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THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH – TANZANIA MAINLAND

NATIONAL IMMUNIZATION PROGRAM FINANCIAL SUSTAINABILITY PLAN

REVISED. NOVEMBER 2003, DAR ES SALAAM.

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TABLE OF CONTENTS Page No.

Table of contents ii Executive Summary iv Acknowledgement viii Abbreviations ix 1.0 COUNTRY AND HEALTH SECTOR CONTENT

1.1 Country profile 1 1.2 National health policy and other Reforms. 1 1.2.1 National Health Policy 1 1.2.2 National policy Reforms 2

2.0 BUDGET PROCESS AND FINANCIAL MANAGEMENT 2.1 Phase I: Pre – Budget Guideline 4 2.2 Phase II: Budget Preparation and scrutiny 4 2.3 Phase III: Budget approval 5 2.4 Phase IV: Budget Execution 6 2.4.1 Disbursement of Funds 6 2.4.2 Procurement of goods and services 6 2.4.3 Accounting 6 2.4.4 Reporting 6 2.4.5 Auditing

3.0 PROGRAM CHARACTERISTICS, OBJECTIVES AND STRATEGIES

3.1 Program characteristics 8 3.2 Immunization Coverage 8 3.3 Vaccine Wastage Rate 9 3.4 New Immunization Technology and Antigens. 9

4.0 BASELINE AND CURRENT PROGRAM COSTS AND

FINANCING

4.1 Baseline Program Costs and Financing Patterns 10 4.1.1 Expenditure Baseline Year (2000/2001) 10 4.1.2 GAVI/Vaccine Fund Expenditure for 2001/2002 (current year) 11

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5.0 FUTURE RESOURCE REQUIREMENTS AND PROGRAM FINANCING

5.1 Projections of Future Financing Levels and Patterns 15 5.2 Estimates of Financing Gap. 16 5.3 Risk Assessment 17

6.0 SUSTAINABILITY STRATEGIES PLAN AND INDICATORS

6.1 Immunization Program Constraints 18 6.2 Financing Strategies, Indicators and action plan 18 6.3 Conclusions and Final Recommendations 26

7.0 STAKEHOLIDER COMMENTS 26 ANNEXES

Annex A – Country and Health Sector Content Annex B – Table 1.1 Pre vaccine Fund Year Projections Annex C – Log frame of Strategies and actions to achieve Financial Sustainability Annex D – Advocacy Messages for key actors Annex E – Stakeholders Comments.

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EXECUTIVE SUMMARY The Immunization Programme on Tanzania mainland has as its goal the reduction in morbidity and mortality due to vaccine preventable diseases. The programme’s broad areas of activity are in routine immunization service delivery, disease surveillance and supplementary immunization activities. In the recent past, Tanzania has revitalized EPI, with improvements in EPI planning process, immunization coverage and safety of immunization, effective mobilization of funds for EPI, introduction of DPT- Hep B vaccine as well as in strengthening community ownership and involvement. In year 2001/02 there has been a switch from sterilizable syringes and needles utilization to the use of auto disable syringes and needles. In the same year DPT-Hepatitis B combination vaccine was introduced into the immunization schedule. A new vaccine, (HiB vaccine) against haemophilus influenzae, a bacterium contributing to major ill health and death in children under five years of age is planned to be introduced into EPI in year 2005/06. The programme is operating in a general macroeconomic environment of low per capita GDP, with limited government resources for health service delivery. The health sector currently receives on average 12% (2003/04) of the total Government resources, with the EPI receiving 2.5% to 3% of this amount. The total programme cost for the Financial Year 2000/01 (excluding personnel shared costs amounting to USD$ 479,256), was US$14,870,992, with per capita expenditure of 0.47 US$. Out of the total program cost, 47% was operational (i.e. US$6,854,055), 31% capital cost (i.e. US$ 4,704,635) and 22% supplemental immunization activities cost (i.e. US$3,312,301). The Government contributed 46% (i.e. US$ 6,813,112 the total program expenditure), whilst, 54% was provided by developmental partners. In 2001, the year when the programme introduced HepB vaccine in its schedule, the programme costs (excluding the personnel shared costs) increased to US$16,580,666 with a per capita cost of 0.51 US$. The break down of the 2001 program expenditure revealed 54% operational cost (i.e. US$8,981,321), 27% capital cost (i.e. US$ 4,399,949) and 19% supplemental immunization activities cost (i.e. US$3,199,396). The year 2001 showed reduction of Government contribution to 39% of the total programme costs with an increase in the donor contribution, partly due to support from the Global Alliance for Vaccines and Immunization. Over the medium term (up to 2008/09), the total program cost will continue to increase, with the increase driven partly by population changes, partly by increasing immunization coverage and partly by the introduction of new vaccine. The cost of the programme, by activity up to the financial year 2008/09 is illustrated in the graph below.

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EPI programme resource requirements projections to the year 2009/10

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5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

SIA's

Routine capitalcosts

Other recurrentcosts

Vaccines

On average, the government contribution during the Vaccine Fund (2003/04 -2005/06) period is 28% with a peak of 38% in year 2004/05. Though a comparison of the government contribution in 2000/01 of 46% to the projected average contribution of 28% during the vaccine fund period (2003/04- 2005/06) shows a decline, absolute quantitative increase of the government contribution is the case. The average GAVI contribution during the Vaccine Fund period is expected to be 49% with a peak of 73% in year 2005/06. The government contribution is expected to increase to an average of 62% during the post Vaccine Fund period. Some support will be secured from multilateral and bilateral organizations. The programme will have a funding gap that increases from US$2.424m in the year 2003/04 to US$19.538m by the year 2008/09. The total funding gap during the period of 2003/04 to 2008/09 is US$ 73.784m (53%) out of US$ 137.963m required by the program. This is depicted in the graph below

Funding gap for the immunization programme up to 2009/10

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

1

Ye a r

Unsecuredfunds

Securedfunds

The programme has identified the following strategies to undertake to fill this funding gap.

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

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The programme will secure additional resources from the health sector, local Governments, private sector and bilateral and multilateral donors. The ability to raise these resources from the Government is the key strategy in which the additional resources will be mobilized, within the financial realities in which EPI is operating. From the current US$ 3,670 (3%) of the health sector resources available to EPI, the programme shall seek an increase to US$9,824 (6%) of the health sector resources by 2008/09. Improvements in programme efficiency through a planned reduction of vaccine wastage to 10% of DPT-HepB by 2004 will be the focus. These strategies shall each raise resources to fill the funding gap as illustrated in the graph below.

Contribution to the funding gap from the different strategies

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5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

2003 2004 2005 2006 2007 2008Year

Remaining gap

M obilize privateresourcesAddit ional donorsupportIncrease mult ilateralcontribut ionsNew GAVI applicat ionfor Hib supportImproved programmeeff iciencyM obilize LGresourcesM obilize addit ionalGovt resourcesTotal secured

An action plan has been outlined for implementation of the above strategies. The implementation of this action plan will be through a functioning Inter Agency Coordinating Committee (ICC). The ICC shall, on a quarterly basis, review progress on the action plan as presented by the financing sub working group, and future plan for activities from the action plan to be completed in the coming quarter. A technical sub-working group of the ICC (the Immunization financing working group) will follow on day-to-day basis the implementation of the actions required to attain financial sustainability. This sub-working group with a maximum of 8 people will include representatives from the EPI programme, the technical organizations of the ICC (WHO and UNICEF), the Ministry of Finance and 3 additional members chosen by the ICC. The financing sub working group shall meet on a monthly basis to review progress on expected activities, and plan for upcoming tasks. . On an annual basis, the ICC shall have a retreat to review progress on financial sustainability based on the district and national based indicators identified, and will chart out the expected activities for the next year. Findings from this retreat shall form the basis for the reporting mechanism to GAVI on progress on financial sustainability.

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ACKNOWLEDGEMENTS The Ministry of Health wishes to acknowledge with sincere gratitude the Financial Sustainability Task Force and others who in one way or another contributed to the development and Finalization of the EPI Financial Sustainability Plan. The Task Force Comprised of Dr. C.S. Akim, Dr. D.P. Manyanga, Dr. M. Kitambi, Mr. S. Kibaja, Mrs. K. Aman, Dr. C. Atsyor, Dr. Lauwo, Mr. F. Blanco, Ms Sakina Othman, Mr. W. Msirikale, Ms. R. Kikuli, Ms. J. Bomani. Inputs from Dr. M. Kibona, and Ms. A. Nswilla are greatly appreciated. The Ministry also acknowledges with gratitude the comments from Dr. A. Mzige, the Director of Preventive Services and Mr. P.A.Ilomo, Mr. V. Maziwisa and Ms. Bryn Sakagawa for technical support. GAVI Secretariat for their financial support and the ICC members for their comments which made this plan possible. Last but not the least, Ms. A. Pandisha, the Secretary for assisting in assembling this document.

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Abbreviations AFP - Acute Flaccid Paralysis BCG - Bacillus Calmette Guerin BD - Becton Dickinson East Africa Operations CDC - Centre for Disease Control CHF - Community Health Fund DANIDA - Danish International Development Agency DFID - Department for International Development DMO - District Medical Officer EPI - Expanded Program on Immunization DPT- HB - Diphtheria, Pertussis, Tetanus and Hepatitis B DPT - Diphtheria Pertussis Tetanus EPI - Expanded Program on Immunization FSP - Financial Sustainability Plan GAVI - Global Alliance for Vaccine and Immunization GDP - Gross Domestic Product GFS - Government Financial Statistics HIPC - Highly Indebted Poor Countries IFMS - Integrated Financial Management System JICA - Japan International Cooperation Agency MCH - Maternal and Child Health MCHA - Maternal and Child Health Aid MDAs - Ministries, Departments and Agencies MOF - Ministry of Finance MOH - Ministry of Health MTEF - Medium -Term Expenditure Framework NIDs - National Immunization Days OPV - Oral Polio Vaccine PER - Public Expenditure Review PM - Program Manager POW - Program of Work PRS - Poverty Reduction Strategies RCCO - Regional Cold Chain Officer RCHS - Reproduction and Child Health Services RHMTs - Regional Health Management Teams RMO - Regional Medical Officer SIA - Supplementary Immunization Activities SNIDs - Sub-National Immunization Days TFR - Total Fertility Rate GOT - Government of Tanzania TT - Tetanus Toxoid UNICEF - United Nations Children’s Fund USAID - United States Agency for International Development US$ - United States Dollars

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WHO - World Health Organization

