The Republic of The Gambia Department of State for

The Republic of The Gambia Department of State for Health &Social Welfare The Financial Sustainability Plan Submitted to GAVI November 2003 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Table of Contents Executive Summary List of Acronyms Acknowledgements 5 6 7 SECTION 1 Impact of Country and Health System Context on Immunization Programme Costs, Financing and Financial Management 1.1 Background 8 1.2 Country Vision and main agenda 8 1.3 Macro-economic trends 9 1.4 Administrative context 10 1.5 Health system context 11 1.6 Health Programme Areas 12 1.7 Health Services Delivery 13 1.8 Health Policy and Health Public Expenditure Review 13 1.9 Budget Process and Financial Management 13 1.10 Budgeting, Financial management systems 14 1.11 Accounting and Audit 15 1.12 Health Financing Information 15 SECTION 2 Expanded Programme on Immunization: Characteristics, Objectives and Strategies 2.1 Background 16 2.2 Programme Objectives 17 2.3 Vaccine Procurement and Financing 19 2.4 Programme Management 19 2.5 Transportation and storage facilities 20 2.6 Financing the National Immunisation Programme 20 2.7 Payment of service providers 21 2.8 Plans for the future 21 SECTION 3 Current Expenditure & Financing 3.1 Introduction 3.2 Baseline and Current Program Costs 3.3 Baseline and Current Program Cost Funding 3.4 Supplementary Immunisation Activities 22 22 25 28 Version: Final Page: 2 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 SECTION 4 Future Resource Requirements and Programme Financing 4.1 FSP Cost Projections 4.2 Strategic Initiatives Planned for and incorporated in the Forecast Period 2003 – 2012 4.3 Probable Sources of Finance & Funding Gap 4.4 Projected Key Indicators 4.5 Scenario B: Projections for inclusion of Pneumococcal Vaccine in 2007 4.6 Key Indicators for Scenario B 29 30 32 34 35 37 SECTION 5 Sustainable Financing Strategic Plan and Indicators 5.1 Key objectives for the Financial Sustainability Plan 5.2 Requirements for Success 5.3 Strategic Plan to Achieve Sustainable Financing 5.4 Conclusion 38 38 39 41 List of Tables Table 1.1: Table 1.2 Table 2.1 Table 2.2 Table 3.0 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 5.1 Health indicators for The Gambia compared with average for Sub-Saharan African countries 9 Projections for key macroeconomic indicators: 2002- 2005 9 Percentage immunization coverage over the last eight years 16 Reported cases of selected vaccine preventable diseases 1995 – 2002 17 Baseline and Current Year Costing - Summary of FSP Table 3.1 and 3.2 23 Baseline Costs 2002 Appendix A Current Year Costs Appendix A Wastage Levels Summary 23 Funding Sources 2002 25 Summary Indicators 28 Projections of Future Resource Needs 29 Projected Vaccine Wastage Savings 30 Cost Projections 32 Projected Funding Gap 32 Projected Financing 32 Projected Key Indicators 34 Projections of Future Resource Needs – Scenario B – Including Introduction of Pneumococcal Vaccine 35 Projected Funding Gap – Scenario B – Including Introduction of Pneumococcal Vaccine 35 Cost Projections Scenario B – Including Introduction of Pneumococcal Vaccine 36 Projected Key Indicators – Scenario B – Including Introduction of Pneumococcal Vaccine 37 Strategic Plan 39 Version: Final Page: 3 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 List of Figures Figure 1.1 Figure 1.2 Figure 2.1 Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 3.5 Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Organisation of the Health Department 11 Organisation of delivery of EPI services 12 Proportion of children fully immunised less than 12 months. 18 The Gambia National Immunisation Program – 22 Baseline Cost Profile 2002 – Excluding Supplementary Immunisation Activities The Gambia National Immunisation Program – 22 Current Year Cost Profile 2003 – Excluding Supplementary Immunisation Activities The Gambia National Immunisation Programme – 25 Financing of Recurrent EPI Activities – Baseline 2002 Excluding Capital Costs & Supplementary Implementation Activities The Gambia National Immunisation Programme – 26 Financing of Recurrent EPI Activities - Current Year 2003 Excluding Capital Costs & Supplementary Implementation Activities Funding Comparison – 27 Baseline 2002 v Current Year 2003 – Excluding Supp. Immunisation Activities and Capital Costs Projections of Future Resource Needs by Cost Categories 29 Projections of Secure and Probable Financing 32 by Source and Funding Gap Projections of Future Resource Needs by Cost Categories – 35 Scenario B Projections of Secure and Probable Financing 35 by Source and Funding Gap – Scenario B List of Appendices Tables 3.1 and 3.2 Section 3 Costing Methodologies. Section 3 Supporting Data Tables Section 4 Summary Cost & Funding Forecasts Section 4 Assumptions made in completing the Future Resource Requirements Appendix F Section 4 Supporting Data Tables Appendix A Appendix B Appendix C Appendix D Appendix E Version: Final Page: 4 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Executive Summary This Financial Sustainability Plan was completed as a requirement for extended GAVI support for the ongoing programme of immunisation of The Gambia. GAVI requires that before support is given a country must develop a credible plan to achieve the goal of financial sustainability in the delivery of immunisation services. GAVI define sustainability accordingly: Although self-sufficiency is the ultimate goal, in the nearer term sustainable financing is the ability of a country to mobilize and efficiently use domestic and supplementary external resources on a reliable basis to achieve current and future target levels of immunization performance in terms of access, utilization, quality, safety and equity. The FSP contains a comprehensive review of the EPI programme in The Gambia. The review covers all aspects from the macro economic environment, the health sector in general, a review and costing of the current programme and a forecast for the ten year period commencing in 2003. This review highlighted three key areas requiring considerable change: ! Funding Shortfalls ! Vaccine Wastage ! Deterioration of the Cold Chain Future programme objectives and strategies were modelled using the Financial Sustainability Planning tool developed by GAVI. The modelling process was iterative in nature and evolved after considerable input from key EPI stakeholders. Various scenarios were considered including the impact on the programme of the introduction of new vaccines. The final programme of changes are presented in Section 4 with supporting Appendix data. After careful consideration the forecasts presented represent the strategic framework necessary to strengthen delivery of immunisation services in The Gambia. Strategic objectives, proposed actions, assigned responsibilities and monitoring indicators were developed and presented in Section 5. The final version was presented to meetings convened with the Ministries of Health & Social Welfare, Finance, and Planning together with members of the EPI