financing situation for the EPI programme in 2001 -the year prior to receiving any support from GAVI/the vaccine fund, 2002, and in 2003-the first full year of GAVI support. This is broken down by programme expenditure categories of routine recurrent expenditure, routine capital expenditure, and expenditure on supplemental immunization activities. Other optional information relating to the expenditure of the programme (proportion of shared buildings, transport and personnel expenditure by sector) are also included in the costing. Routine recurrent expenditure represents those expenses for the routine programme for activities that require regular (annual) input of funds. On the other hand, routine capital expenditure represents the expenses on capital activities by the programme. SIA expenditure represents expenses on the supplemental immunization activities carried out by the programme. The total costs for the programme are illustrated in figure 3.1 below (details in table 3.1) Figure 3.1: Trends in past programme costs by cost category, 2001 – 2003 in USD millions

$-

$0.2

$0.4

$0.6

$0.8

$1.0

$1.2

$1.4

$1.6

$1.8

$2.0

2001 2002 2003

Other opt ional information

Other SIAs

M easles Campaigns

Polio Campaigns

Other capital costs

Cold chain equipment

Vehicles

Other rout ine recurrent costs

Transportat ion

Personnel

Inject ion supplies

New and underused vaccines

Tradit ional Vaccines

13

Actual expenditure in each of these years is represented in table 3.1 below. Table 3.1: EPI expenditure by category in Lesotho, USD, 2001 – 2003

Cost Category 2001 2002 2003

Routine Recurrent Cost USD (%) USD (%) USD (%)

Vaccines (routine vaccines only) 50,435 5.0% 51,582 5.2% 92,664 5.0%

Traditional Vaccines 47,380 49,063 78,554

New (HepB) and underused (DT) vaccines 3,055 2,519 14,110

Injection supplies 20,792 2.1% 24,168 2.4% 19,696 1.1%

Personnel 183,646 18.2% 158,838 16.0% 218,967 11.8%

Salaries of full-time NIP health workers 70,355 63,243 85,483

Per-diems for outreach vaccinators/mobile teams 113,291 95,595 133,484

Transportation 1,329 0.1% 1,819 0.2% 1,063 0.1%

Fixed site and vaccine delivery 1,204 1,648 963

Outreach activities 125 171 100

Maintenance and overhead 163,608 16.2% 167,794 16.8% 171,220 9.2%

Short-term training 24,476 2.4% 34,869 3.5% 35,563 1.9%

IEC/social mobilization 26,235 2.6% 34,201 3.4% 38,782 2.1%

Supervision, Monitoring and Disease Surveillance 7,501 0.7% 8,728 0.9% 72,460 3.9%

Other Outreach costs (excluding per-diems, transport and ice) 19,549 1.9% 3,567 0.4% 0 0.0%

Other routine recurrent costs 14,094 1.4% 41,132 14,094

Annual cost for hiring aeroplane 14,094 14,094 14,094

Other communication costs 0 27,038 0

Subtotal Recurrent Costs 511,665 526,698 664,509

Routine Capital Cost

Vehicles 19,208 1.9% 19,600 2.0% 10,000 0.5%

Cold chain equipment 25,224 2.5% 30,731 3.1% 40,492 2.2%

Other capital costs 480 0.0% 1,568 0.2% 2,100 0.1%

Subtotal Capital Costs 44,912 51,899 52,592

Supplemental Immunization Activities

Measles Campaigns 0 0.0% 0 0.0% 628,608 33.9%

Vaccines 0 0 41,382

Injection supplies 0 0 15,375

Other operational costs 0 0 571,851

Subtotal Supplemental 0 0 628,608

Shared cost and other optional information

Shared Personnel Costs 255,543 25.3% 215,627 21.7% 301,090 16.3%

Shared Transportation Costs 326 0.0% 446 0.0% 522 0.0%

Building 197,135 19.5% 201,158 20.2% 205,263 11.1%

Subtotal Optional 453,004 417,231 506,875

GRAND TOTAL 1,009,581 995,828 1,852,584

Routine (Fixed Delivery) 876,616 896,495 1,090,392

Routine (Outreach Activities) 132,965 99,333 133,584

Supplemental Immunization Activities 0 0 628,608

14

Pre-vaccine fund year (2001) and vaccine fund year (2003) expenditure Table 3.1 shows that the programme cost approximately 1 million USD in 2001. The recurrent programme largely drives these costs, with costs for personnel as the largest single expenditure category (18% of total programme costs by EPI personnel, and 25% by contribution from other shared personnel). Vaccine expenditure contributes a small proportion (5%) of the overall expenditure. However, by the year 2003, the first full year with GAVI support, we see the programme expenditure almost doubled. This increase is largely a result of:

1. The increased strength of the local currency, from 10.4 Maloti to 1 USD in 2002, to 7.6 Maloti to 1 USD in 2003. this leads to an apparent increase in costs of some cost categories, particularly the personnel costs

2. Introduction of new activities. Most prominent is the measles campaign in 2003. The HepB antigen was also introduced in the same year. This however leads to a marginal increase in the total programme costs as it was introduced towards the end of the year (October 2003). The main expenditure driver is the SIA (over 30% of total costs), with the personnel costs reducing in their share of the total costs. However, vaccine expenditure still represents only 5% of the total programme costs. Pre vaccine fund year (2001) and vaccine fund year (2003) financing Financing for these programme expenditures came from a series of sources. These are illustrated in figure 3.2 below. Figure 3.2: Financing sources for immunization in USD, 2001 - 2003

$-

$0.2

$0.4

$0.6

$0.8

$1.0

$1.2

$1.4

$1.6

2001 2002 2003

CHAL

CDC

JICA thru UNICEF

Ireland Aid

UNICEF

WHO

GAVI - Vaccine Fund

Sub-nat ional Gov.

National Government

15

The Government provides the bulk of the programme expenditure. This represents the large impact of expenditure due to shared inputs (shared personnel, transport and buildings), and personnel costs for the programme. Some programme activities relating to maintenance and overheads were under funded, with funds made available not enough to cover the estimated total maintenance and overhead expenditure. A review of these funding sources for the pre-vaccine fund, and vaccine fund years without the optional information (shared costs above) is illustrated below. Figure 3.3: Contribution to programme expenditure by partner for routine recurrent, capital and SIAs for Lesotho, 2001 2003

National Government

41%

Sub-national Gov.0%

GAVI - Vaccine Fund

0%

WHO20%

UNICEF6%

Ireland Aid11%

JICA thru UNICEF

18%

CDC0%

CHAL4% National

Government26%

Sub-national Gov.0%

GAVI - Vaccine Fund

19%WHO13%

UNICEF11%

Ireland Aid4%

JICA thru UNICEF

18%

CDC8%

CHAL1%

The national Government is the main source of funding for the specific cost categories for immunization in 2001, contributing over 40% of the total costs. WHO represented the second major source of funding then, followed by JICA (through UNICEF). Government resources were largely for personnel (salaries and per diems), with some additional funds for transport. On the other hand, the partner support is used for other operational programme activities. JICA funds were largely used for vaccine purchases, while WHO was supporting a series of programme operational expenditures, particularly disease surveillance and training activities. Development Cooperation Ireland (Ireland Aid) support is largely for SIAs. UNICEF funds are largely for training, social mobilization, monitoring and supervision. By the year 2003, the programme financing changed, due to the changed programme activities. GAVI/vaccine fund resources are now seen, due to the introduction of the new vaccine, safer injection materials, and immunization services support (ISS). In addition, new partners for the SIAs are seen, such as CDC. As a result, the proportion of Government funding in relation to total routine programme, and SIA costs reduced to 25%. In addition, UNICEF (and JICA funds) is increasingly taking on the costs associated with vaccine clearance and transportation, a responsibility that should be for Government resources.

16

Section IV: Future resource requirements, financing and funding gap analysis We reviewed the future programme costs, and sources of financing. Figure 4.1 below presents the trends in costs for the programme in the future.

Figure 4.1: Future programme costs by categories, USD millions

$-

$1.0

$2.0

$3.0

$4.0

$5.0

$6.0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Other opt ional information

Other SIAs

M easles Campaigns

Polio Campaigns

Other capital costs

Cold chain equipment

Vehicles

Other rout ine recurrent costs

Transportat ion

Personnel

Inject ion supplies

New and underused vaccines

Tradit ional Vaccines

Programme costs are illustrated further in table 4.1. We see a dramatic increase in programme costs over the period, a result of the increased programme activities and strategies. In 2004, the high programme costs are maintained as in 2003, at approximately USD 2 million due to additional SIAs, this time for polio. In 2005, the costs will reduce, but increase again in 2006 to over USD 2.5 million due to the planned introduction of the Pentavalent vaccine. Costs further increase in 2007 due to the measles campaign that will be carried out then, before settling back at approximately USD 2.5 million. Significant increases in costs are again seen in 2011, corresponding to the year for the next measles SIA. We look at the relation of the routine programme costs to the number of children immunized with DPT3 this is illustrated in the figure 4.2 below. This represents the costs for the routine programme (routine capital and recurrent costs), compared against the expected number of children in each year receiving the DPT3 antigen.