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1.0 COUNTRY AND HEALTH SECTOR CONTEXT 1.1 Country Profile The Tanzania mainland, together with Zanzibar forms the United Republic of Tanzania. Tanzania mainland (Tanganyika) attained Independence in 1961 and became a Union with the Island of Zanzibar in 1964. It lies just south of the equator between the Great Lakes of Victoria, Tanganyika and Nyasa on the Western frontier and the Indian Ocean on the East. It lies between the Latitude 1°S and 12°S and Longitudes 30°E and 40°E and it covers an area of approximately 945,050 Km2 including 59,050 Km2 on inland waters. Tanzania mainland has 21 regions and 117 districts. Each district is divided into divisions, which in turn are composed, of 3-4 wards (5-7 villages form a ward). The district is the most important administrative and implementation authority for public services. The United Republic of Tanzania has an estimated population of 34.5 million in the year 2002, (2002 population Census), of which 33.6 million constitute of Tanzania mainland. About, 20% (6,716,921 million) of the Mainland population are women of child bearing age and 4% (1,343,384 million) children under 1 year of age. These two age groups represent the populations that are eligible to receive immunizations. The population growth rate is 2.9% The government has continued to implement with notable success, various policies and reforms. Significant progress has also been made in the macroeconomic stabilization, which has facilitated positive economic growth in recent years. Overall GDP growth has steadily risen from 3.3 percent in 1997 to 5.6 percent in 2001 and 5.6 percent in 2002 despite a substantial deterioration in the terms of trade, notably the collapse of prices of the major traditional export crops. The government of Tanzania predicts that real economic growth will be 6.1percent in 2003 and increase to 7.2 percent by 2006. It is expected that continued macroeconomic stability and economic growth will help reduce poverty and increase equity. Continued economic growth may also enable the government to allocate additional resources to the immunization program Government reforms have also shifted the focus of health development to the districts. The EPI must now focus on building the capacity of the districts to help manage delivery of immunizations. 1.2 National Health Policy and Other Reforms 1.2.1 National Health Policy The National health policy which was formulated in 1990 is currently being reviewed by the Ministry of Health so that the policy addresses ongoing health sector and other reforms. The Tanzania health policy vision is to improve the health and well being of all Tanzanians with a focus on those at most risk and to encourage the health system to be more responsive to the needs of the people. (See also National Health Policy Objectives in Box 1.)

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Box 1: National Health Policy Objectives • Reduce the burden of disease, maternal and infant mortality and increase life expectancy through

the provision of adequate and equitable maternal and child health services, promotion of adequate nutrition, control of communicable diseases and treatment of common conditions.

• Ensure that the health services are available and accessible to all people wherever they are in the country, whether in urban or rural areas.

• Train and provide competent and adequate number of health staff to manage health services with gender perspective at all levels. Capacity building of human resources at all levels in management and health services provision will be the ultimate goal of the Government.

• Sensitize the community on common preventable health problems; improve the capabilities at all levels of society to assess and to analyze problems and to design appropriate action through genuine community involvement including community health financing.

• Promote awareness in government and the community at large that, health problems can only be adequately solved through multi-sectoral cooperation, involving other sectors.

• Create awareness through family health promotion that the responsibility for ones health rests squarely with the individuals as an integral part of the family, community and the nation.

• Promote and sustain public private partnership in the delivery of health services. • Promote traditional medicine and alternative systems of healing.

The Immunization Program is geared at achieving the above-mentioned vision and aims to protect the majority of children against vaccine preventable diseases. 1.2.2 National Policy Reforms The Tanzania Development Vision 2025, The National Poverty Eradication Strategy, Poverty Reduction Strategy Paper and the Tanzania Assistance Strategy are among recent Government policy documents that have set the Social Economic Development Agenda for the country. The health sector is among the priority areas. During the period 2001/02, the Government fulfilled the conditionality for the completion point of the Enhanced Highly Indebted Poor Countries (HIPC) Initiative debt relief tied to the PRSP, consequently making the government eligible for debt relief under the program. The savings from the debt relief, approximately US$23 million over three years, will be utilized in the implementation of the PRS and some of these funds will be used to support the immunization program. Financing of the strategy has been outlined in the Medium-Term Expenditure Framework (MTEF).

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Box 2: SWAP Mechanism The Sector Wide approach (SWAP) characterizes a method of working between government and development partners where all available funding for the sector supports a single sector policy and expenditure program, under government leadership adopting common approaches across the sector and progressing towards relying on government procedures to disburse and account for all funds. The sector wide approach in Tanzania started in July 1999 by developing a joint plan of work (POW) and Plan of Action (POA). Six development partners signed a side Agreement in April 1999 to jointly fund the Plan of Action through Basket Funding. These donors include DANIDA, DFID, CDC, Ireland Aid and NORAD. Other partners decided to continue funding the POA through the traditional means of vertical programs. In 2001 two other development partners joined the basket fund, KFW and GTZ. NORAD moved from the health sector and joined the education sector. In the process, a Basket Funding Committee was formed with the responsibility of assessing and approving priority plans designed for pooled financing within the context of the annual POA and Medium Term POW. The BFC also oversees the movement of funds from donor and government sources through to the Consolidated Fund.

One of the targets of the Tanzania Development Vision 2025 and other policy reforms is to reduce infant and maternal mortality rates by three-quarters of the current levels by the year 2025. The Immunization Program aims at assisting the achievement of this vision target. Currently, the Government is implementing the Public Service Reform Program (PSRP). In June 2000, phase two of the PRSP 2000-2011 was launched. The focus of the PSRP is on building the capacity of systems of pay reforms, meritrocatic recruitment and promotion, delegated management and continuous management performance. One of the PSRP medium term targets is to facilitate Ministries to formulate strategic, operational and action plans. For the Immunization Program to be sustainable, it must fit into these plans. Ongoing Local Government Reforms, among other reforms, are facilitating the implementation of sectoral reforms including those of the health sector. Each district health plan includes both curative and preventive services which are related to immunization and based on health service priorities. Activities included are the costs of outreach program, fuel, and salaries for health personnel including those who directly work on immunization activities such as DCCO’s, RCCO’s, MCH Coordinators and other members of the council and Health Management Teams. These costs are not included in this FSP. From 1996, the management of day to day immunization activities at the service provisional point was left to the Councils as part of the Health Sector Reforms. The Central MOH is left with the role of policy formulation, issuance of guidelines and immunization standards, procurement of vaccines, cold chain equipment and supplies and monitoring and supervision.

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2.0 BUDGET PROCESS AND FINANCIAL MANAGEMENT The financial year in Tanzania Mainland runs from July to June. The key macro economic processes in Tanzania are:

MTEF – The Medium Term Expenditure Framework budget process which is an annual exercise that sets 3 year rolling resource targets for the different sectors and programmes. It is triggered by the issuance of budget guidelines, which normally have budget ceilings for each sector. Immunization activities have a budget line item, which guarantees that it will receive a certain amount of funds each year. However, if the sector finds that the allocated resources are inadequate, then a case has to be made for allocating more funds during the distribution of resources process within the MOH.

Basket Fund – This is a pool of donor resources for the sector. The EPI program is allocated a certain amount of funding from the Basket Fund.

SWAP - During the SWAP meeting the health sector presents the Plan of Action (POA) and medium term Plan of Work (POW) that can be funded by both Development Partners and Government.

PER – The PER is a process whereby the past financial performance of the sector including the EPI is reviewed and projections of future requirements are made. The Permanent Secretary presents the MOH-PER paper during the review.

TAS – The Tanzania Assistance Strategy is a coherent national development framework for managing external resources to achieve the development strategies as stated in the Vision 2025, the National Poverty Eradication Strategy and the PSRP.

The table below highlights key macro economic figures for the Tanzania Mainland.

Table 1: Trends on allocation and disbursement of the governmental funds. (billions of Tanzania shillings)

2000/01 2001/02 2002/03 Population 31,664,944 32,610,653 33,584,607 Total health budget 178.17 217.19 243.22

Recurrent Government 75.47 (82%) 91.63 (80%) 109.39 (72%) Donor 16.48 23.29 42.81 Development Government 5.14 (19%) 5.34 (15%) 6.03 (15%) Donor 21.67 30.79 34.54 Off budget expenditure Government - (0%) - (0%) 1.20 (2%)

Budget breakdown

Donor 59.41 66.14 49.25 EPI budget Total EPI budget requirements 15 15 17 Total EPI Govt allocation 1.80 3.46 2.91 Proportionate Govt funding for EPI programme 0.12 0.23 0.17 Total EPI Govt budget as proportion of total Govt health budget 2.23% 3.57% 2.50%

Note: Information from Health Sector PER update FY 2003 and Tanzania MTEF 2003/04 to 2005/06 The health sector has been receiving on average 12% of the total Tanzania Mainland budget over the years assessed. Developmental partners to the health sector were contributing approximately half the health budget. However, most donor funds are used for other expenditures apart from recurrent program expenditures.

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In addition, these donor funds were more likely to be spent on off-budget compared to Government funds. Government funding for the programme has been at about 20% of total programme costs, even following the introduction of the HepB vaccine. The Government budget process and financial management has four phases namely, pre-budget guideline phase, preparation and scrutiny phase, approval phase and execution and financial management phase. The preparation and execution of the budget for the EPI follows these phases. 2.1 Phase 1: Pre-Budget Guideline This phase involves the review and projection by the President’s Office, Planning and Privatization in consultation with the Ministry of Finance, of macroeconomic performance in areas of policy targets, economic growth, inflation, government finance, monetary and credits development, exchange rate and external sector. It is also at this phase that the Public Expenditure Review is conducted initially by the PER Sector Groups and later at the national level involving development partners. (The PER exercise also does projections of medium-term sectors and total government resource requirements as per determined priorities}. It is at this juncture that global resource allocation to sectors; Ministries, Departments, Regions and Local Government authority are made. Both the macroeconomic review and projection and PER exercise provide important inputs to the budget guidelines. The final output of this phase is the issuing of guidelines for the preparation of Medium-Term Plan and Budget Framework document. Normally the guidelines are issued in December of each year. For the Immunization Program this phase may serve as an important entry point for soliciting resources by making sure that the program requirement are reflected in the health sector PER. 2.2 Phase II: Budget Preparation and Scrutiny The issuing of the budget guidelines triggers this phase. The President’s Office, Planning and Privatization in collaboration with the Ministry of Finance are the institutions responsible for the formulation of the guidelines. The guidelines provides Ministries, Departments, Regions and Local Government Authorities instructions on important issues to consider in the preparation of their budget, such as policy priorities, the format to use and indicative budget ceilings. It is at this stage that the Ministries, Departments, Regions and Local Government Authority begin the preparation of their budget based on MTEF. Currently, it is only Ministries, Departments and Regions that use the MTEF format. The Local Government Authorities are expected to start using the MTEF format in 2003/04-2005/06 budget cycle. The health sector at this stage would also involve Development Partners participating through SWAP and Basket Fund in its MTEF formulation. This is the stage where the actual allocation of resources to programs, objectives, targets and activities of the Ministries, Departments, Regions and Local Government Authorities are done. For the Immunization program this phase may serve as another important entry point for soliciting resources that are required for the program. The Ministries, Departments, Regions and Local Government Authority would submit their MTEF to the Ministry of Finance for scrutiny and consolidation of the total government MTEF. 2.3 Phase III: The Budget Approval The consolidated total government MTEF proposal would be submitted to the Cabinet to get the executive approval and later submitted to the Parliament for the legislature approval.