management and ICC including donor partners. Stakeholder comments have been taken into consideration in the final draft. It is anticipated the FSP act as primary aid to the Government of The Gambia, senior health officials and particularly the senior management of the EPI programme to ensure the successful delivery of immunisation services in The Gambia. It’s success can only be measured by the steps that are taken to start the process of moving The Gambia on its way towards financial sustainability. Most importantly of all the FSP acts as a vital mechanism to help enable the children of The Gambia to continue to receive the best possible protection against vaccine preventable diseases. Version: Final Page: 5 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Acronyms AD Syringe ADB AFP CFAA CHN CHP CRS DFID DHT DOSH EPI EU GAVI GDP GoG HDI HIPC HMIS ICC IEC IDA IFMIS IMF MCH MRC NEFCOM NGO NHA NID NNT PER PHC PHO PHNP PRGF PRSP SDR SEN SIAs SRN SSA SWAp UNICEF VHS WHO BCG DPT Hep B Hib OPV TT Auto-Disable Syringe African Development Bank Acute Flaccid Paralysis Country Financial Accountability Assessment Community Health Nurse Community Health Post Catholic Relief Services Department for International Development (UK Gov) Divisional Health Team Department Of State for Health Extended Programme on Immunisation European Union Global Alliance for Vaccines & Immunization Gross Domestic Product Government of The Gambia Human Development Index debt initiative for Heavily Indebted Poor Countries Health Management Information System Inter-agency Co-ordinating Committee Information Education Communication International Development Association Integrated Financial Management Information System International Monetary Fund Maternal & Child Health Medical Research Council National Emergency Finance Committee Non Governmental Organisation National Health Accounts National Immunisation Day NeoNatal Tetanus Public Expenditure Review Primary Health Centre Public Health Officer Participatory Health & Nutrition Project Poverty Reduction and Growth Facility Poverty Reduction Strategy Programme Special Drawing Rights State Enlisted Nurse Supplementary Immunisation Activities State Registered Nurse Sub-Saharan Africa Sector Wide Approach United Nations Children’s Fund Village Health Services World Health Organisation Mycobacterium bovis BCG (Bacillus Calmette-Guerin) Diptheria, Pertussis, Tetanus Hepatitis B Haemophilus influenzae type b Oral Poliomyelitis Vaccine Tetanus Toxoid Version: Final Page: 6 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Acknowledgements The Department of State for Health (DOSH) would like to express gratitude to all the individuals and the various development partners particularly WHO, UNICEF and GAVI for valuable technical support in the development of this financial sustainability plan (FSP) and also members of the task force for the drafting and review of the plan. The review and input by the ICC is also highly appreciated. The participation and efforts of the Central EPI Unit officers has been tremendous. The contribution made by the two consultants (national and international) hired for the assignment and funded by WHO is acknowledged. This plan will support the efforts of the Department of State for Health in implementing its policy to provide quality immunization services for the protection of all children under five years of age and all women of child bearing age from vaccine preventable diseases. Special thanks goes to the task force and our development partners who have contributed in one way or another towards the provision of the health care services in The Gambia. In the same vein a request is being put forward to willing bilateral and multilateral partners and individuals within and outside The Gambia to support this plan with any resources at their disposal. PREPARATION AND REVIEW TEAM TASK FORCE MEMBERS NAME Dr. Ayo Palmer Dr. O. Sam Dr. Mariatou Jallow Dr. B.D. Tagodoe Mr. M.K. Cham Mrs. Naffie Barry Dr. P. Mshana Dr. Kulmani P. Kulimani Mrs. Yamundow Jallow Mr. Robert Ninson DESIGNATION Programme Officer Director Deputy Director MO/EPI Ag. Director of Planning Deputy Permanent Sec. Human Resource Development Specialist Health System Research Specialist Ag. EPI Manager EPI Surveillance Officer INSTITUTE UNICEF DOSH DOSH WHO DOSH DOSH WHO WHO DOSH DOSH CONSULTANTS Mr. William Meaney Mr. Robert Hight International Consultant National Consultant Version: Final Page: 7 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 SECTION 1 1. Impact of Country and Health System Context on Immunization Programme Costs, Financing and Financial Management 1.1. Background The Republic of The Gambia, on the West Coast of Africa, is one of the smallest countries on the African continent with a population of 1.4 million1 and an estimated annual growth rate of 4.2% based on the 1993 census. The Gambia became independent in 1965. The democratic process was interrupted by a military takeover in 1994. By early 1997 The Gambia returned to constitutional rule following presidential elections. Since then two elections have been held and the next election is due in 2006. The country is divided into five administrative divisions (Western, Lower River, Central River, Upper River and North Bank) and two municipalities (Banjul and Kanifing). The Gambia is bordered on both sides by Senegal except the small opening to the Atlantic Ocean. It covers an area of 10,680 square kilometres and stretches an approximately 400-kilometre length on either side of The Gambia River, which divides the country in almost two equal halves. Due to civil unrest in neighbouring countries, notably the Cassamance region of Senegal, Sierra Leone and Liberia, The Gambia has increasingly become a haven for refugees which put additional demand on the health service of The Gambia. 1.2. Country Vision and main agenda The Government’s current national development objectives and priorities are defined in the Mission Statement of Vision 2020, which expresses The Gambia’s aspirations and socio-economic strategy for the period 1996-2020. It accords high priority to the social sectors of Health and Education, gives and calls for focussed attention on child survival, protection and development programmes. The Government recently prepared a Poverty Reduction Strategy Paper (PRSP), which was presented to both the International Monetary Fund (IMF) and World Bank Boards of Directors in July 2002. Child health and survival is one of the priority areas highlighted in the PRSP and in the Millennium Development Goals, 2015. The PRSP presents the country's programme for the coming years, and the Government is preparing a comprehensive technical assistance programme Preliminary data from 2003, Population Census, Central Statistic Department. Detailed information will be provided once the census data is finalised. 