17

Figure 4.2: Routine costs per DPT3 child for immunization in Lesotho, USD millions 2001 - 2013

$0.0

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

$35.0

$40.0

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

We see that the routine programme costs approximately USD 20 per DPT3 child immunized, up to the year 2006 when the Pentavalent vaccine is introduced. Then, the average routine programme costs increase to over USD 30 per DPT3 child immunized. Regarding finances available to fund these costs, table 4.2 illustrates the status of financing for the programme. This shows that, starting in the year 2005, there are funding gaps in areas beyond maintenance and overheads. These gaps are illustrated in the figure below: Figure 4.3: Secure/probable funding and funding gaps for immunization in Lesotho USD millions

18

$-

$1.0

$2.0

$3.0

$4.0

$5.0

$6.0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Funding Gap

0

0

0

CHAL

CDC

JICA thru UNICEF

Ireland Aid

UNICEF

WHO

GAVI - Vaccine Fund

Sub-national Gov.

Nat ional Government

19

Funding from Government, UNICEF, WHO, JICA are all going towards supporting the programme activities in this period. Government funds are for shared costs, together with the costs for EPI personnel, and the funds it has been contributing to the recurrent routine programme (including its ad hoc contribution for vaccines in 2004). The WHO and UNICEF funds are available as secured funds till the end of their present cooperation agreements with Government (2005 for WHO, and 2006 for UNICEF). Beyond this, their funds from their regular budgets are represented as probable funds. GAVI support on the other hand is for injection safety support up to 2005, Immunization System Strengthening and Hepatitis B support up to 2006. From 2006, support for the Pentavalent (only Hib portion of the vaccine) for 5 years is provided by GAVI. Funding gaps begin to become significant in 2006, increasing dramatically in 2007,and remain high. Dramatic increase in the funding gap is seen again in 2011. The initial increases in the funding gap up to 2006 are a result of partial funding for the different programme categories. Regarding the recurrent programme costs, vaccine costs are secured through 2006 through JICA, for the traditional vaccines, and GAVI for the new vaccines. In addition, funding is secured from Government for personnel costs. However, partial funding is available for the other recurrent programme costs. Injection safety support from GAVI ends in 2004, with JICA support through UNICEF replacing this up to 2006 requirements. From the year 2007, traditional vaccine costs, and injection supply requirements are part of the funding gap. In addition, the planned measles SIAs lead to increase in the funding gap, as it’s not known where these funds will come from. With the end of the GAVI Pentavalent support in 2010, the funding gap in 2011 increases even further, to over USD 1.7 million (USD 3.8 million when the measles SIAs are being implemented.

Table 4.1: Programme costs by cost categories, 2004 – 2013 in USD

Cost Category 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Routine Recurrent Cost USD USD USD USD USD USD USD USD USD USD

Vaccines (routine vaccines only) 162,704 148,029 1,331,433 1,090,996 1,111,744 1,133,978 1,156,658 1,179,791 1,203,387 1,227,454

Traditional Vaccines 76,810 68,802 31,962 29,797 29,321 29,907 30,505 31,115 31,738 32,372

New and underused vaccines 85,894 79,227 1,299,471 1,061,199 1,082,423 1,104,071 1,126,153 1,148,676 1,171,649 1,195,082

Injection supplies 49,265 53,438 41,029 41,776 42,583 43,435 44,304 45,190 46,093 47,015

Personnel 223,346 244,408 261,492 266,721 272,055 277,497 283,046 288,707 294,482 300,372

Salaries of full-time NIP health workers 87,192 105,531 119,837 122,233 124,678 127,172 129,715 132,309 134,956 137,655

Per-diems for outreach vaccinators/mobile teams 136,154 138,877 141,655 144,488 147,377 150,325 153,331 156,398 159,526 162,717

Transportation 1,085 1,660 575 2,349 2,395 2,443 2,492 2,542 2,593

Fixed site and vaccine delivery 983 1,504 521 2,128 2,170 2,213 2,258 2,303 2,349

Outreach activities 102 156 54 221 225 230 234 239 244

Maintenance and overhead 171,962 180,837 185,171 210,809 353,317 360,383 185,392 189,100 192,882 196,739

Short-term training 32,269 32,914 33,572 34,244 34,929 35,627 36,340 37,067 37,808 38,564

IEC/social mobilization 33,734 34,409 35,097 35,799 36,515 37,245 37,990 38,750 39,525 40,315

Supervision, Monitoring and Disease Surveillance 108,464 117,053 128,076 132,771 135,426 138,135 140,898 143,716 146,590 149,522

Other Outreach costs 7,859 8,017 8,177 8,341 8,507 8,677 8,851 9,028 9,209 9,393

Other routine recurrent costs 23,569 24,040 24,520 25,012 25,512 26,022 26,542 27,073 27,614 28,166