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2.4 Phase IV: The Budget Execution This stage involves disbursement of funds, procurement of goods and services, accounting, reporting and auditing. The phase may also serve as an avenue for the monitoring and tracking of the program resource inflows and expenditure. 2.4.1 Disbursement of Funds All funds for implementing the approved Government budget are disbursed through the exchequer system using the Integrated Financial Management System (IFMS}. All Ministries, Departments, Regions and Local Government Authorities are required to prepare cash flows indicating funds required on a monthly and quarterly basis throughout the year. For the priority sectors as stipulated in the PRS, releases of funds for recurrent expenditures are on quarterly basis at the beginning of every quarter. (The amount released is equal to, at the minimum, one fourth of the approved budget with a provision for additional funds for special expenditures that require a lump-sum payment). For other sectors releases of funds are on a monthly basis. (The amount released is equal to, at the minimum, one twelfth of the approved budget with provisions for additional funds for special expenditures that require lump-sum payments). Releases of funds for development expenditures are dependent on action plans, physical and financial progress reports and cash flows. Some donors channel their assistance directly to the projects without using the exchequer system and the IFMS. 2.4.2 Procurement of Goods and Services The new Public Procurement Act and regulations govern the procurement of goods and services for the government. The Act emphasizes on the use of open tendering process. The Immunization Program is required to abide to the Act in all its procurement transactions. It is important therefore for the program management to be conversant with the procurement procedures for smooth and timely implementation of activities. 2.4.3 Accounting The financial transactions of the government are done through the exchequer systems and IFMS. All revenue collection, payments, issuing of cheques, expenditures and procurement commitments are managed though the IFMS. Immunization Program financial transactions for all monies budgeted on the Government budget are also accounted through the exchequer and IFMS. 2.4.4 Reporting The Immunization Program is required to prepare financial and physical progress reports on a quarterly, mid-year and annual basis in the prescribed format described in the Public Finance Act and regulations and the guidelines for the preparation of a Medium-Term Plan and Budget Framework. Monthly reports are also prepared when required. Since EPI activities are part and parcel of the MOH annual plan, these reports are used as monitoring tools and therefore management tools to determine the progress of the activities being implemented. These reports will be similar to those required under FSP. 2.4.5 Auditing Auditing of Government accounts is performed by the Office of the Controller and Auditor-General who report their findings to the Parliament through the Public Accounts Committee and Local Government Accounts Committee for Ministries/Regions and Local Government Authorities respectively. Regulations also allow private audit firms to do special audits with the approval and on behalf of the Office of the Controller and Auditor-General. The Immunization Programme accounts are audited by the Office of Controller and Auditor General.

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Box 3: Shortcomings in the Budgeting Process and Financial Management: The current shortcomings in the budgeting process and the management of financial resources that may reduce the financial sustainability of the immunization program are as follows:

Poor forecasting of revenues especially external donor finance. Donor assistance and sector support spent off budget and not linked to government priority programs.

Unrealistic budgeting for essential expenditure. Weak links between PRS priorities, sector policies and the MTEF. Sub-sector

priorities do not reflect strategic priorities. Weak link between budget allocations and sector performance and absorptive

capacity. Actual expenditures do not reflect budget allocations. Delays in disbursement of funds and procurement of goods and services. Poor quality and untimely reporting of accounts and auditing.

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Box 4: Program Objectives

Routine: To monitor vaccine wastage and reduce wastage for DPT-HB from 20% of DPT-

HepB IN 2002 % to 10 percent by 2004. To improve vaccine safety by providing auto-disable syringes for 100 percent, BCG,

DPT-HB, Measles and TT vaccines by 2003. To achieve 90 percent coverage of all antigens for children under one year at district

level by the year 2005 including new vaccines such as Hepatitis B. To achieve 90 percent protection of children at birth from risk of neonatal tetanus

through TT immunization of their mother by 2005. To introduce Hib vaccine by 2005.

Accelerated disease control: To eradicate polio by the year 2003. To eliminate neonatal tetanus (incidence less than one case per1000 live birth) by

year 2004 in every district. To investigate and control 90 percent of measles outbreaks by 2004.

Disease Surveillance: To maintain non-Polio Acute Flaccid Paralysis (AFP) rates greater than one over

100,000 children who are less than 15 years of age. To integrate enhanced surveillance for polio, measles, and Neo-Natal Tetanus cases

with AFP Surveillance. To achieve 80% completeness and timeliness of routine immunization reporting from

districts to national level.

3.0 PROGRAM CHARACTERISTICS, OBJECTIVES, AND STRATEGIES

3.1 Program Characteristics The Expanded Program on Immunization (EPI) in the country started in 1975. The program is involved in delivering safe vaccines for vaccine preventable diseases to under one and women of child bearing age and/or populations at risk. It should be noted that, the private sector especially the non for profit which provides almost 40% of health services in the country. Also these facilities provide Immunization services. The government supports them with vaccination and other financial support in form of subsidies (salaries and bed grant). The programme also involves procurement of vaccines, supplies and equipment from the manufacturer/suppliers to the point of vaccine administration in a recommended condition. In the process of delivering vaccines, appropriate storage and transport facilities are important issues of the program. The current available vaccines in the program are BCG, OPV, DPT-HB, TT and Measles vaccines. Additional information about the program is located in Annex A.

3.2 Immunization Coverage During the year 2001, immunization coverage for TT2+ among pregnant mothers was 77 percent. For the schedule of children under one year, coverage for BCG was 90 percent, OPV3 68 percent, DPT3 87 percent and Measles was 86 percent.

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Box 5: Strategies to Improve Immunization Program Performance

Supporting fixed health facilities. Currently, there are 3544 health facilities providing immunization services which will be supported by:

Constant supplies of vaccines and kerosene. Constant maintenance and repair of cold chain equipment. Employment of enough MCHAs who provide immunization services. Transportation of vaccines from central level to the health facilities.

Improve mobile and outreach services. Ten percent of the immunization services are outreach and mobile. The strategies to improve the mobile and outreach services are:

Motivation of health workers. Provision of transport facilities at district level.

Reduction of missed opportunities, dropout rates, etc. This will be achieved by:

1 .Interaction of clinical and public services to health workers. 2. Strengthen social mobilization activities at the community level. 3. Constant supplies of vaccine, kerosene and cold chain spare parts. 4. Regular supervision of health workers. 5. Motivation of health workers e.g. training and retraining.

Targeting low performing districts for special strategies. This includes targeting the hard to reach populations by providing appropriate transport, appropriate storage i.e. sub-district vaccine stores and encourage community ownership/participation and advocacy at all levels.

3.3 Vaccine Wastage Rate The EPI previously used annual meeting to collect information on wastage rates. The monitoring system was established in June 2002 and it involves the use of vaccine wastage monitoring forms at all levels. Other initiatives to reduce vaccine wastage includes, training of health workers on vaccine forecasting and vaccine stock management, use of a multi-dose open vial policy and arrangements of effective immunization sessions.

3.4 New Immunization Technology and Antigens The program introduced DPT-HB in FY 2002/03, and plans to introduce DPT-HB-Hib in FY 2005/06. DPT-HB vaccine will be introduced to achieve an expected coverage rate of 90% for all antigens in all districts by 2005. The Hib disease burden rapid assessment conducted in October 2001 suggested that there is a great need of Hib vaccine to be introduced in the routine immunization schedule. The assessment revealed that Meningitis based estimates (low end) of 15,000 cases with 2,500 deaths per year, Meningitis based estimates (high end) of 18,000 cases with 3,000 deaths per year. Child mortality based method of 19,000 cases with 3,300 deaths per year. To address injection safety, EPI has introduced the auto destruct syringes in place of sterilizable needle and syringes. Other measures undertaken to improve injection safety include sensitization, education of health workers, and the construction of incinerators in all district hospitals. All of these measures have cost implications.

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4.0 BASELINE AND CURRENT PROGRAM COSTS AND FINANCING. 4.1 Baseline Program Costs and Financing Patterns The Immunization Program began receiving GAVI funds during the 2001/02 financial year. Prior to receiving GAVI funds, the immunization program received funding from both the central government and other partners DANIDA, WHO, UNICEF, DFID, Ireland Aid, JICA, GlaxoSmithKline and Rotary International. In 2002/03 the program continued to receive funds from the central government, GAVI/Vaccine Fund and other partners such as UNICEF, WHO, JICA, DANIDA, Ireland Aid, USAID and the Basket Fund. UNICEF, DANIDA and JICA support routine immunization activities whereas other partners WHO, UNICEF, DFID, and Rotary International support campaigns. From 2001/02-2005/06, GAVI is expected to play a significant role in supporting Tanzania’s immunization program. GAVI will provide financial support to the introduction of DPT-HB and to assist with system strengthening. Note that GAVI funds have to be divided between the Tanzania Mainland and Zanzibar. . 4.1.1. Expenditure for Baseline Year (2000/01)

The budget for immunization activities submitted at the MOH for initial discussion was US$24,317,000 and the amount submitted to the MOF was US$ 15,600,000. The large difference between the budget and actual allocation (expenditures) can be explained by the fact that program needs often outweigh the funds that are actually provided to the immunization program through central government and partner sources. During the pre-vaccine fund year (2000/01), actual expenditures were approximately US$14,870,992 (0.47 USD per capita). Details of breakdown by donors and cost categories of the programme expenditures are provided in table 1.1, Annex B. the cost categories included are the operational and capital costs for the programme, plus the costs due to supplemental immunization activities. In addition to these costs, the programme also incurs costs shared with other programmes in the sector. Personnel costs attributable to the EPI programme were estimated based on the proportion of time the different personnel spend on EPI activities. An estimated cost of USD$ 479,256 could be attributed to the programme. If this is included in the programme costs, then the total cost of the programme raises to USD 15,350,248. The Government input into the programme represented 46% of the total programme costs and was the highest contributor to the programme. Of the donors supporting the programme, JICA contributed the highest proportion of support, followed by UNCEF and DANIDA. Below is a summary of the breakdown by cost categories for which the funds were utilized.

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Financial Year 2000/01 major cost categorization for the EPI programme

Vaccines17%

Other recurrent costs30%

Rout ine capital costs31%

SIA's22%

The largest cost item for the programme was capital costs, followed by the operational costs (minus vaccines). The high capital costs were largely due to high investment in the cold chain system. Vaccines cost represented 17% of the total programme costs. 4.1.2 GAVI/Vaccine Fund Expenditures for 2001/02 (Current Year) During 2001/02, the first year that Vaccine Funds were received, total expenditures for the Immunization Program increased to US$16,609,242, equivalent to 0.51 USD per capita. Details of breakdown by donors and cost categories of the programme expenditures are provided in annex A, table 1.21. As with the FY 2000/01, the cost categories included are the operational and capital costs for the programme, plus the costs due to supplemental immunization activities. Inclusion of the shared costs raises total programme costs to USD$ 17,139,748. The changes in the funders for the programme in the year 2001/02 over 2000/01 are illustrated in the diagram below.