1 Version: Final Page: 8 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 to support it. In addition, the IMF approved (also in July 2002) a new three year arrangement under the Poverty Reduction and Growth Facility (PRGF). The Gambia has made some progress towards achieving its health goals, though slow by comparison of its national vital indicators to other countries in the region. The Table below compares key indicators in The Gambia with those in the Sub-Saharan African region. Table 1.1: Health indicators for The Gambia compared with average for SubSaharan African (SSA) countries GNP per capita (1997 US$) 340 Life expectancy 1999 Fertility Rate 1999 Infant Mortality rate (per 1,000) 1999 75 92 Illiteracy (% of pop. Aged 15+) 2000 63 40 Access to safe water (%of pop.) 2000 62 55 The 53 5.5 Gambia SSA 510 47 5.3 Source: World Development Indicators, 2001 1.3. Macro-economic trends The economy is predominantly agrarian with a low per capita income of approximately US $330 per annum. Real GDP growth in 2001 was estimated at 5.7 per cent (Economist Intelligence Unit, 2002, p. 31). The total external debt in 2000 was estimated at US $438 million and the debt to export ratio for the same period was 13.8 per cent (Department of State for Finance & Economic Affairs). Human Development Index (HDI) is 0.405 with a ranking of 160 out of 173 countries (HD Report, 2002, p. 152). Poverty is endemic and increasing. The 1998 poverty study indicated that 69 per cent of the population are below the poverty line. The national debt now stands at US $657m. The productive sector has witnessed severe constraints culminating in 2002 in the declaration of a severe food shortage by the Government. Tourism, a major foreign exchange earner is on the decline, thus, resulting in the significant decline of the domestic currency, the Dalasi, against all foreign currencies. High inflation and exchange rate fluctuation have severely reduced household incomes particularly in rural areas. The prices of food and other basic commodities, which are mostly imported, have also escalated with dramatic increases in the prices of staples and fuel. Macro-stability is a key component of poverty reduction, therefore attention has been given to assessing the potential contribution of its various components for the period 2002-2005. Table 1.2 Projections for key macroeconomic indicators: 2002- 2005 Indicator 2002 2003 Real GDP growth (%) 6 6 Fiscal deficit (grants) as GDP 5 2.7 Export growth (SDR, assuming an exchange rate of 21.3) 8.4 8.2 Current Account deficit (excluding grants) as % GDP 13.2 12.3 Current Account deficit (including grants) as % GDP 5.4 5.0 Gross official reserves as months of imports (including 5.0 5.2 transit trade) c.i.f Broad money growth 13.2 9.9 Inflation 5.5 4.0 Source: Department of State for Finance and Economic Affairs. 2004 6 2.3 5.3 11.6 5.8 5.4 9.6 3 2005 6.2 1.9 3.5 10.3 2.7 5.5 9.6 3 Version: Final Page: 9 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 To address fiscal imbalances, the Government has launched a comprehensive work programme to strengthen its capacity to execute and monitor its budget effectively. At the macro level, the Government has been working with several development partners in The Gambia. Apart from the International Development Association (IDA), the largest development partners of The Gambia are: the European Union, the African Development Bank, the United Kingdom (DFID) and agencies of the United Nations family. Bilateral donor support is rare. Specifically with regards to EPI, the main partners are: UN agencies (UNICEF/ WHO); International NGOs (Rotary International, Christian Children’s Fund, Catholic Relief Services), Taiwanese Government, Red Cross and The Medical Research Council of the UK. The Gambia is on track to achieve external debt sustainability within the context of the enhanced HIPC initiative. The Gambia has benefited from interim debt relief from IDA, ADB and IMF. As of August 31st 2002 the IDA had approved 30 credits for The Gambia totalling about US$271m. Twenty four credits have been completed and closed and the current portfolio consists of six projects (Participatory Health, Population and Nutrition, Third Education Sector, Poverty Alleviation and Capacity Building, HIV/AIDS Rapid Response, and Capacity Building for Economic Management, and Gateway) totalling US$99m. Future potential sources of funding for the EPI include the funds emanating from debt relief, the extension of the IDA funded Participatory Health, Population and Nutrition Project and the likelihood of a second new health sector project under the IDA to be implemented in September 2005. 1.4. Administrative context In order to strengthen the involvement and participation of civil society, the Government has embarked upon the reform of the Local Government system in the form of decentralisation. This will have an important impact on civil society and grassroots involvement in participatory planning and monitoring of programmes. The Local Government Act was enacted by Parliament in 2002. It provides the legal and administrative framework to support Area Councils and Municipalities to respond to the developmental needs of their communities, to articulate and elaborate development plans and to encourage community participation. Some steps have been taken in its implementation. However, the process of implementing these reforms has been fraught with controversy and therefore delayed. Furthermore, a key supportive mechanism, the Local Government Finance & Audit Bill, is still yet to be reviewed and enacted by Parliament. Once this Bill is enacted the Local Councils will begin the process of establishing systems towards greater autonomy in decision making, the management of human resources and the financing and delivery of all public services including immunisation within their administrative area. A divisional SWAp system, the Divisional Development Fund, is proposed. This Fund will serve as the repository of all funds derived from donors, central government and locally generated revenue. Integrated divisional plans will be used as the basis for the allocation of the funds. Version: Final Page: 10 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 1.5. Health system context The health system is organised around a three-tier system with increasing complexity in the type and range of services delivered. The Primary Health Care (PHC) or Village Health Services (VHS) are community based services co-financed by government and the communities. The secondary/district level covers major health centres, minor health centres and dispensaries. Four main hospitals now constitute the tertiary level. The policy is to manage the hospitals as semi or autonomous health care providers, with their management boards, and routine management under chief executive officers. These hospitals receive subventions from the Department and report directly to the Secretary of State for Health, through the Permanent Secretary. The Director of Health Services, Chief Pharmacist and Chief Nurse provide policy and regulatory advice to the Secretary of State. The Permanent Secretary serves as the Chief Administrator and Accounting Officer of the Department. The Secretary