Annual cost for hiring aeroplane 14,376 14,663 14,956 15,256 15,561 15,872 16,189 16,513 16,843 17,180

Other communication costs 9,193 9,377 9,564 9,756 9,951 10,150 10,353 10,560 10,771 10,986

Subtotal Recurrent Costs 814,257 844,805 2,048,567 1,847,044 2,022,937 2,063,394 1,922,464 1,960,914 2,000,132 2,040,133

Routine Capital Cost

Vehicles 26,010 26,530 27,061 27,602 28,717 29,291 29,877 30,475

Cold chain equipment 2,497 71,428 144,193 2,703 47,505 3,342

Other capital costs 8,843 4,245 4,330 5,520 9,764 4,687 4,780 6,095

Subtotal Capital Costs 37,350 30,775 102,819 177,315 2,703 85,986 37,320 34,657 36,570

Supplemental Immunization Activities

Polio Campaigns 734,145

Vaccines 61,704

Other operational costs 672,441

Measles Campaigns 1,858,306 2,167,381

Vaccines 75,155 81,350

Injection supplies 36,028 38,998

Other operational costs 1,747,123 2,047,033

Subtotal Supplemental 734,145 1,858,306 2,167,381

Shared cost and other optional information

Shared Personnel Costs 307,112 315,048 323,178 332,129 338,772 345,547 352,458 359,508 366,698 374,032

21

Cost Category 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Shared Transportation Costs 532 543 554 565 576 588 600 612 624 636

Building 209,368 213,556 217,827 222,183 226,627 231,160 235,783 240,499 245,308 250,215

Subtotal Optional 517,012 529,147 541,559 554,877 565,975 577,295 588,841 600,619 612,630 624,883

GRAND TOTAL 2,065,414 1,411,302 2,620,901 4,363,046 2,766,227 2,643,392 2,597,291 4,766,234 2,647,419 2,701,586

Routine (Fixed Delivery) 1,187,154 1,264,252 2,471,069 2,351,857 2,610,122 2,484,165 2,434,879 2,433,193 2,478,445 2,529,232

Routine (Outreach Activities) 144,115 147,050 149,832 152,883 156,105 159,227 162,412 165,660 168,974 172,354

Supplemental Immunization Activities 734,145 1,858,306 2,167,381

22

23

Table 4.2: Secure, probable and funding gaps for the EPI programme, 2004 – 2013 Secure Funding 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

USD USD USD USD USD USD USD USD USD USD USD USD USD

National Government 659,973 579,888 741,999 1,429,260 790,878 819,007 838,429 856,940 874,059 891,519 909,331 910,654 928,848

GAVI - Vaccine Fund 0 37,400 171,206 172,559 170,065 1,336,871 1,098,599 1,082,423 1,104,071 1,126,153 0 0 0

WHO 98,756 103,292 118,599 98,276 98,276 0 0 0 0 0 0 0 0UNICEF 28,358 85,893 94,157 38,000 32,000 35,000 0 0 0 0 0 0 0Development

Cooperation Ireland 53,000 51,000 34,000 0 0 0 0 0 0 0 0 0 0JICA thru UNICEF 88,914 101,251 157,749 321,584 155,802 69,760 0 0 0 0 0 0 0

CDC 0 0 75,000 0 0 0 0 0 0 0 0 0 0CHAL 19,549 0 10,000 0 0 0 0 0 0 0 0 0 0

Total Secure Funding 948,550 958,724 1,402,710 2,059,679 1,247,021 2,260,638 1,937,028 1,939,363 1,978,130 2,017,672 909,331 910,654 928,848

Total Requirements 1,110,158 1,087,118 1,891,041 2,065,414 1,411,302 2,620,901 4,363,046 2,766,227 2,643,392 2,597,291 4,766,234 2,647,419 2,701,586

Funding Gap 5,735 164,281 360,263 2,426,018 826,864 665,262 579,619 3,856,903 1,736,765 1,772,738

Probable Funding 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

USD USD USD USD USD USD USD USD USD USD USD USD USD

WHO 0 0 98,276 98,276 98,276 98,276 98,276 98,276 98,276 98,276

UNICEF 0 0 0 35,000 35,000 35,000 35,000 35,000 35,000 35,000Total Probable Funding 0 0 98,276 133,276 133,276 133,276 133,276 133,276 133,276 133,276

Total Resource Requirements 2,065,414 1,411,302 2,620,901 4,363,046 2,766,227 2,643,392 2,597,291 4,766,234 2,647,419 2,701,586

Funding Gap 2,065,414 1,411,302 2,522,625 4,229,770 2,632,951 2,510,116 2,464,015 4,632,958 2,514,143 2,568,310