1 Expenditures for traditional vaccines total a higher figure than expected. This is attributed to the difficulty in attaining exact amounts spent on vaccines by the donors. Funds attributed to vaccine expenditure will usually include other donor expenditures, such as Technical Assistance. Relations of funders for the EPI programme, 2000/01 and 2001/02

12

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

16,000,000

18,000,000

2000 2001Year

Cos

t (U

SD) GAVI

MulitlateralsBilateralsGovernment

The chart above illustrates the overall increase in the programme expenditure. There is also slight reduction in the proportion attributed to Government (from 46% to 41% and that from the bilaterals supporting the programme. This is attributed to the reduction in support especially from JICA, even with the introduction of Ireland Aid, USAID and other basket funding donors the contribution were not able to offset the reduction. However, Mulitlaterals (WHO, UNICEF) support increased largely due to increased support for the Supplemental Immunization activities that were carried out. The introduction of GAVI support ensured resources available were higher than those for the previous year. Below is a summary of the breakdown by cost categories for which these funds were utilized.

Financial Year 2001/02 major cost categorization for the EPI programme

Vaccines20%

Other recurrent costs35%

Routine capital costs26%

SIA's19%

There is a slight increase in the proportion of costs due to vaccines, from 17% in 2000/01 to 20% in 2001/02. This is attributed to the introduction of the HepB vaccine. The proportion of costs due to recurrent programme activities increases too, again a result of the introduction of the HepB vaccine.

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5.0 FUTURE RESOURCE REQUIREMENTS AND PROGRAMME FINANCING: Estimates of future resource requirements have been derived using projections of the program objectives which were described in Section 3. The projections are calculated using the multi-year financing plan that was developed as part of the program’s Multi-Year Strategic Plan. Projections of resource requirements, future funding levels and patterns, and estimates of financing gaps have been developed based on the two funding periods, the GAVI/Vaccine Fund period 2001/02- 2005/06 and the Post–Vaccine Fund period 2006/07-2009/10. For each of the period, projections of resource requirement have used one scenario which is to introduce DPT-Hib in 2005/06. Also the projections for future funding have used one option which assumes GAVI Vaccine Fund is used over the period of 5 years (2001/02-2005/06). This is summarized in the diagram below.

EPI programme resource requirements: 2000/01 to 2009/10

-

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

SIA's

Routine capitalcosts

Other recurrentcosts

Vaccines

We see an increase in the programme costs over the years, with two peaks at the periods when the HepB is introduced (2002), and again when the Hib vaccine is expected to be introduced (2005). The causes for cost increases include an increase in the size of birth cohort, and strategies for increased coverage and new vaccine introduction. The new vaccine introduction causes to the highest increase in programme costs, this makes that the vaccine cost increasingly becomes the cost driver for the programme.

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The table below is a breakdown of the expected program requirements for specific line items for 2002/03-2009/10.

Table 2.1: Resource Requirements, 2002-2009 (in US$)

2002 2003 2004 2005 2006 2007 2008 2009 Operational Cost Vaccines 5,919,294 5,954,968 6,065,263 22,454,568 18,805,037 19,331,578 18,872,862 20,429,303Vaccines (traditional 6 antigens) 1,521,003 1,557,477 1,418,065 1,645,917 1,9692,062 1,739,379 1788,001 1,038,147Vaccines (new and underused vaccines) 4,397,491 4,397,491 4,464,188 20,000,651 17,113,005 17,592,200 18,084,700 18,531,155Injection supplies 2,016,845 2,073,317 2,131,370 2,346,123 2,250,935 2,313,960 2,378,751 2,445,356Personnel (per diems) 274,285 274,285 293,080 274,285 274,285 274,285 274,285 274,285Transportation 78,744 85,036 78,744 85,036 78,744 85,036 78,744 85,036Maintanance and Overhead 22,195.0 15,037.9 23,195.0 7,895.0 7,895.0 22,195.0 15,037.9 25,086.1Kerosene/gas 904,207.0 904,207.0 904,207.0 904,207.0 904,207.0 904,207.0 904,207.0 904,207.0Distribution of vaccines and supplies 202,247.0 202,247.0 202,247.0 202,247.0 202,247.0 202,247.0 202,247.0 202,247.0Short-term training 322,300 134,900 200,964 222,990 79,100 146,120 222,990 222,990IEC / Social mobilization 151,223 62,815 195,078 151,223 36,938 169,201 62,815 54,916Monitoring and surveillance 1,204,252 1,158,335 1,017,057 1,414,388 1,387,878 1,567,055 1,505,469 1,960,950Sub total operational costs 11,095,592 10,865,148 11,111,204 28,062,962 24,027,265 25,015,884 25,517,408 26,604,376Capital costs Vehicles 42,326 62,921 46,000 105,247 - 108,921 - 105,247Cold chain equipment 1,933,181 2,311,006 2,203,243 2,234,858 965,279 897,564 988,132 1,109,789Subtotal capital costs 1,975,507 2,373,927 2,249,243 2,340,105 965,279 1,006,485 988,132 1,215,036 Supplementary Immunization Activities (polio and measles) Vaccines 930,500 - - 1,356,203 - - - 1,912,144Injection supplies 567,000 - - 685,621 - - - 966,674Per diems 50,000 - - 50,000 - - - 70,496Operational costs 1,335,896 5,483 5,483 1,335,896 - - - 7,911Subtotal SIA's 2,883,396 5,483 5,483 3,427,720 - - - 2,957,225TOTAL COSTS 15,954,495 13,244,558 13,365,930 33,830,788 24,992,544 26,022,369 26,505,540 30,776,637Per capita 0.48 0.38 0.38 0.92 0.66 0.67 0.68 0.76Optional information Shared personnel costs 479,256 479,256 479,256 479,256 479,256 479,256 479,256 479,256Long Term Training 71,250 51,250 71,250 51,250 51,250 55,113 75,113 -GRAND TOTAL (with optional information) 16,505,00113,975,064 13,916,436 34,361,294 25,523,050 26,556,,738 26,059,909 31,255,893

The total program requirements from the financial year 2002/03 to 2008/09 without the personnel shared costs add up to US$ 153,916,244. Of this, US$ 76,095,771 is to be used between 2002/03 and 2005/06, and US $77,520,453 will be used from 2006/07 to 2009/10. This is without the option information of shared personnel costs.

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5.1 Projections of Future Financing Levels and Patterns: Total available funding based on available information is shown in Table 4 below. Some partner information was not available at the time the plan was prepared. Figures for government funding are projected allocations described in the Guidelines for the Preparation of the Medium-Term Plan and Budget Framework 2002/03–2004/05 Report (MTEF) and health sector PER exercise. Figures for the Basket Fund, GAVI/Vaccine Fund, UNICEF, WHO and JICA were gathered from the Ministry of Health MTEF for 2002/03–2005/06 (vol. II). The GAVI Secretariat has also recently confirmed its commitment of approximately US$ 28,171,436 over the five years period. Some funding estimates described as “possible” were based on conservative estimates of average past contributions from partners or were set as financing targets. For JICA, funding estimates for the period of 2003/4- 2005/06 has been based on the commitments shown in their comments (annex E) and the World Bank, for example, funding estimates are targets since the EPI program would like to request support from these partners to help with cold chain equipment replacement.

Table 4: Projected Funding by Partner, 2001-2008 (thousands of USD) Funding Source 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

Government 3,300 3,498 3,708 3,930 4,166 4,416GAVI/Vaccine Fund 4,800 3,000 17,536 0Basket Fund 696 424 422 419 415 411UNICEF 600 819 825 820 813 804WHO 1,175 1,219 1,167 1,159 1,150 1,137JICA 250 250 250 200 200 200*The unused funds from GAVI in 2001/02 (USD 3.9 million) are included in the 2005/06 estimates for GAVI funds. *The government contribution through out includes US$1.5m budgeted under the MOF and disbursed directly to the Councils for purchase of Kerosene/gas On average, the government contribution during the VF period is 28% with the highest contribution in year 2004/05 where it contributes 38% of the total resource required for the period. The contribution rises to an average of 62 % during the post VF period. On the other hand, GAVI contribution during the VF is 49% with the highest contribution of 73% in 2005/06 year. The government’s projected contribution has been estimated based on present allocation patterns. Due to the fact that the GOT is committed to the implementation of its Poverty Reduction Strategy (PRS) and that immunizations are one of the targets within the PRS, it has been assumed that the GOT will continue to finance immunization activities. Funding estimates of other partners were calculated using their average contribution to the program over the past several years. Only those partners with a high probability of funding the program in the future are included. Estimated amounts from bilateral partners (apart from JICA) are not included as it is not feasible to have these estimates from them at present. Because of high uncertainty, the estimates are quite conservative and will have to be reviewed from time to time.

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5.2 Estimates of Financing Gap

The diagram below show estimates of the financing gap based on the scenario and option described above which is introducing DPT-HB-Hib in 2005/06 and GAVI/Vaccine Fund support is used to purchase Vaccine and support operational costs for the remaining GAVI/Vaccine Fund period. From this information, it shows that the program’s funding gap increases in 2003/04 and decreases in 2004/05 before rising in year 2005/2006. A huge increase, US$24.6 million will occur when the pentavalent vaccine is introduced. This is partly a result of the Hib introduction, and partly due to the measles campaign planned for the same year.

Funding gap for the EPI program, up to 2008/09

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

2001 2002 2003 2004 2005 2006 2007 2008

Ye a r

Unsecuredfunds

Securedfunds

Table 5.1 Funding gap in thousands of US$. 2003 2004 2005 2006 2007 2008 Total Proj req 13,245 13,366 33,831 24,993 26,022 26,506 137,963 Total funding

10,821

9,210

23,908

6,528

6,744

6,968 64,179

Fund gap 2,424 4,156 9,923 18,465 19,278 19,538 73,784 *The projected resource requirement does not include the optional information on shared personnel costs and long term training (see table 2.1 above). From the above information, the funding gap increases significantly in the years 2005/06 as a result of the introduction of pentavalent and the campaign in the same year. For the period prior to the introduction of the Hib vaccine (2001/02 to 2004/05), only 17% of the programs cost is classified as unsecured. This increases to 63% for the period following the Hib introduction (2005/06 to 2008/09). The program is faced with a total funding gap that increases from US$ 2.424m in year 2003/04 to

US$ 19.538m by year 2008/09. The total funding gap during the period of 2003/04 to 2008/09 is US$

73.784m (53%) out of US$ 137.963m required by the program.

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5.3 Risk Assessment

It should be noted that this gap is large because of the difficulty in forecasting resources available far into the future, from whichever source. As a result, a number of donor/organizations that will be investing in the program by then are not included in the secured funds. The aim is to illustrate the level of uncertainty in funding the program objectives, as opposed to illustrating program under funding. The major source of secured funds is the GAVI resources, as illustrated in the diagram below.