of State serves as the Chief Executive of the Department. Health sector management also follows a three-tier system. The management of health resources, both human and material remain heavily centralised. Health reforms were embarked upon in 1993 to overcome this centralised decision making through structural changes at the Ministry of Health. Selected administrative and management responsibilities were devolved to the Divisional Health Teams (DHTs). Despite this the DHTs remain functionally weak and powerless especially with respect to human and financial resource management. This has undermined attempts at increasing efficiency of service delivery at divisional and community level due to lack of decision making at community level. Figure 1.1 Organisation of the Health Department Office of the Secretary of State (Secretary of State, Permanent Secretary and his deputies) Directorate of Health Services (Director of Health Services, Chief Pharmacist, Chief Nurse) " Health Programme (Child Health and Survival) " Health Services Delivery Directorate of Planning & Information "Policy analysis and Budgeting "Health Human Resource Plan "Health Systems Research "HMIS In addition, there are the Directorates of Support Services and Social Welfare. Version: Final Page: 11 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 1.6. Health Programme Areas Health Programme Areas develop national programme policies and set national strategic targets. There are several vertical programmes. These require considerable administration which place competing demands on service providers at all levels. One of the main areas of focus is Reproductive and Child Health Programme which includes the following: ! Reproductive Health ! Integrated Management of Childhood Illness ! Expanded Programme on Immunization Figure 1.2 Organisation of delivery of EPI services MCH team (MCH, HEALTH FP & EPI) FACILITY Base clinic Monday & Thursday Village 1 Village 2 Village 3 Outreach Station 3 Outreach Station 1 Village Village 4 Village 5 Village Village 6 Village 7 Village Outreach Station 2 Village Village 8 Village 9 Village Village There are 196 out reach stations (key villages). Each out reach station serves 6-9 satellite villages. Version: Final Page: 12 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 1.7. Health Services Delivery Health services are provided by both public and private providers. The private sector is expanding mainly with respect to outpatient care. Divisional Health Services are provided through: ! Major Health Centres (Divisional Hospitals) ! Minor Health Centres ! Outreach Clinics (Maternal and Child Health Outreach posts) ! Community Health Posts (Village health services) ! Private providers in the division including the Traditional Healers 1.8. Health Policy and Health Public Expenditure Review The new health Policy Framework, “Changing for Good” was produced to incorporate new socio-economic and health development challenges to ensure access to quality essential health care to the Gambian population. Amongst the key policy issues identified are availability and access to essential drugs and vaccines, and partnership in the financing of health services provision. Public expenditure reviews (PER) are undertaken annually and are aimed at assessing the performance of the health department with regard to the implementation of the Health Policy to identify achievements, failures and obstacles to implementation, as well as available opportunities. During the period 1992–2000, the health recurrent budget showed an upward trend in both nominal and real terms. The recurrent health expenditure, as a share of the total government expenditure, ranged between 10.8% and 13.4%. This represented real per capita recurrent expenditure of US$ 3.96 to US$ 5.91. In 2000, the recurrent expenditure on health as a proportion of the GDP reached 11.17%, which was slightly below the average in sub-Saharan Africa. The public expenditure per capita in the health sector in 2000 was US$ 6, which was just half of the WHO recommended standard required to provide minimum health care services. 1.9. Budget Process and Financial Management The national budget development process begins with the release of the call circular for the Department of State for Finance and Economic Affairs (Finance) to all government funded departments and institutions. The call circular explains the revenue forecast for the year being planned for, the budget policies and the allocations to the departments and institutions. Since, 2002, a national budget meeting is also organised, where all the stakeholders including civil society meet to discuss the “sharing of the national cake”. This forum is used to explain the rationale behind the allocations. It also serves as an opportunity for PRSP priority sectors, of which EPI is one, to provide an update on their activities and funding constraints. The departments then proceed to make their budgets in line with what they consider their priority areas. This is followed by budget bilateral meetings (between Finance and the departmental budget team), where Finance, in addition to assessing for allocative efficiency, pays special attention to compliance to the allocation ceiling. Within Health, over the last two years discussion of the Health Agenda have preceded discussions on the annual budget. These discussions are then followed by further inter-departmental Version: Final Page: 13 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 discussions regarding sharing of the allocated health budget. For the 2003 budget preparation, even the allocations for the purchase of health goods like drugs, fuel for ambulances and vaccines were discussed and agreed upon. For the 2004 budget preparation, in addition to discussions of the intra-departmental sharing formula, a major addition was the setting up of per capita allocations targets for drugs, vaccines and food for in-patients. These per capita targets form the basis for bilateral negotiation with Finance. It is hoped that future negotiations between Health and Finance will use this mechanism for allocating funds. This approach has been used for the funding of drugs, vaccines and food at the divisional level based on the size of the population within the division. The HIPC funds allocation to Health for the past two years supports priority areas, like vaccines and essential drugs purchase. From 2004 however, HIPC fund to Health is considered as investment in the form of seed capital for essential drugs and vaccines. The Government Local Fund allocations to divisions would then be used to purchase from the Essential Drugs and Vaccines Supply System based in the Central Medical Stores. 1.10.Budgeting, Financial management systems 1.10.1. Financial Information System (IFMIS) Finance is at an advanced stage in the establishment of an Integrated Financial Management Information System (IFMIS). For a start the system would include the PRSP priority sectors. Within Health, a new computer has been allocated to the Accounts Unit to improve on the tracking of health expenditure. 