Secure + Probable Funding 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

USD USD USD USD USD USD USD USD USD USD USD USD USD

National Government 1,429,260 790,878 819,007 838,429 856,940 874,059 891,519 909,331 910,654 928,848

Sub-national Gov. 0 0 0 0 0 0 0 0 0 0GAVI - Vaccine Fund 172,559 116,627 1,336,871 1,098,599 1,082,423 1,104,071 1,126,153 0 0 0

WHO 98,276 98,276 98,276 98,276 98,276 98,276 98,276 98,276 98,276 98,276UNICEF 38,000 32,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000Development

Cooperation Ireland 0 0 0 0 0 0 0 0 0 0JICA thru UNICEF 321,584 209,240 69,760 0 0 0 0 0 0 0

CDC 0 0 0 0 0 0 0 0 0 0CHAL 0 0 0 0 0 0 0 0 0 0

Secure + Probable Funding 2,059,679 1,247,021 2,358,914 2,070,304 2,072,639 2,111,406 2,150,948 1,042,607 1,043,930 1,062,124

Total Requirements 2,065,414 1,411,302 2,620,901 4,363,046 2,766,227 2,643,392 2,597,291 4,766,234 2,647,419 2,701,586

Funding Gap 5,735 164,281 261,987 2,292,742 693,588 531,986 446,343 3,723,627 1,603,489 1,639,462

Section V: Sustainable financing strategies, actions and indicators The previous sections of this document have described the context, with constraints and opportunities, the programme objectives and plans; and cost implications and the financing options. We have illustrated the financial requirements in the medium to long term for the immunisation programme. In this section, we define the strategic plan that illustrates how the country will pursue financial sustainability for immunisation within existing and new mechanisms for resource mobilisation and use. Following a review of the opportunities and challenges, the section presents the proposed combination of strategies to be adopted. 5.1 Opportunities and challenges to financial sustainability in Lesotho

5.1.1 Opportunities Opportunities for funding are varied and exist at international, national and sub national levels. At the international level, there has been relatively strong donor support for immunisation activities in Lesotho through the multilateral agencies such as WHO and UNICEF and multi-bilateral support particularly JICA and Development Cooperation Ireland. Donors have in the past offered substantial resources for supplemental immunisation campaigns, reflecting their high level of trust in the immunisation programme. At the central level, the immunisation programme is a priority programme for the Government, and health sector. This receives significant recognition from policymakers, the head of state, donors and religious authorities. There are also a series of ongoing sectoral reforms that offer an opportunity to improve financing for immunization. The country is commencing an MTEF process, whereby the Government will be outlining its priorities over a 3 year rolling planning period. Decentralization is also taking root, with higher probability of allocation of resources for immunization activities by sub national units. Regarding the health sector, there exists significantly good health service physical infrastructure in a large proportion of the country. This offers the opportunity to offer fixed services to a large proportion of the population, and plan outreaches from units closer to the communities being targeted. 5.1.2 Challenges In spite of these opportunities, the challenges are still enormous. At the international level, there exist many other Global health initiatives targeted at specific interventions, in addition to GAVI. As such, many donors are channelling their resources through these initiatives with an effect on the amounts of resources they can avail directly to Government budget support. At the national level, the population still remains relatively poor, as shown by the low GDP, with a resultant limited ability to mobilise resources from its population. The high number of competing priorities for the Government resources compounds this in general and the health sector in particular. Many new, costly, but highly cost effective interventions are directly competing with the immunization programme for the meagre resources available. As a result, health spending by Government is low and spending for immunization within the health sector lower still. However, resource allocation for health, and within health, for EPI, is not related to the priority status/impact on developmental goals due to the absence of a rational allocation process. Reallocation of resources and budget cuts are common.

24

Further organizational problems further hamper adequate financing. There is lack of a coherent vision to guide activities and ensure these are done in the most efficient manner. There are weak financial management systems in place with a result of difficulty in accessing funds when needed by the implementation units. Absorptive capacity for funds is also very poor. This is related to the low numbers of health personnel and low skills among the few that exist to be able to adequately and efficiently absorb available funds or implement programme strategies satisfactorily. These human resource capacity gaps exist overall in the health sector particularly of significance in health planning and for the immunization programme in particular. Human resource gaps exist at all levels, from the central to the implementation level and is made more difficult by a high level of attrition of health workers. Regarding overall health service implementation, activities are highly fragmented with little coordination of integration efforts ongoing. There are high implementation costs incurred as a result of the difficult terrain in the country. Transport facilities are poor or often non existent, making delivery of services very difficult. In addition, the present GOL policy of vehicle use (only from 8am – 5pm) hinders smooth operations of the programme. This leads to very poor supervision and monitoring of service implementation with poor maintenance of equipment and high wastage in implementation (as seen for vaccines). Finally, there is a poor linkage between the communities and households, limiting the ability to utilise the communities in health service delivery. 5.2 Alternative policy scenarios In light of the funding gap presented in section 4 of this FSP document, the Government is exploring all possible options for ensuring the programme provides the best possible outcomes for the population, while working within the financing realities of the sector. Therefore, the government of Lesotho will consider the programatic implications, the impact on disease burden, the impact on child mortality and morbidity, and financial implications of other vaccine formulation options. Projections of costs for the EPI as alternatives to the maintenance of the above strategies (see section 4) were conducted for the following alternatives to the present programme strategies, with the aim of reducing the programme costs, and thus funding gap:

Alternative 1: Maintaining of the present antigens (no Hib introduction in 2006) Alternative 2: Reduced SIAs carried out for measles Alternative 3: Rationalization of per diems for health workers for outreach activities

The table 5.1 below illustrates the cost, programatic, and disease burden implications for each of these alternatives compared against the costed, baseline scenario (including Hib introduction in 2006).

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Table 5.1: Cost, programatic and disease burden implications of different policy options for Lesotho

Vaccine option

Cost of programme Programatic implication Disease Burden implication

Current option As illustrated in section 4 None None Alternative 1: Maintaining of the present antigens (no Hib introduction in 2006)

Significant reduction in cost, avoiding bulk of cost increase seen in 2006. High funding gap to occur after 2011 avoided

Missed opportunity to introduce additional antigen to population

Maintenance of high burden due to Hib disease in country

Alternative 2: Reduced SIAs carried out for measles

Avoid high costs due to SIAs in future

Reduced SIA activities, but need to increase routine coverage to delay onset of epidemics

Measles incidence higher, with frequent epidemics depending on routine coverage and efficacy

Alternative 3: Rationalization of per diems for health workers for outreach activities

Reduce personnel costs (reduced per diem costs)

Difficulty in ensuring outreaches are carried out, possibly limiting coverage

Possibility of higher disease burden due to all immunizable diseases

The impact on the overall cost is shown in the figure 5.1 and table 5.2 below. Figure 5.1: Impact of different policy alternatives on overall cost and funding gap for immunization, 2004 – 2013

Ba se l i ne

$ -

$ 1.0

$ 2.0

$ 3.0

$ 4.0

$ 5.0

$ 6.0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

No H i b

$ -

$ 1.0

$ 2.0

$ 3.0

$ 4.0

$ 5.0

$ 6.0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

No pe r di e ms

$ -

$ 1.0

$ 2.0

$ 3.0

$ 4.0

$ 5.0

$ 6.0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

No S I A ' s

$ -

$ 1.0

$ 2.0

$ 3.0

$ 4.0

$ 5.0

$ 6.0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

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Table 5.2: Total programme costs, available resources, and funding gaps for the 2004 – 2013 period in Lesotho

Baseline No Hib No SIAs No per diems

Total Secure Funding 15,792,229 10,542,118 15,119,788 14,301,381

Total resource Requirements 28,582,812 20,545,197 23,884,684 27,091,964

Funding Gap 12,790,583 10,003,079 8,764,896 12,790,583

Gap/total cost 44.7% 48.7% 36.7% 47.2% Table 5.2 shows that with no introduction of the Hib vaccine, the total programme costs will reduce by over USD 8 million over the period 2004 – 2013 however, the total secured funding also reduces by over USD 5 million (GAVI funding for the new vaccine not provided). The result is that, while the programme costs reduce, the funding gap as a proportion of the total resource requirements will increase to just under 50%. On the other hand, removal of SIAs will also reduce the total resource requirements over the same period by approximately 5 million, but will have little impact on the secured funding. As a result the funding gap will reduce dramatically with the proportion of the gap to total resource requirements falling to 36%. The programatic implications will however be very high. The campaigns represent progress towards a global goal, with the country reduced to not being able to match this global effort. In addition, resources for campaigns are more easily mobilized in general than resources for the routine programme. These resources have supported investments in the routine programme particularly relating to capital investments. Lack of the campaigns would therefore affect the availability of funds for this. Finally, the country may have to introduce a second measles dose in the absence of SIAs with the associated logistics eroding any financing gains that were made. Finally, the option of removal of per diems for health workers will reduce the programme costs over this period by approximately USD 1.5 million. There will however be no impact on the absolute funding gap as the total secured funding will reduce by the same amount (funds for per diems are provided by Government). This will therefore lead to an apparent increase in the proportion of the gap to total resource requirements. In addition, the outreach activities go towards achievement of a core programme goal of increasing coverage. As such, removal of funds for these would most probably impact negatively on achievement of core programme objectives. Basing on cost information alone, the absence of SIAs would lead to the most cost-favourable position, as the programme costs, and funding gaps will reduce. However, the Government preferred option is the current, baseline option as this impacts most on the disease burden, and so on the Government’s developmental, and PRSP objectives. The programme requires the correct mix of alternatives that maintain the programme objectives while fitting within the financial realities within which the programme is operating. We see that all the alternatives to the current, proposed option will lead to increases in disease burden, though may lead to reduced programme costs. Further analysis of cost effectiveness for these alternatives may need to be done to quantify the impact of each of the alternatives. To be able to maintain this option, the Government is to have a series of strategies and actions to ensure this is maintained.