Secured program funds by source, 2001/02 to 2008/09

0

5,000

10,000

15,000

20,000

25,000

30,000

2001/ 02 2002/ 03 2003/ 04 2004/ 05 2005/ 06 2006/ 07 2007/ 08 2008/ 09

Others

JICA

WHO

UNICEF

Basket Fund

GAVI/VaccineFund

Government

GAVI/Vaccine Fund and Government support constitute a large proportion of the secured funds for the VF period. The government and Basket Fund financing are dependent on the actual allocation in respective years. These commitments depend on the outcome of negotiations and prioritization through the PER and MTEF processes. Since the government budget is calculated in Tanzania shillings any exchange rate fluctuation will affect contribution levels. The present program strategy as outlined in section 3 and in the EPI Multi Year Plan presents the most cost effective use of the Government’s resources, and leads to the highest reduction in both mortality and morbidity for the particular conditions for which vaccines are being provided. 6.0 SUSTAINABILITY STRATEGIES PLAN AND INDICATORS 6.1 Immunization Program Constraints In the implementation of immunization activities, there are various constraints, which affect the performance and sustainability of the program. These constraints include:

(i) Inadequate funds for funding all planned activities. For example during the baseline year, the budget for cold chain equipment was US$3.6m and the available funding was US$3.3,a shortfall of US$1.2m which is 8 percent

18

(ii) Delays in disbursement of funds from both government and Development Partners. For

example, during 2001/02, the GAVI/Vaccine Fund support disbursement was delayed for nine months due to bureaucracy in discussions (decision-making) between MOH, WHO and UNICEF on who should be the custodian of the funds. Currently, the program is also faced with administrative delays in the disbursement of funds. The funds from the Basket for the year 2001/02 were released during the third and fourth quarter. The remaining funds from the Basket of the first and second quarter were released together in the last quarters. This affects the implementation of scheduled activities. For government funds, the amount released during the first and second quarter did not correspond to the requested amount.

(iii) Sometimes the program is faced with a problem of receiving fewer funds as compared to

pledges from different sources.

(iv) Delays in the procurement process affect the implementation of program activities. For example during 2001/02, the procurement of bicycles and cold chain equipment was delayed. Delays in honoring pledges lead to funds being frozen and therefore affecting program performance.

(v) Lack of adequate and qualified health staff especially at the facility level, leads to poor

forecasting and inefficient handling of vaccine supplies. This is one of the reasons for high wastage rate, which currently stands at an average of 20 percent for DPT-HepB in 2002.

(vi) Failure to realize additional resources as indicated in the financing strategies under section

6.2.

(vii) Failure to increase efficiency in reduction of wastage rate of DPT-HepB to 10% from the rate of 20% in 2002

6.2 Financing Strategies, indicators and action plan To address the funding gap illustrated under section 5.2 above, the FSP Task Force has developed a series of financing strategies and indicators to help address current and future financing needs. The strategies are designed to mobilize existing and additional resources, ensure reliability of resources and increase the efficiency in the use of resources. Some specific strategies include:

(1) Mobilizing new resources; (2) Improving reliability of resources, and (3) Increasing the efficiency of the EPI program

Mobilizing additional resources The strategies and actions to be used by the program to mobilize additional resources are varied. These additional resources shall be sought from government (both central and local), private sector and donors. The program shall institute a number of activities to ensure these resources are achieved each year, and are reflected in the MTEF. These are outlined in the log frame that is Annex C. They are presented within the text that follows

19

Additional central Government resources The resources sought have to fit within the financial realities of the sector, and so amounts sought shall be based on proportions of the sector budget, as opposed to basing them on the overall needs of the program. Central Government funding for the EPI program is presently at USD$2.91 million, representing 2.5% of the total health sector budget (table 1). This proportion is small, compared to the impact socially, economically and politically of the program for the Government and communities. This proportion is reduced from a level of 3.6% of the health sector budget the previous year As such, the program shall, within the financial realities within which the sector operates, and keeping in mind the needs of other health sector program, shall strive to have an increased resources through a gradual increase in its proportion of the health sector resources. This increase shall be sought in the medium to long term to ensure it has limited, or no impact on other Ministry of Health program or activity budgets. From the present 2.5% of the sector budget, the resources for the next financial year shall be at 3.6%, to reverse the slide in the sector proportion of the health budget and revert to the previous years share. Following this, the program shall seek a 1% increase in its proportion of the health budget from 4% to 6% by 2008/09. The implications of this financially are illustrated in the tables below.

2003 2004 2005 2006 2007 2008 Govt health budget/expenditure 122,345 129,686 137,467 145,715 154,458 163,725Proportion of health to EPI Govt budget 3.0% 3.6% 4.0% 4.0% 5.0% 6.0%Amount 3,670 4,669 5,499 5,829 7,723 9,824Incremental amount on secured funds 370 1,171 1,791 1,898 3,557 5,407 The ability to achieve these resources from Government will greatly impact on the ability of the other strategies to realise the expected resources. Additional local Government resources The Local Government’s are resource constrained, and rely largely on resources from the central Government for their activities. However, some program activities can be funded locally, particularly those relating to the usually funded activities for Local Governments. The activities relate to social mobilization of communities for routine EPI activities. In the long term, the program shall seek to shift 50% of the resources being spent on social mobilization to the local Governments. This shift shall be phased to ensure lessons learned are taken up in the most cost effective manner, and the Local Governments are only able to take up these costs based on their capacities. The strategy shall be to have 30% of these costs transferred to the Local Governments in the Financial Year 2003/04, 40% in the FY 2004/05 and 50% in 2005/06. The expected resources mobilized are illustrated in the table below

2003 2004 2005 2006 2007 2008 Social mobilization resources 63 195 37 151 37 169Proportion to LG's 30% 40% 50% 50% 50% 50%Incremental amount from LG's 18.84 78.03 18.47 75.61 18.47 84.60Note: High costs in the years 2004/06/08 are a result of community sensitization meetings to be held in these years

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To mobilize additional Government (central and local Government) resources requires a plan focused at the key stakeholders responsible for resource allocation for the program. These stakeholders include both technical and political actors, for which key advocacy messages shall be synthesized and presented in a brief (Annex D). The message from the program to the political actors shall focus on the possible political dividends of the strategy (the strategy involves the first introduction of new vaccines in 20 years), its relation to the ruling part manifesto and the social implications of not being able to implement the strategy. These actors shall be:

- The Office of the President, State House from whom the program would benefit from a clear message of support for the strategy (particularly relating to introduction of Hib in 2005)

- The office of the Prime Minister for advocacy within Government, - The Parliament for wider political support for the strategy

An information memorandum shall be prepared and presented to the Cabinet highlighting the EPI strategy, with its financial feasibility to achieve cabinet endorsement for the strategy. This shall make resource mobilization less difficult. The technical actors include persons from the Ministries of Health and Finance. These include:

- Minister of Health for top level political support in the sector, and to the wider Government - Ministry of Health Permanent Secretary for support from the top most key technical officer in the

ministry - Ministry of Health Director, preventive services who is the head of the directorate - Ministry of Health Director, policy and planning - Ministry of Finance and Economic Affairs health technical officer - Ministry of Finance and Economic Affairs Directors of planning and budgeting

For these technical actors, the focus of the advocacy shall be on highlighting the financial feasibility of the strategy, and the lack of impact on other programs, sectors and the overall macroeconomic framework of the country. Also highlighted shall be the availability of funding in the short, medium and long term, the impact of the strategy on disease burden, and the implications of not implementing the strategy. Included in the advocacy shall be actors at the regional and district level, where the advocacy focus shall be on the feasibility of the strategy, and their required activities in support of sub national resource generation efforts. Resources from private sector The private sector includes the private for profit actors, and the Non Governmental Organizations. A number of these have the potential to support specific program activities, but require to be provided with the appropriate message and strategies for collaboration. The NGO actors include humanitarian organizations, while the for profit sector includes the large actors in the commercial sector like the communication and beverage companies. Actions relating to these include initial identification of the appropriate actors to target. The program shall identify 2 to approach in the 1st year, starting with a humanitarian organization to understand the approach before contacting a commercial company. For each, background information is first required relating to estimates of the organizations advertising/support budget and activities it has supported in the past. The particular activities it could support are then identified within the program activities. Before contacting each, it is important to have a brief that highlights:

- Proposed areas of collaboration with the organization, - Resources sought - Benefits of the collaboration to the organization - Benefits of the collaboration to the EPI program and the Ministry of Health - Social benefits (to the community) of the collaboration

21

The resources sought from these shall be conservative, as it is a new sphere of operation for the program. As such, amount sought shall be limited at an equivalent of 50% of the social mobilization costs starting the Financial Year 2004/05. The expected resources are illustrated below.

2003 2004 2005 2006 2007 2008 Social mobilization resources 63 195 37 151 37 169Proportion to private sector 30% 50% 50% 50% 50%Incremental amount from private sector - 59 18 76 18 85 Additional resources from present EPI donors The program has a number of donors presently supporting its activities. These are the multilaterals WHO and UNICEF, bilateral donors (DFID, DANIDA, JICA, KFW and CDC) and GAVI. While the multilateral donors are able to provide some indication of support to the program in the medium to long term, it is not feasible for the bilaterals. As such, their possible contributions in the medium to long term cannot be estimated. Support from GAVI is secured up to 2005/06. From the multilateral donors, increased resource input into the program shall be sought, particularly for the areas of support being offered at present. Increases in support shall be sought, up to 50% increase in the present support. This increment shall be sought over time, from 30% of the present secured funds, up to a 50% increment by the end of the present GAVI support in 2006/07. The resource implications of this are illustrated below.

2003 2004 2005 2006 2007 2008 Secured resources 1,775 2,038 1,992 1,979 1,963 1,941Proportional increments 10% 20% 30% 50% 50% 50%Amounts sought 178 408 598 990 982 971 As the Hib vaccine is introduced at the end of the present GAVI support, the introduction of this vaccine will only marginally benefit from the present GAVI support. As such, a separate application shall be made to the GAVI board relating to the Hib vaccine. The Hib vaccine represents 70% of the pentavalent vaccine costs. This application shall be for 100% of the pentavalent proportion due to the Hib vaccine in 2006/07, reduced to 50% by the year 2008/09 as other sources of funds take over the vaccine fund. The resource implications are illustrated below. 2006 2007 2008 Cost of pentavalent vaccine 20,809 17,113 17,592 Proportion due to Hib 70% 70% 70% Proportion of Hib costs sought 85% 80% 70% Additional amount sought 12,381 9,583 8,620 Additional resources from other donors (past or new donors) Some donors have supported the program in the past (locally or in other countries), and are not supporting the routine program presently. These either provide targeted support (for example during NIDS) or have ceased to support EPI activities. The program shall seek funds from these donors for the routine program, as they have expressed support for immunization activities.

22

In addition, there are donors that have not supported the program before but are supporting activities similar to those of the program in other sectors or programs. These too shall be sought. They include multi-laterals such as the World Bank. The program shall seek to incrementally raise resources from these donors to the equivalent of the bilateral support prior to GAVI introduction. Resources sought each year are illustrated below.