1.10.2. Disbursement System Disbursement to sectors/departments is influenced by revenue generation capacity. The main source of revenue for The Gambia is from taxation, and unfortunately the base for taxation is very small. Previously, quarterly allocations were disbursed to department including the EPI Unit. The traditional approach for disbursement to departments has been quarterly allocations, however, this could not be maintained for the 2003 budget. The Department of Finance embarked on prudent expenditure control measure, and a monthly cash flow budget system was introduced. With the cash flow budget, departments are provided monthly budget “envelopes”, and they decide on their budget line allocations, and present their expenditure to the National Emergency Finance Committee (NEFCOM) for review, before payments are processed. This means that disbursements may not always match requests and delays can be experienced in accessing allocated funds. For EPI divisional activities funds are normally controlled and released by the Central EPI Unit to the DHTs. This disbursement can lead to delays in the implementation of divisional activities. Version: Final Page: 14 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 1.11. Accounting and Audit The departmental accounts units process payments and maintain the books of accounts (cash book and vote charge books) The Internal Audit department of Finance serves as the clearing house for all the payment requests. The Accountant General Department ensures adherence to the Financial Instructions before payments are finally effected. One of the agreements from discussions of the Country Financial Accountability Assessment report was the production of the Auditor General’s Opinion on the annual financial report provided by the Accountant General. 1.12.Health Financing Information Funding has been secured from the Participatory Health Population and Nutrition Project to conduct the National Health Accounts (NHA) for 2001 and 2002. It is hoped that this report would guide the Department of Health in designing the Health Financing Policy. The Health Policy “ Changing for Good” advocates for basket funding, The World Bank has taken the lead in this area by supporting the design of a health development strategic Plan using SWAp. In addition, the new health policy identifies the Essential Care Package for The Gambia, as the benefit package for which government will provide financial support. Version: Final Page: 15 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 SECTION 2 2. Expanded Programme on Immunization: Characteristics, Objectives and Strategies 2.1. Background The national Expanded Programme on Immunization (EPI) was launched as part of the Primary Health Care (PHC) strategy in 1979/80. The main strengths of the EPI are high accessibility with 85% geographical coverage, high coverage rates reaching over 80% for most antigens; high public awareness and demand for immunisation and the near eradication of poliomyelitis. The focus is on providing routine vaccination using mobile teams for traditional EPI antigens (BCG, DPT, Oral Polio Vaccine, Measles), Tetanus Toxoid vaccines and Yellow fever. Hepatitis B and Haemophilus influenzae type b (Hib) vaccines were introduced in 1997 following demonstration of their effectiveness in clinical trials. The Central EPI Unit, which is responsible for the overall management of the programme, is inadequately staffed and equipped. A recent review of the cold chain indicates current equipment is in urgent need of upgrading. More than half the equipment is more than ten years old. Storage capacity also needs to be expanded. Despite these constraints the EPI has been very successful and percentage coverage is high. Table 2.1 Percentage immunization coverage over the last eight years Antigen 1995 1996 1997 1998 ² 1999 2000 2001* BCG 99.4 99.6 99.2 99.0 96.3 96.1 99.6 OPV3 94.5 87.0 98.5 95.2 87.8 91.8 90.3 DPT3 96.3 95.9 96.2 96.7 87.5 74.4 87.9 Hib3 96.7 87.5 74.4 86.5 Hep B3 88.0 93.4 92.8 87.6 86.9 94.4 Measles 91.1 93.8 91.1 91.9 87.9 91.7 93.2 Yellow Fever 91.1 94.6 91.6 90.8 85.6 90.8 93.4 TT2 95.9 90.7 86.7 96.8 70.6 75.5 NA Fully Immunised 79.5 80.6 83.7 79.8 64.1 68.6 61.8 infants (<1yr) BCG-DPT3 Drop Out 3.1 3.7 3.0 2.3 8.8 21.7 11.9 Rate Fully Immunised 83.4 87.0 86.9 87.7 78.6 72.0 71 children <2yr ² From 1998, the tetravalent vaccine DPT/Hib was used; * Preliminary results EPI Coverage Report 2001/2002 Source: EPI Coverage Surveys Reports, DOSH, The Gambia 1995 - 2000 2002* 99.9 89.9 94.2 93.2 94.4 93.2 93.4 NA 72.8 5.7 81 Version: Final Page: 16 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 The success of EPI is also reflected in the decline of reported cases of vaccine preventable diseases as per Table 2.2 Acute Flaccid Paralysis (AFP) surveillance system: Table 2.2 Reported cases of selected vaccine preventable diseases 1995 – 2002 Disease 1995 1996 1997 1998 1999 2000 2001 2002 Measles 195 312 1585 127 856 336 99 32 AFP/Polio 1* 1* 0 0 0 0 0 0 AFP 0 0 0 0 0 13 14 15 NNT 7 2 0 0 1 2 0 0 Yellow fever 0 0 0 0 0 0 0 0 Cerebral-spinal 46 410 1685 703 252 205 75 52 meningitis *Source: Routine data – DOSH The Gambia The EPI is mainly co-ordinated at the central level for operational activities. At the senior level there is an Inter-agency Co-ordinating Committee (ICC) chaired by the Secretary of State for Health which aims at co-ordinating the inputs of a range of partners mainly of NGOs and the UN agencies. More recently, the role of the ICC has been broadened to undertake a more active role in the implementation of the routine programme. 2.2. Programme Objectives While the general objective of the EPI is to reduce childhood morbidity and mortality due to EPI targeted diseases (tuberculosis hepatitis B, poliomyelitis, diptheria, pertussis, tetanus, haemophilus Influenzae type B, measles and yellow fever), the programme aims to realize the following general objectives in the next five years: ! To raise the awareness among Gambians on the benefits of immunization and the consequences of failing to get children vaccinated at the right time ! To maintain high immunization coverage ! To ensure the sustainable availability and delivery of vaccines in the programme. ! To strengthen and improve the disease surveillance system with special emphasis on the EPI targeted diseases ! To ensure injection safety in the EPI delivery system Specifically the objectives are: ! To increase immunisation coverage to 95% and above for all the antigens. ! To increase to 90% fully immunized children under one. ! To prevent stock-outs of all EPI antigens at all levels and improve effectiveness of purchasing system ! To reduce measles morbidity and mortality by 90% and 95% respectively. ! To maintain the elimination level of neonatal tetanus to less than 1 case per 1,000 live birth in every division. ! To eradicate poliomyelitis by the year 2005 ! To reduce vaccine wastage to the target levels specified in the costings in Section 4 ! Immediate strengthening