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5.3 Strategies and actions for financial sustainability The strategies the programme shall pursue to ensure financial sustainability shall be in the areas of:

1. Mobilizing additional resources, 2. Improving the reliability of its resources, and 3. Improving programme efficiency

5.3.1 Mobilizing additional resources The programme shall seek additional resources to close the financing gaps it anticipates. The programme shall seek additional resources from Government by ensuring its costing and financing information is included in the new MTEF. This shall ensure it is included in the core planning and budgeting process for the GOL. Negotiations on increased financing can then be efficiently done, particularly with regard to GOL financing for vaccine purchases. Expected GOL funding shall be sought bearing in mind the total health sector and GOL resource envelope and competing priorities. Vaccine preventable diseases are estimated by WHO to contribute up to 8% of the total disease burden in the country (based on WHO Global burden of disease estimates in its 2004 World Health Report). As such, the programme shall target eventually having 8% of health sector funds utilized for immunization activities. Half of this (4%) shall be used for vaccine purchase, with the other half used for other programme operational costs. In addition, the programme shall seek additional resources from its partners. There shall be targeted resource mobilization form specific partners, based on the respective cost category for which funds are required, and the priorities of the partner. As an example, the funding gaps relating to capital investments shall be discussed with partners that support such investments e.g. JICA, while funding gaps for SIAs shall be discussed with the multilateral partners through whom most of the funds usually are channeled. The FSP plan shall be presented to various partners, including those currently not active in health, and/or EPI. The publicity of the programme shall be increased among these potential funders, with the programme achievements and financial situation elaborated. This shall ensure a wider group of partners are aware of the programme’s objectives and strategies, and the resultant costing and financing implications, and can decide on how best to support it, in line with their own priorities. 5.3.2 Improving reliability of resources The programme shall not only seek additional resources, but also seek to have its resources available to it in a more reliable manner. At present, the programme is only aware of its financing for less than 1 year’s equivalent of activities. This makes long term planning very difficult, and the programme has to rely more on ad hoc operational activities in line with the availability of funds. As mentioned above, the programme shall ensure its requirements are included in the GOL/health sector MTEF estimates. This provides a sectoral framework into which costing and financing estimates are elaborated on a 3 year rolling framework. A number of partners including EPI supporting partners like Development Cooperation Ireland shall be channeling the bulk of their resources through the MTEF process. As such, the programme’s costing and financing process (and so the FSP outputs) shall be better integrated into the GOL processes. It shall frequently review its 3 year funding gaps to ensure these are reducing as its efforts to mobilize more resources are bearing fruit. In addition, the programme shall seek to have improved accounting and reporting mechanisms. This will ensure its partners and GOL are always aware of how the resources are utilized in the programme, and

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avoid situations where funds are not committed because previous ones were not appropriately accounted for. The Ministry shall seek to have improvements in the planning and budgeting cycle processes, particularly at the district level. This will be aimed, as with above, at improving the flow of funds to the implementation levels, ensuring availed funds reach the intended beneficiaries in the most efficient manner. Finally, as with mobilizing additional resources, discussing of the programme's costing and financing situation with partners shall improve the awareness of the programme and its financing situation in the medium term, so enabling partners better plan their resource commitments in the future. 5.3.3 Improving programme efficiency Finally, the programme shall seek to ensure the finances it has or is able to mobilize are utilized in the most efficient manner with the best possible outputs derived from these funds. As mentioned in the beginning of this section, there are a number of issues that lead to inefficiencies both within the wider MOHSW (such as inadequate transport facilities, or low numbers and skills of health workers), or in the EPI (such as high vaccine wastage, and poor maintenance of equipment). Putting in place strategies to work towards limiting of these inefficiencies shall help free additional resources and be a strong advocacy tool to attract additional resources. The MOHSW shall accelerate strategies for strengthening capacity of health workers in health care micro planning organization and management. This at present is a key weakness among the implementation staff, with inadequate ability to ensure they are offering efficiently services within their areas of responsibility. The programme and the MOHSW shall also seek to improve/strengthen the monitoring and evaluation systems, particularly for EPI. At present, monitoring information is not accurately flowing in a timely and complete manner to all the levels where it is needed, and there is little feedback on this information provided. Comparison of efficiency among different EPI service delivery units (districts) shall be done to ensure adequate focus is maintained on inefficient units. The programme elaborated its multi year plan for 2002 – 2006 period. In addition, an EPI review was carried out that elaborated the key issues for focus for the programme. Review of status of implementation of respective recommendations made in these shall be done, including elaboration of reasons for the implementation/non implementation of respective recommendations. This shall be aimed at providing further guidance in development of a new multi year plan, based on feasible activities A further rationalization of the EPI management structure in the country shall be done. This shall be aimed at seeking that most appropriate system/structure that ensures efficient implementation of immunization related activities in the entire country. Finally, the programme shall seek to reduce wastage- particularly of vaccines. The present wastage rates shall be reduced through better needs assessment, cold chain improvement, and use of most efficient vaccine vial sizes. In addition, the continued use of the DT booster dose shall be reviewed.