2003 2004 2005 2006 2007 2008 Secured donor funds (minus multilaterals) 946 674 672 619 615 611Donor support prior to GAVI introduction 5,548 5,548 5,548 5,548 5,548 5,548Proportion of funds sought 30% 40% 80% 50% 70% 80%Amounts sought 1,664 2,219 4,438 2,774 3,884 4,438 Increased donor funds will be sought in the year 2005 to support the measles campaign that will be held that year. The program shall engage these donors to increase its resource base. For those that have expressed support for the program before, or in other countries, the initial activity shall be to determine reasons for non support of the present program. Based on these, two donors shall be engaged annually. For each, the program shall prepare a strategy that is based on:

- Activities for which support is required, with amounts of funds sought, - Impact of the additional funds on the program activities - Benefits to the community, and the donor for the support

Expansion of the ICC The ICC shall be expanded to include any new financial donors that are mobilized as a result of this strategy. This shall act as an incentive to them illustrating the openness (transparency) with which program activities and issues are handled. Increasing reliability of resources Resource reliability becomes more difficult with planning into the future. However, it enables the program develop and align its strategies in the future in line with the financial realities in the sector. As such, the program shall seek to increase the reliability of its resources, both from Government and donors. This strategy shall lead to financial sustainability indirectly, and not leading to direct resources to the sector. Increasing reliability of public resources The program shall ensure that its needs are included in the MTEF estimates. This shall be a result of active review of activities and costs of the program annually before the MTEF ceilings are determined, and ensuring this information gets to the Ministry of Finance formally or informally. In addition, the program shall ensure its resources remain protected within the Government, and sector budgets to ensure allocated resources are received by the program. Increasing reliability of donor resources

23

Advocacy illustrating the program strategies and performance shall be intensively applied to the present and potential EPI donors, in order to build and maintain confidence in the program. This shall be aimed at ensuring targeted resource requirements from the donors are met. Increasing program efficiency Reduce vaccine wastage Vaccine wastage causes significant increases in program costs. This is particularly so for the new vaccines, which are very expensive. The program shall institute a monitoring mechanism for vaccine wastage by district. The present (2002) wastage rate of 20% for DTP-HepB shall be reduced to 10% before the Hib introduction. The impact of this reduction is illustrated in the table below.

2003 2004 2005 2006 2007 2008 Present vaccine costs (20% wastage) 5,955 6,065 22,455 18,805 19,332 19,873Changes in vaccine wastage sought 15% 10% 10% 10% 10% 10%Effect on program costs 5,785 5,718 20,665 16,965 17,440 17,928Amounts saved by program 170 348 1,790 1,840 1,891 1,944 Further reductions in the vaccine wastage rates shall be sought based on focused activities in districts with high wastage rates. Inter district meetings will be organized to review activities being carried out that practically lead to reductions in vaccine wastage. The Kampala tool for vaccine costing and projection will be used to update the yearly focus of vaccine. Also the use of the open vial policy implementation will reduce wastage of vaccine. Maximize efficiency of static units for vaccination Health facilities offer the most cost effective method of offering immunization services. These are limited in coverage and so for higher coverage, outreach services are a necessity. At present, only 75% of the health facilities are offering immunization services. This is because of two reasons.

1) Some facilities are with overlapping areas of responsibility, such that it is not economical to have both offering immunization services. This is particularly so for facilities in urban areas

2) Some facilities lack basic resources (human or infrastructure/equipment) to be able to offer immunization services

The program shall seek to determine numbers of facilities not offering immunization because of lack of resources. In the short term, the program shall focus on ensuring resources directly relating to the program are made available in more facilities. In the medium term, the program shall advocate for improved availability of resources required at the facility but are out of control of the program, such as human resources. Advocacy shall focus on costs to the system of absence of these resources. Long term advocacy shall focus on improving numbers of static facilities per population bases, again having advocacy based on financial implications of lack of these in the respective areas. Maximize efficiency of outreach sessions Many of the outreach sessions are inefficiently carried out, with very few, if any clients seen. There are two plausible reasons for this:

i) Poor social mobilization, and ii) Poor selection of outreach sites

These are costly to the program. The program shall determine costs incurred for outreaches carried out that see different numbers of clients. These shall be used to determine a recommended number of clients seen at each outreach, with social mobilization strategies geared at achieving this target. In addition, rationalization of establishment of outreach posts will be carried out by the program.

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Use of private providers These are varied, and the sector rather complex. However, they are a source of health care and should be sought as possible providers of immunization services, particularly in hard to reach areas. Criteria will be determined by the program for collaboration with these actors, based on distance from a provider of immunization, and the resources (human and infrastructure) available to the provider. The diagram below shows the impacts of the above strategies on the funding gap.

Closing the financing gap: Contribution from respective strategies

0

5000

10000

15000

20000

25000

30000

35000

40000

2003 2004 2005 2006 2007 2008Year

Remaining gap

M obilize privateresourcesNew donor support

Increase mult ilateralcontribut ionsNew GAVI applicat ionfor Hib supportImproved programmeeff iciencyM obilize LGresourcesM obilize addit ionalGovt resourcesTotal secured

Significant reductions are brought about by the increased Government contribution to the programme, maintenance of donor support and the new application to GAVI for support following Hib introduction. However, ability to raise the additional resources from Government is the cornerstone strategy, as it acts as a key advocacy message when mobilizing the resources from the other actors. There are a number of strategies, whose cost implications are not included such as increasing resource reliability, maximised use of static units for immunization and increased collaboration with the private sector. These indirectly aid the attainment of the above strategies through acting as advocacy messages. Process to achieve financial sustainability The action plan is summarized in the logframe that is Annex C. A summary of the indicators to monitor from the action plan up to 2006 is summarized in the table below.

Strategies Indicator Indicator value

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Base-line

2003 2004 2005 2006 2007 2008

EPI budget as a proportion of Govt. health budget

3% 3% 3.6% 4% 4% 5% 6% Mobilize additional Govt resources

Govt contribution as proportion of recurrent programme costs

Mobilize additional local Govt resources

Proportion of EPI social mobilization costs funded from district-own resources

0% 30% 40% 50% 50% 50% 50%

Number of private firms supporting EPI program

0 2 4 6 8 8 8 Mobilize additional private resources

Proportion of EPI budget funded from private resources

0% 30% 40% 50% 50% 50% 50%

Mobilize additional resources from present EPI donors

Proportional increase in funds from present donors

0% 10% 20% 30% 50% 50% 50%

Mobilize resources from new donors

Proportional contribution from bilateral donors

-- 30% 40% 80% 50% 70% 80%

Expansion of ICC Number of new ICC members 0 Proportion of program costs funded by Govt 3% 3% 3.6% 4% 4% 5% 6% Increase reliability of public

resources Proportion of resources secured in the Medium Term

Improve reliability of donor resources

Proportion of 3-year secured program costs funded by donors

Reduce vaccine wastage Vaccine wastage rate 20% 15% 10% 10% 10% 10% 10% Increase vaccination offered through static units

Proportion of health facilities offering immunization

75%

Use of private providers in providing vaccination

Proportion of areas with no health facilities using private providers for vaccination

Increase in numbers of infants per outreach session

Average number of children per vaccination outreach

The ICC shall implement the action plan, with a technical sub working group from it following up on a daily basis the implementation of the actions required to attain financial sustainability. This sub working group (the Immunization financing working group) shall include a maximum of 8 people, who will include representatives from the EPI program (EPI manager and one staff), technical organizations on the ICC (WHO and UNICEF), Ministry of Finance and 3 additional members chosen by the ICC. The ICC shall, on a quarterly basis, review progress on the action plan as presented by the financing sub working group, and plan for activities from the action plan to be completed in the coming quarter. For its part, the financing sub working group shall meet on a monthly basis to review progress on expected activities, and plan for upcoming tasks. On an annual basis, the ICC shall have a retreat to review progress on financial sustainability based on the indicators used, and chart out the expected activities for the next year. Findings from this retreat shall form the basis for the reporting mechanism to GAVI on progress on financial sustainability (required with the Annual Performance Report) The different indicators for the above strategies shall be used by the ICC to monitor performance towards financial sustainability. They are both district and nationally based indicators, and are based on routinely available information, eliminating a need for data collection to monitor progress towards financial sustainability.

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6.3 Conclusions and Final Recommendations Tanzania Mainland’s Financial Sustainability Plan has developed one possible scenario and financing option, and strategies which aim to address financial sustainability needs of the immunization program. The FSP recommends that the pentavalent vaccine, DPT-HB-Hib, be introduced throughout the country during 2005/06. Section 5 has analyzed the funding gap for the GAVI/Vaccine fund period and the post GAVI/Vaccine fund period. In order to ensure that adequate funding is available, the FSP recommends that the GOT apply for additional support from GAVI/Vaccine Fund for the post GAVI/Vaccine period. The application will propose that the Vaccine Fund pay for the pentavalent vaccine and operational costs for the remaining period of the GAVI/Vaccine fund period. If the average cost price per dose of the vaccine drops making the vaccine more affordable, let us say, by 2007 and beyond, then the Government and other development partners will be able to fund for the vaccine. Even if the price of pentavalent vaccine decreases, Tanzania Mainland wiil faces significant funding gaps between projected program requirements and expected financial resources during and after the GAVI/VF period. The FSP Strategic Plan is designed to help reduce this funding gap by setting targets and indicators to help ensure mobilization of resources, increased reliability of resources and increased program efficiency. Tanzania Mainland’s strategic plan is quite ambitious and will require the active and sustained participation of multiple stakeholders. Furthermore, it is expected that GAVI at the global level will provide assistance with advocacy for additional funding from its partner organizations. It is also hoped that GAVI will bring all of its resources and influence to bear on its pharmaceutical partners to reduce the price of pentavalent vaccine. 7.0 STAKEHOLDERS COMMENTS In preparing the FSP, the Task Force involved other partners including the ICC members. The first ICC meeting was held on 11th November, 2002 and the second was on 20th November, 2002 in both the meetings members commented on the FSP. Following the comments from GAVI secretariat, the tasks force with the support of an external consultant from WHO-AFRO revised the document and submitted the same to the ICC members who made their comments. These comments together with those made earlier by JICA, USAID and UNICEF are attached to this document (Annex E).

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Annex A – Program Characteristics

(i) Program organization and Management The Expanded Program on Immunization is under the Reproductive and Child Health Section, which belongs to the Directorate of Preventive Services of the MOH. At the national level there is a Program Manager who is the overall in-charge of the program. The program comprises of four sections, which are Monitoring, Training, Administration and Cold Chain/Logistics. The role of the Program at Central level is to formulate policy guidelines and standard and guidelines on immunization strategies for immunization, planning and budgeting, training, procurement and storage of vaccines, supplies and equipment, distribution, monitoring and evaluation. The Central level is also vested with the role of managing the resources i.e. storage, distribution facilities, and equipment. At the regional level, the program is under the Regional Medical Officer (RMO) who is being assisted by Regional Cold Chain Officer (RCCO) and Regional MCH Coordinator. Their functions include planning and budgeting, storage, distribution, monitoring and supervision, training, technical support and management of resources of immunization activities at regional level. At the district, the District Medical Officer (DMO) is the in-charge of the program and is being assisted by the District Cold Chain Officer (DCCO) and the District MCH Coordinators. Their roles include: planning and budgeting for immunization activities, storage and distribution, monitoring and supervision, facilitating the implementation, training and providing technical support to the facilities.