of the cold-chain by increasing capital investment for replacement of old equipment and by adopting a policy of solarisation. ! To integrate in a sustainable manner the Pneumococcal vaccine, if the current trial proves successful, into the routine EPI in 2007 ! To develop posters on EPI target diseases and the vaccination schedule. Version: Final Page: 17 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 ! ! ! To develop key messages on immunization targeting parents and care-givers. To continue to use auto disposable (AD) syringes for all EPI vaccinations. To ensure the use and proper disposal of safety boxes by all facilities conducting immunization services There has however been increasing concern over the ageing cold chain system; the erratic financing of the EPI, and the number of children below the age of one who are not fully immunised. Figure 2.1: Proportion of children fully immunised less than 12 months 100 80 per cent 60 40 20 0 95 96 97 98 99 2000 2001 2002 year *Source: EPI Coverage Surveys Reports, DOSH, The Gambia 1995- 2000 Also of concern is the high wastage rate of vaccines. From recent data vaccine wastage is estimated to range from 17% to 60%. The study did not identify reasons for high wastage rates. A further concern was the recent increase in drop out rates in 2000 and 2001. Recent coverage surveys indicate that drop out rates have been reduced to acceptable levels. Cold Chain Equipment The total cold chain equipment available in the country is 85. Of these, 59 are located at the various facilities of which 18 are at the DHT stores. There is inadequate capacity for storage (for 0 to 8ºC) including freezing capacity at the national level. About 50% of the total equipment is solar (Electrolux RCW 42 DC). The main energy source used in operating refrigerators at the periphery is solar. Electric compression and absorption equipment are installed at national and divisional level vaccine stores. Version: Final Page: 18 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 2.3. Vaccine Procurement and Financing Prior to 1998, traditional donor agencies, mainly UNICEF, assumed responsibility for the procurement of routine vaccines (the traditional six antigens and yellow fever) and the maintenance of the cold chain system. Financing for the procurement of Hepatitis B and Hib has been precarious and heavily dependent on external donors, namely ADB and more recently the Italian government. In 1998, the financial support provided by UNICEF ceased. Prior to and after this period, UNICEF continued to facilitate the process of seeking alternative sources of finance from external donors. The Gambia became a signatory for the Vaccine Independent Initiative (VII) for Sahelian countries in January 1999 for a period of two years. The EU pledged a total of US$250,000 from regional counterpart funds for the procurement of routine vaccines. In 1999, as part of the agreement the Government created a budget line specifically for vaccines and supplies. In 2000 and 2001 funds allocated for the procurement of vaccines amounted to US$131,275 and US$111,542 respectively. From data derived from the recent EPI Financing study in 2001, the government contribution in 2000 and 2001 as a proportion of total cost was 26% and 22% respectively. The contribution of the Government of The Gambia (GoG) was mainly in the area of operating costs: personnel salaries, maintenance of health facilities and vehicles. A number of other partners also contributed to the financing of the National Immunization Days, notable amongst these are the World Health Organization, the Participatory Health and Nutrition Project (IDA Project), Christian Children Fund and others. The EPI Financing Study also revealed that the annual cost of the EPI taking into consideration capital and recurrent costs was nearly 35% higher than previously estimated. The major contributors to this cost are vaccines and the lack of investment in cold chain equipment. The outreach strategy is over 60% more costly than the fixed strategy, which is reflected in the differences also realised in fully immunising children with the alternative strategies. Overall, at US$37, the cost of fully immunizing a Gambian child is considerably higher than is the case for other countries where comparable data exists in the sub-region. 2.4. Programme Management There is a need to strengthen the managerial and technical capacity of the management of the national programme. But equally is the need to strengthen the integrated management of Reproductive and Child Health programmes. The Reproductive and Child Health Programme Manager under the technical directive of the Director of Health Services should co-ordinate the activities of the three programmes of Reproductive health, Integrated Management of Childhood Illnesses and Expanded Programme on Immunisation. The procurement of the vaccines has been satisfactory so far. The major constraint is in the safe and proper storage of the vaccines. The construction of a multi-purpose warehouse funded by the African Development Bank has been mentioned several times, however, the definite time frame for the commencement and completion of this work has not been made known. Details on this warehouse construction need to be provided. Version: Final Page: 19 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Until the time that more information is available on the new warehouse, the requirement for quarterly vaccine delivery to the central store will need to continue. The storage facilities in Banjul are to serve as transit and buffer stock stores. There is a need to have at Central level (Banjul) a cold room for storage of a minimum of 5 months national vaccines stock. 2.5. Transportation and storage of vaccines The EPI services, which are integrated into the MCH services, are delivered using fixed and outreach delivery sites. Thus reliance on transportation remains a key concern. This will be more so in the future when the existing 196 outreach delivery points are transformed to fixed Community Health Posts with a full staff complement to deliver integrated services. The need for reliable transport for out reach services will be a focus of the Multi-year plan. This will be addressed mainly through the provision of reliable vehicles and support for a replacement and maintenance plan. The use of the two refrigerated vans used as carriers available to the Programme needs to be reviewed. The present indiscriminate use of the vans is a concern for their life span. These carriers could support vaccines distribution to the divisional/regional medical stores. The reform proposed is for the vans to also support vaccines distribution to providers in the Western region- Western division, Kanifing Municipal area and Banjul city area. For distribution in the other divisions (five), there is a need for small distribution vans for each of them. A major threat to vaccines is the storage quality in the divisional stores and at health facilities. There is need to invest in solar refrigeration, due to the