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5.4 Implementation and follow up of financial sustainability strategies The implementation monitoring and follow up of these strategies shall be carried out by the ICC. Monitoring indicators, with frequency of follow up are illustrated in the table 5.2 below.

Table 5.2: Financial sustainability actions and monitoring indicators

Indicators

Strategy Actions

Responsible persons

Freq of follow up Indicator

Base line

Tar get

% national GOL health expenditure on vaccines

0% 5%

GOL EPI expenditure as a proportion of GOL health expenditure 8% Target additional resources from GOL through

MTEF process HPD/ EPI

Annually

GOL EPI recurrent programmeexpenditure as a proportion of GOLrecurrent expenditure

8%

Targeted resource mobilization from specific partners

WHO/ UNICEF

Annually Proportion of programme costs in MTEF planning period funded

80%

Present the FSP plan to various donors including those who are not currently active EPI and health

WHO/ UNICEF

Semi annually

Number of partners approached for funding for EPI

-- 3/year

Mobilizing additional resources

Increase of EPI publicity among potential funding partners

WHO/ UNICEF

Annually Number of additional partners agreeing to provide funding for EPI

-- 1/year

Include programme costs and financing in MTEF HPD Annually

Proportion of districts with fully costed EPI plans 0% 100%

Improved accounting and reporting by programme

EPI Quarterly Proportion of districts with EPI surveillance plan

0% 100%

Rationalize systems for allocation of resources OHSW in M

HPD Annually Allocation formula developed and implemented

Improved planning and budgeting cycle processes especially at district level HPD Quarterly

Number of programmes and districts conforming to the planning and budgeting cycle

100%

Improved reliability of resources

Present the FSP plan to various donors including those who are not currently active EPI and health

ICC Semi annually

In service capacity aimed at improving efficiency of service delivery EPI Annually

% of personnel trained in planning/organization skills each year 0% 100%

Reduce vaccine wastage EPI Quarterly DPT3 Vaccine wastage rate 37% 10%

Performance ranking of districts developed and implemented

Improve monitoring and evaluation systems for programme performance

EPI/ HPD

Quarterly Number of supervisory visits to districts

using supervisory checklists 100%

Rationalize programme management structure FHD Continuously

Technical review for appropriate programme structure to achieve programme objectives

Improved programme efficiency

Update EPI multi year plan EPI Continuously

Progress of Multi year plan reviewed

The ICC shall be responsible for monitoring implementation and follow up. A technical sub working group (FSP team) shall follow up on a regular basis, on behalf of the ICC, the implementation of the actions required to attain financial sustainability. This shall include representation from the EPI (EPI manager, surveillance officer and logistician), Health Planning Department, technical organizations on

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the ICC (WHO and UNICEF), Ministry of Finance, and 1 additional member chosen by the ICC. This group will designate a focal point to oversee the implementation process and coordinate the key players An action plan shall be elaborated by this team, which includes the short term actions required to follow up, and implement each of the above strategies and activities. The ICC shall review and monitor progress on a quarterly basis on the action plan as presented by the FSP team and plan for activities from the action plan to be completed in the coming quarter. For its part, the FSP team shall meet on a quarterly basis to review progress on expected activities and plan for upcoming tasks. On an annual basis the ICC and other stakeholders shall meet to review progress on financial sustainability based on the indicators used and actions expected then adapt the financial sustainability strategies and actions for the coming year based on the issues in the previous year. Outputs from this annual meeting shall form the basis for the reporting mechanism to GAVI on progress on financial sustainability (required with the Annual Performance Report)

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