(ii) Program Performance Immunization Schedules There are two immunization schedules currently in use. The first schedule is targeting to children under one year of age and the second is for women of childbearing age, that is, 15-49 years.

(i) Immunization schedule for under one year ANTIGEN SCHEDULE

BCG At birth OPV0 At birth DPT-HB1, OPV1 Four weeks DPT-HB2, OPV2 Eight weeks DPT-HB3, OPV3 12 weeks MEASLES Nine months

(ii) Child Bearing Age (15-49 years)

ANTIGEN SCHEDULE TT1 Any time in first contact TT2 One month after the 1st visit (TT1) TT3 Six months after TT2 TT4 One year after TT3 TT5 One year after TT4

Annex B: Pre Vaccine Fund year projections Table 1.1: Pre Vaccine Fund Year Costing (2000/01)

TOTAL Government

(Central) Government

(Local) UNICEF DANIDA JICA DfID WHO KFW USAID CDC

Operational Cost US$ US$ US$ US$ US$ US$ US$ Vaccines 2,601,714 Vaccines (traditional 6 antigens) 2,601,714 36,975 835,402 363,312 830,213 43,680 350,732 141,400 Vaccines (new and underused vaccines) - 0 Injection supplies 608,931 77,855 208,850 322,225 Kerosene/gas 904,207 895,219 8,988 Distribution of vaccines and supplies 202,247 112,359 89,888 Personnel (per diems) 274,285 274,285 Transportation 82,801 43,475 39,326 Maintanance and Overhead 14,299 1,939 5,618 6,742 Short-term training 277,558 277,558 IEC / Social mobilization 107,817 107,817 Monitoring and surveillance 1,780,197 1,717,018 63,179 Sub total operational costs 6,854,055 3,544,500 0 1,044,252 853,210 830,213 0 89,748 350,732 0 141,400 Capital costs - Transport (vehicles/bicycles) 59,359 59,359 Cold chain equipment 4,645,276 1,312,431 60,366 224,719 3,047,760 Subtotal capital costs 4,704,635 1,371,790 0 60,366 224,719 3,047,760 0 0 0 0 0

Supplementary Immunizaiton Activities (polio and measles) - Vaccines 1,609,752 Injection supplies 316,653 Per diems 50,000 Operational costs 1,335,896 Subtotal SIA's 3,312,301 1,896,821 159,303 1,156,177 100,000

TOTAL COSTS (without optional information) 14,870,992 6,813,112 0 1,263,921 1,077,929 3,877,973 1,156,177 89,748 350,732 100,000 141,400 0 46% 0% 8% 7% 26% 8% 1% 2% 1% 1% Optional information - Shared personnel costs 479,256 479,256 Long Term Training - 0

GRAND TOTAL (with optional information) 15,350,248 7,292,368 0 1,263,921 1,077,929 3,877,973 1,156,177 89,748 350,732 100,000 141,400 48% 0% 8% 7% 25% 8% 1% 2% 1% 1%

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Table 1.2: Vaccine Fund year costing (2001/02)

TOTAL Government

(Central) Government

(Local) UNICEF DANIDA JICA Ireland Aid WHO USAID GAVI Basket

Operational Cost US$ US$ US$ US$ US$ US$ Vaccines 3,310,240 Vaccines (traditional 6 antigens) 1,396,560 1,000 908,800 670,787 Vaccines (new and underused vaccines) 1,913,680 0 1,913,680 Injection supplies 2,082,453 1,293,455 227,200 561,798 Kerosene/gas 904,207 904,207 Distribution of vaccines and supplies 202,247 202,247 Personnel (per diems) 274,285 274,285 Transportation 85,036 85,036 Maintanance and Overhead 7,895 7,895 Short-term training 301,107 177,629 54,708 68,770 IEC / Social mobilization 282,100 282,100 Monitoring and surveillance 1,531,751 882,736 81,235 18,103 473,521 76,156 Sub total operational costs 8,981,321 4,110,591 0 1,136,000 1,232,585 81,235 18,103 0 0 2,441,909 144,926 Capital costs - Transport (vehicles/bicycles) 62,921 62,921 Cold chain equipment 4,337,028 1,750,406 224,719 2,361,903 Subtotal capital costs 4,399,949 1,813,327 0 0 224,719 2,361,903 0 0 0 0 0

Supplementary Immunizaiton Activities (polio and measles) - Vaccines 1,246,500 Injection supplies 567,000 Per diems 50,000 Operational costs 1,335,896 Subtotal SIA's 3,199,396 533,657 2,252,786 263,117 149,836

TOTAL COSTS (without optional information) 16,580,666 6,457,574 0 3,388,786 1,457,304 2,443,138 18,103 263,117 149,836 2,441,909 144,926 39% 0% 20% 9% 15% 0% 2% 1% 15% 1% Optional information - Shared personnel costs 479,256 479,256 Long Term Training 51,250 51,250

GRAND TOTAL (with optional information) 17,111,172 6,988,080 0 3,388,786 1,457,304 2,443,138 18,103 263,117 149,836 2,441,909 41% 0% 20% 9% 14% 0% 2% 1% 14%

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Annex C: Log frame of strategies and actions to carry out to achieve financial sustainability of the program

The program shall monitor the implementation of the FSP through following up on the strategies outlined in the Financial Sustainability plan (Section 6) with the monitoring indicators outlined. Below is a list of plausible strategies and actions, with expected timescales to them and indicators for monitoring the progress. Issues are noted regarding the progress on the indicators, from which the actions for the next time period are elaborated. Actions with a deadline of September 30th are background activities, some of which are already completed but are included here for completeness. They are required for a more holistic look at the FSP implementation process.

Indicator value Timeline for activities 2003 2004 2005 2006

Strategies Actions Key players

Indicator Base-line Target

9 10 11 12 1 2 3 4 1 2 3 4 1 2 3 4 Develop the brief / flyer highlighting key FSP messages

FSP team

Meeting with Director Preventive Health to highlight key FSP strategies and expected actions

EPI manager

Preparation of advocacy documents

Production and circulation of brief among govt and DP’s

EPI team

Meeting with Director, Policy and Planning

EPI budget as a proportion of Govt. health budget

Meeting with MOH Permanent Secretary (through Director Preventive)

FSP team

Meeting with Health Minister (through Permanent Secretary)

EPI team

Meeting with top management MOH (through PS/Minister of Health)

EPI team

Meeting with MoF health and budget technical officers

Meeting with Presidents office, planning and privatisation

Meeting with president’s office, state house

Meeting with prime Minister’s office

Mobilize additional Govt resources

Presentation of FSP information memorandum to cabinet

4

Indicator value Timeline for activities 2003 2004 2005 2006

Strategies Actions Key players

Indicator Base-line Target

9 10 11 12 1 2 3 4 1 2 3 4 1 2 3 4

Identify programme activities that can be supported (in kind or through funding) by local Govts

FSP and EPI teams

Proportion of EPI budget funded from district-own resources

Identify key Local Government actors to whom advocacy to be targeted

EPI & FSP team

Mobilize additional local Govt resources

Regional meetings with local govt actors

EPI team

Identify programme activities that can be supported (in kind or through funding) by private firms

FSP team

Number of private firms supporting EPI program

Identify key firms that have in the past supported:

- EPI activities - Health Sector activities - Other social sector activities

For each, highlight activities supported

EPI team

Proportion of EPI budget funded from private resources

Identify firms that are key players in the private market

EPI team

Mobilize additional private resources

Develop strategy for collaboration with 2 firms/year, highlighting:

- Areas of collaboration - Resources sought - Benefits to the firm - Social benefits of support

(benefits to community)

FSP team

Engage firms identified Mobilize additional resources from

Identify areas of programme each is supporting, and has potential of supporting

FSP team

Per capita contribution from present EPI donors

5

Indicator value Timeline for activities 2003 2004 2005 2006

Strategies Actions Key players

Indicator Base-line Target

9 10 11 12 1 2 3 4 1 2 3 4 1 2 3 4 Highlight possible areas for additional funding for donor in the activities they are supporting, or can support. Should have

- Additional amount being sought

- Amount of counterpart funding

- Impact of additional funding

EPI and FSP teams

present EPI donors

Meetings arranged with donors EPI teamr

Identify EPI past donors not supporting the program presently, with amount of support and areas of programme each is supporting

EPI team

Per capita contribution from past EPI donors

0 USD per capita

Seek reasons for not supporting present activities (e.g. do they only support NID’s, was there a change in donor policy, e.t.c)

EPI and FSP teams

Develop strategy for collaboration with donor that seeks funding and highlights how any issues that are stopping the donor from supporting the program are tackled

FSP team

Mobilize resources from donors that have in past supported program

Engage donors

Identify 2 potential EPI donors/year not supporting the program, with amount of support and areas each is supporting

FSP team

Per capita contribution from new EPI donors

0 USD per capita

Seek reasons for not supporting EPI activities (e.g. donor policies, not aware it needs support, etc.)

EPI and FSP teams

Develop brief for each donor that seeks funding for specified activities, and highlights how any issues hindering donor support are to be tackled

FSP team

Mobilize resources from new donors

Engage donors International resource mobilization

Continued provision of information to international partners on:

- Vaccine costs, - Health sector budget - Govt budget,

FSP team

6

Indicator value Timeline for activities 2003 2004 2005 2006

Strategies Actions Key players

Indicator Base-line Target

9 10 11 12 1 2 3 4 1 2 3 4 1 2 3 4 Expansion of ICC

Ensure new donors mobilized are part of ICC, and in regular attendance meetings

EPI team

Number of new ICC members

Identify and highlight funding gap in the present planning cycle for the Govt (Medium Term Expenditure Framework, if available)

FSP team

Proportion of program costs funded by Govt

Increase reliability of public resources

Advocate for protection/ring fencing of the bulk of program funds from Govt (particularly for vaccine purchases)

ICC Proportion of resources secured in the Medium Term

Improve reliability of donor resources

Secure guarantees from donors for funds promised to the program

EPI team, MOH director

Proportion of 3-year secured program costs funded by donors

Compute cost savings through reductions in vaccine wastage rates for the different regions/districts

FSP team

Vaccine wastage rate

Ensure a proper functioning system to monitor vaccine wastage rates by district is available

EPI team

Reduce vaccine wastage

Initiate additional strategies that will lead to lowering of Vaccine Wastage rates based on: - Those used in districts with low

rates - Known strategies that can be

introduced by the program

EPI team

Quantify cost savings through increase in potential vaccination posts in country

FSP team

Proportion of health facilities offering immunization

75% Increase vaccination offered through static units

Support districts to identify health facilities not offering EPI services

EPI team

7

Indicator value Timeline for activities 2003 2004 2005 2006

Strategies Actions Key players

Indicator Base-line Target

9 10 11 12 1 2 3 4 1 2 3 4 1 2 3 4 Identify reasons for non-provision of EPI services and define strategies to ensure these facilities start vaccination services in the short to medium term

EPI and FSP teams

Identify program-specific threats that hinder facilities offering EPI services and define strategy to ensure these are acted upon

EPI team

Define criteria for use on private facilities to identify those that can offer vaccination

FSP and EPI teams

Proportion of areas with no health facilities using private providers for vaccination

Meeting to sensitise districts on identification and use of private providers as static units for immunization

EPI team

Use of private providers in providing vaccination

Follow up on use of private providers in offering immunization

Implement strategy to increase engagement of local actors in mobilization for EPI

FSP and EPI team

Average number of children per vaccination outreach

Review and rationalise criteria for establishment of outreach posts

EPI team

Increase in numbers of infants per outreach session

Quantify cost savings through improved attendance at vaccination outreached

FSP team

Agreement on indicators to measure districts performance against each other

EPI and FSP teams

Use of performance standards by centre for districts

Information on performance of districts reported in regular ICC meetings

ICC

Annex D: Advocacy messages for key actors.