erratic nature of electricity supply services, at the divisional medical stores and in all the other vaccines storage facilities countrywide. The Divisional Public Health Officer (Manager of Divisional Disease Control) should take full responsibility of both the vaccines inventory control and cold chain monitoring 2.6. Financing the National Immunisation Programme There are other proposed reforms in the management of the National Essential Drugs and Vaccines Supply system. The Central Medical Stores would be converted to an autonomous Supplies Institution, with its own management board, procurement system, and accounting department. A good portion of HIPC funds allocated to Health in the next few years would be used to capitalise this new medical supplies organisation. This would ensure availability of routine vaccines in the country. Partnership would be pursued in the following areas: ! Introduction and purchase of newer vaccines ! Human resource capacity development ! National Immunization Days ! Strengthening the distribution and cold chain systems and immunisation safety ! Research into newer vaccines ! Expansion of service delivery points. Version: Final Page: 20 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 2.7. Payment of service providers The important assumption here is that all the health care providers would maintain their own revenue accounts. Providers would have to purchase their vaccines at the divisional supplies depots. The payment mechanism to providers would be defined in the new Health Financing Policy to be developed. A National Health Insurance is an option which would include Community Micro-Health Insurance, however, immunisation as a public health good would remain funded by Government. 2.8. Plans for the future In the next five years the focus will be on the recruitment of new staff and capacity building of existing central and divisional staff with a focus on programme managers and logistics, surveillance, data management and social mobilisation. The rehabilitation and expansion of the cold chain system nationwide including changing all CFC refrigerators to non-CFC refrigerators; the provision of supporting infrastructure, for example generators and the expansion of storage capacity centrally and within the divisions. SIAs will continue for measles, the integrated EPI/ Vitamin A supplementation programme will be strengthened as will the use of injection safety materials. New vaccines likely to be implemented include Pneumococcal once the results of the trial are known. Version: Final Page: 21 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 SECTION 3 3. Current Expenditure & Financing 3.1. Introduction The current programme costs and financing are based on a comprehensive review of the EPI program. Due to the relatively small size of the country data was collected on EPI in all divisions and from all health facilities rather than taking sample data. Data collection took place from June to August 2003. The basis for calculation of the data requirements for Section 3 is according to the methodology of the FSP guidelines and assumptions outlined in Appendix B. Areas of particular interest in assessing current cost which required additional data collection and analysis were: ! Vaccine costs and vaccine wastage ! Transport costs ! Personnel costs ! Cold chain investment The baseline year has been costed using the standard cost model. The current year was not complete at time of writing and costs were estimated using the forecasting tool. Where possible 2002 costs were calculated in the forecasting tool to ensure consistency of data. It should be noted capital costs were assumed to remain unchanged between the baseline and the current year. 3.2. Baseline and Current Program Costs Figures 3.1 & 3.2 Vaccine costs account for more than half of the total programme costs excluding Supplementary Immunisation interventions. Vaccine costs in 2003 are disproportionately high due to the build up of buffer stocks of the new combined DPT / Hib vaccine. Personnel costs at 3% of the current expenditure may be explained by a low wage economy and the exclusion of foreign workers employed by donor organisations. Version: Final Page: 22 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Total programme costs are summarised below and is compiled from the total of costs exclusive to the EPI programme and the programmes allocation of shared costs. Table 3.0: FSP Table 3.1 and 3.2 Baseline and Current Year Costing 2002 Program Costing Operational Cost Vaccines Injection supplies Personnel Transportation Maintenance and overhead Training Short term + Long Term Social mobilization-IEC Surveillance and monitoring Subtotal Operational Capital Cost Vehicles Other Capital Costs Subtotal Capital TOTAL Excluding SIAs Polio Vaccines for NID Measles Vaccines for NID Subtotal Supplementary Immunisation Activities GRAND TOTAL 129,742 87,452 $217,194 $1,650,107 67,281 252,518 $319,799 $1,969,906 6.6% 4.4% 11.0% 84% 3.4% 12.8% 16.2% 100% 7.9% 5.3% 13.2% 100% 129,742 87,452 $217,194 $1,772,250 435,688 385,225 $820,913 $2,593,163 5.0% 3.4% 8.4% 68% 16.8% 14.9% 31.7% 100% 7.3% 4.9% 12.3% 100% 858,669 68,761 75,266 44,013 56,437 45,936 183,107 100,723 $1,432,913 43.6% 3.5% 3.8% 2.2% 2.9% 2.3% 9.3% 5.1% 72.7% 52.0% 4.2% 4.6% 2.7% 3.4% 2.8% 11.1% 6.1% 86.8% 997,973 61,939 63,537 33,699 62,057 46,344 186,769 102,738 $1,555,055 38.5% 2.4% 2.5% 1.3% 2.4% 1.8% 7.2% 4.0% 60.0% 56.3% 3.5% 3.6% 1.9% 3.5% 2.6% 10.5% 5.8% 87.7% Total US$ Share (%) Total US$ 2003 Share (%) Vaccines Vaccines account for 64% of routine recurrent cost (52% of total programme costs excluding SIAs in 2002) and are a major component of the EPI program. Vaccine Wastage Vaccine Costs are exacerbated by high wastage levels particularly in the case of reconstituted drugs. Table 3.3 Wastage Levels Summary Vaccines Vial Size Wastage Reconstituted Vaccines BCG 20 55.2% Measles 10 60.2% Yellow Fever 10 56.1% Other Injection Vaccines DPT 10 21.0% Hib 10 33.2% Tetanus (TT) 20 27.2% Hep B 10 20.7% Other Vaccine Polio (OPV) 20 26.2% Note: Wastage calculated as percentage of total vaccine used. Version: Final Page: 23 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Detailed analysis of the wastage and how it was calculated is provided by the costing model and supported by supplement information in Appendix B The country policy is to provide immunisations on demand to ensure maximisation of coverage of immunisation. This approach means that vials of vaccine are generally not fully utilised. If only one immunisation is given from a vial of BCG vaccine, 19 potential doses are wasted. It is clear however that there is an opportunity for cost savings for improved vaccine stock management are substantial. EPI Personnel Personnel costs are very low as a percentage of the total delivery costs. Health Sector staff salaries are set by central government and have been consistently declining in US$ terms as the local currency devalues. Low salary rates have resulted in high staff turnover which has the following negative impacts: • Training costs remain high as new staff have to be trained to replace experienced staff leaving the health system. • Remaining staff have inadequate training and experience leading to: o High wastage levels of Vaccine. o Cold Chain and other Equipment not properly maintained. Cold Chain Equipment A recent review of cold chain equipment2 demonstrated that there is insufficient capacity and that equipment is overdue for replacement and often no longer functional. A substantial proportion of the solar fridges are fifteen year old and have become unserviceable as replacement batteries and other key parts are no longer available. The government is working with various funding agencies to obtain replacement equipment. Incinerators Incinerators are old and often inoperable. It is planned to introduce 11 new incinerators at a total cost of US$38,500. 