1. Generic advocacy messages The FSP in itself is the advocacy document. However, it is unlikely that the different parties that need to be targeted require to know all that is in the FSP. There are however a few key generic messages that need to be teased out of the FSP. These should be as few as possible, (strive for a maximum of 6) and have clear supporting evidence (from the FSP or otherwise) for them. They will include (but not be limited to) the following:

Message Evidence EPI strategy being adopted gives best value for money for the health sector, general govt. and the communities

Economic benefit: Use of vaccines leads to lower costs to MOH (need to quantify this) Use of vaccines is less costly to communities in terms of time spent ill, and resources spent seeking care (need to quantify this) Political benefit: Vaccination in most populations is a proxy for willingness to deliver health services by a Govt New vaccine introduction, or improvement of vaccination access strategies are a rare event that can be exploited for political gain Social benefit: Vaccines reduce ill health and so make population more available for work (need to quantify this)

The strategy being adopted is affordable in the medium to long term

Short term resources available (illustrate this. short term definition dependent on budget cycle) Evidence for potential for medium term resource availability (where may the resources come from?) Evidence for long term resource availability (link economic growth rate to resource needs of programme)

Increased investment in EPI by govt will not lead to reductions in other programme resources

Increased investment phased, not one-off expectation (illustrate this) Increased investment by Govt within expected growth of health budget (illustrate this for the short to medium term)

Strategy falls within the health sector development strategies/plan (SWAp)

FSP strategies fall within the short, medium and long term Govt development strategies (as outlined in the NHP, Tanzania Assistance Strategy, MTEF and PER, PRSP, Vision 2025 documents)

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2. Targeted advocacy messages For each of the different actors, the advocacy focus will be different as outlined in the table below

Actor Key focus of messages Contact type Expectations Monitoring of achievement

The President’s office, State house

Political dividends of funding of the strategy for the Govt Implementation of ruling party manifesto Impact of financial implications on economic trends Social Implications of failure to implement strategy

Cabinet meeting where cabinet information memorandum presented

Clear and consistent message of support of the strategy from the highest office in the country

Information memorandum endorsed The president voicing support for introduction of further vaccines beyond traditional ones

Office of the Prime Minister

Political dividends of funding of the strategy for the Govt Social Implications of failure to implement strategy

One on one meetings with, and availing of brief to Prime Minister

Advocacy for strategy within Government and media

Members of Parliament

Political dividends of introducing new vaccines, and funding of the strategy Social and economic implications of failure to implement strategy

Advocacy meeting Social services committee with clear understanding and support of strategy

Office of the Minister of Health

Political dividends of funding of the strategy for the health sector Financial feasibility of the strategy and how it fits into the financial realities of the sector Political and social implications for health sector of failure to implement strategy

One to one meeting with Minister of Health

Clear and consistent message of support for the strategy from the top Ministry of Health official

Office of the Minister of Health expresses support for strategy, particularly introduction of new vaccines in public statements

Permanent secretary

Financial feasibility of the strategy and how it fits into the financial realities of the sector Financial implications of the strategy for other programs Impact on disease burden with and without the strategy Implications of additional resources through the strategy on macro economic policies of Govt Political, social and economic implications of failure to implement strategy

One to one formal meetings between program and Director (more than one should be held)

Active support for the strategy from the top most technical officer in the Ministry of Health

Permanent Secretary seen to be actively supporting the strategy.

Director preventive Services

Financial feasibility of the strategy and how it fits into the financial realities of the sector Financial implications of the strategy for other programs Impact on disease burden with and without the strategy Implications of additional resources through the strategy on macro economic policies of Govt Political, social and economic implications of failure to implement strategy

One to one formal meetings between program and Director (more than one should be held)

Active support for the strategy from the top most technical officer in the Ministry of Health

Director preventive services seen to be actively supporting the strategy by --------

Director policy and planning

Financial feasibility of the strategy and how it fits into the financial realities of the sector Financial implications of the strategy for other programs Impact on disease burden with and without the strategy Implications of additional resources through the strategy on macro economic policies of Govt Political, social and economic implications of failure to implement strategy

One to one formal meetings between program and Director (more than one should be held)

Active support for the strategy from the top most technical officer in the Ministry of Health

Director policy and planning seen to be actively supporting the strategy by --------

Ministry of Health top management

Financial feasibility of the strategy and how it fits into the financial realities of the sector Financial implications of the strategy for other

Presentation at a meeting of the top management

Ministry of Health top management aware of strategy

Presentation of strategy highlights at top management

4

Actor Key focus of messages Contact type Expectations Monitoring of achievement

(PS, directors, chief medical officer and all heads of independent departments)

programs Impact on disease burden with and without the strategy Political, social and economic implications of failure to implement strategy

details, with endorsement by it

meeting by ----- Minutes of top management meeting expressing views on the strategy

Ministry of Finance technical official

Feasibility of the strategy and how it fits into the financial realities of Govt and the health sector Availability of funding for the strategy in short, medium and long term Implications of additional resources through the strategy on macro economic policies of Govt

One to one meetings

Clear understanding of full financial implications of implementation or non implementation of strategy Modification of immunization ceiling by MoF

Advocacy for strategy within Ministry of Finance by concerned official

Presidents office planning and privatisation

Feasibility of the strategy and how it fits into the financial realities of Govt and the health sector Availability of funding for the strategy in short, medium and long term Implications of additional resources through the strategy on macro economic policies of Govt

One to one meetings

Clear understanding of macroeconomic implications of FSP

Key Development Partners

Long term Govt financial feasibility of the strategy and how it fits into the financial realities of the sector Implications on disease burden of additional resources for the strategy Implications of not implementing strategy

One to one meetings following a broad meeting with the key partners

Clear understanding of full financial implications of implementation or non implementation of strategy

Advocacy for strategy by key development partners Increased financial commitment to strategy by DP’s

Regional and district technical officials

Practicability/feasibility of strategy Implications of strategy on delivery of vaccination

Discussion within regular regional technical meeting

Clear understanding of roles in implementation of FSP

Technical officers properly carrying out their roles regarding FSP implementation

Regional and district administrative officials

Feasibility of additional investment to specific program areas Political and social benefit to sub national unit for added investment

One to one meetings by sub national technical officers

Clear understanding of full financial implications of implementation or non implementation of strategy to the sub national unit

Increased financial commitment by sub national units to strategy

ANNEX E: STAKEHOLDERS COMMENTS

ICC COMMENTS ON THE REVISED IMMUNIZATION FINANCIAL SUSTAINABILITY PLANS Following the revision of the document, ICC made comments which have been incorporated in the revised document. 1. JICA

We have carefully gone through the document and found out that some statements or sentences need improvements, changes or even corrections in order to put the information carried much clearer. Other comments are;

• In Table 4; Projected Funding by Partners, 2001-2008, JICA, is projected to support until the year 2008/09. However, JICA is no where intending to support beyond 2005/06.

• Under Section 6.1: Immunization Program Constraints, the wastage rate of antigen is shown as 25%. It should be better to show wastage rates for each kind of vaccine.

2. USAID The document is a good product and a result of enhanced partnership led by the MOH. Generally, the plan is strategically sound: it pulls together three important tactics-advocacy; fundraising and achieving economies of scale in the existing program. It is very clearly articulated; the summary tables with activities for advocacy, fundraising and cost savings were very useful. Other key areas of interest:

• The background section on Tanzania’s budgeting process was interesting. It helps to clarify why advocacy will be so important for EPI

• Increasing savings: the principal area in which the plan proposes to achieve is in vaccine wastage. We would suggest a more aggressive examination of the different costs associated with EPI to see there are possible savings in other areas.

• Increased donor support: We would also suggest that there be a research into other global vaccine initiatives. For instance that the Gates Foundation is very involved (a lot of their money already goes to GAVI); this might be a good time for us to look at Global Alliance for EPI – We are sure that all countries will have the same spike in costs as they introduce the new vaccine and that many countries will also have the same shortfall in funding.

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3. WHO In general he updated FSP document is a comprehensive, well prepared and WHO is looking forward to it as a plan which once implemented will lead to a more sustainable immunization program. WHO is fully committed to provide technical support towards sustainable immunization services especially with the introduction of new vaccines? The identified strategies to reduce the financing gap if well implemented will lead to a sustainable plan.

4. DCI – (Ireland Aid).

Generally the document is well written and strategies very explicit. Most of our comments are on improving read-ability (editorial and some few suggestions on strategic areas to focus.

5. UNICEF

After reviewing the revision of the FSP, UNICEF would like to submit to the team finalizing the document the following comments.

Baseline Program costs and Financing Patterns. Paragraph 1, states “….where as other partners WHO, UNICEF, DFID and Rotary International only support campaigns.” It is recommended that the text eliminates the word only, as WHO and UNICEF support routine activities. Projected funding of UNICEF to EPI Program (table 4) The contribution of UNICEF to EPI program in 2003 is expected to total 600,000 USD, as indicated in the table. Support in the period 2005/2008 cannot be determined at present, as it would depend largely on success of fundraising for activities planned jointly with the GOT/MOH. For Supplementary immunization Activities, and in line with previous support, UNICEF, would aim at covering half of the costs related to such activities. The revised FSP includes a comprehensive plan for resource mobilization and strategies for program sustainability. UNICEF supports this plan and will make all efforts as a partner to the Government of Tanzania to facilitate and support the processes necessary for its success.

4

References

1. Medium Term Expenditure Framework 2002/03-2004/05 2. Tanzania Assistance Strategy 2001 3. Guidelines for the Preparation of Medium Term Plan and Budget Framework for

2002/03-2004/05 (December, 2001) 4. Poverty Reduction strategy Paper (October, 2000) 5. Tanzania Development Vision 2025 6. National Health Policy 1990 7. The Economic Survey 2001 8. Guidelines for preparing a National Immunization Programme Financial

Sustainability Plan (May 2002) 9. Hib Disease Burden Assessment (EPI 2001). 10. Five year EPI Strategic plan 11. EPI review of 2000

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