2 “COLD CHAIN ASSESSMENT IN THE GAMBIA Trip Report” Author: Souleymane Kone; ICP/EPI-Log, WHO/Abidjan Dates: 28 April to 2 May 2003 Version: Final Page: 24 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 3.3. Baseline and Current Program Cost Funding Figure 3.3: The Gambia National Immunisation Programme Financing of Recurrent EPI Activities - Baseline 2002 Excluding Capital Costs & Supplementary Implementation Activities 1% 3% 0% 16% 31% National Government UNICEF WHO Aventis Pasteur MRC CISP Cadre Du Project 28% GAVI 13% 8% Baseline Year 2002 Table 3.4: Funding Sources 2002 Funded by Items Funded Aventis Pasteur UNICEF MRC WHO HIB vaccine – field trial Supplementary Immunisation Activities, Vaccines, Per diems, Training Hib / DPT Vaccine – Donation agreed for period of Pneumococcal field trial. Monitoring & Disease Surveillance, Supplementary Immunisation Activities, Vaccines, Per diems, Training Capital Purchases, vaccines, training Traditional Vaccine, Infrastructure, Personnel, IEC Social Mobilisation. Value $,000 414 438 228 168 % Cost 21% 22% 12% 9% Other Donor Government Total 252 451 1,969 13% 23% 100% Version: Final Page: 25 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Figure 3.4: The Gambia National Immunisation Programme Financing of Recurrent EPI Acctivities - Current Year 2003 Excluding Capital Costs & Supplementary Implementation Activities 19% National Government UNICEF WHO Aventis Pasteur 50% 13% MRC CISP Cadre Du Project GAVI 4% 0% 14% 0% Historically The Gambia has benefited from participation in field trial of new vaccines given its size and population. In the baseline year reliance was placed upon the donations of Hib vaccine from Aventis Pasteur and the Medical Research Council. Since the market cost of Hib vaccine is high in comparison to traditional vaccines, this equated to funding equivalent to 73% of vaccine costs and 38% of the total routine program budget. The Government contribution is recurrent corresponding mainly to traditional vaccines, personnel, logistics and cold chain maintenance. The Medical Research Council (MRC) vaccine trial commenced in 2000 and provided supplies of Hib and DPT vaccine as part of funded trial of the Pneumococcal vaccine covering the Upper and Central River Divisions. The immunisation phase of the MRC trial ended in April 2003, however, excess stocks from the trial have continued to be made available to these divisions. It is anticipated that these immunisation supplies will be exhausted by the end of 2003 resulting in an increased funding gap. Aventis Pasteur provided donations of Hib as part of a vaccine trial which was completed in 2001. Following the end of the trial, as part of an agreement with the Government, Aventis Pasteur agreed to donate a total of one million dose of the vaccine over a period of 5 years. The remaining stocks from this donation continued to be utilised until finally exhausted in October 2003. The funding gap has been filled by the provision of the combined DPT + Hib vaccine under the GAVI programme. Version: Final Page: 26 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 UNICEF is the main long term support partner of The Gambia Expanded Program on Immunization. UNICEF was in charge of vaccines and material of vaccinations and cold chain; office equipment and supplies also fuel. From1999 to 2002, the Italian Government, through UNICEF provided temporary funding for provision of HepB Vaccine which was replaced through GAVI support in 2003. WHO contribute for the financing of EPI routine activities and is one of the main funding sources for NIDs. support . CISP and Cadre Du Project – Limited targeted funding has been provided by these donors. There is no ongoing long term agreement. Areas councils provide personnel (labourer for cleansing service) for health services and chairs, tables and benches for outreach stations. Due to lack of information, the estimation of their contributions remains unquantified. Capital equipment has been funded through a broad spectrum of donor agencies on an add hoc basis. GAVI funding of the programme began in November 2002 with initial funding of US$100,000. This was used to supplement government expenditure and donor funding. The change in funding received in the baseline 2002 versus the current year 2003 is contrasted below: Figure 3.5: Funding Comparison - Baseline 2002 v Current Year 2003 Excluding Supp. Immunisation Activities and Capital Costs 1,800,000 1,600,000 1,400,000 1,200,000 Total Funding 1,000,000 800,000 600,000 GAVI Cadre Du Project CISP MRC Aventis Pasteur WHO UNICEF National Government 400,000 200,000 2002 Year 2003 Version: Final Page: 27 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 3.4. Supplementary Immunisation Activities The WHO and UNICEF have been the major donors for the Supplementary Immunisation Activities. These activities have incorporated the National Immunisation Days3 for the eradication of Polio and Extended Programme of Immunisation of Measles4. 3.5. Key Indicators Table 3.5: Summary Indicators Total Recurrent NIP Costs Total Supplementary Immunisation Activities Costs Capital Expenditure Population Surviving Infants DPT-3 Coverage Cost of DPT-3 Child Cost Per Capita - Recurrent NIP Costs Cost Per Capita - SIA % Government Funding of Recurrent NIP Activities % Vaccines in Cost of Recurrent NIP Activities Baseline $1,416,534 $319,799 $217,194 1,503,376 56,286 85% $29 $0.94 $0.21 31% 61% Current Year $1,464,234 $820,913 N/A 1,566,517 58,650 N/A N/A $0.93 $0.52 27% 68% -$0.01 $0.31 -4% 8% Difference $47,700 $501,114 63,142 2,364 Routine immunisation cost per capita has remained stable at US$ 0.95 whereas spending on supplemental immunisation activities has increased due to the combination of monitoring of the performance of the Polio NID and the introduction of the Measles Plan for extended immunisation. 3 4 Report on National Immunisation Days October – November 2002 The Gambia. Republic of The Gambia – Measles Plan of the Extended Programme of Immunisation 2003 – 2007. Version: Final Page: 28 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 SECTION 4 4. Future Resource Requirements and Programme Financing. 4.1. FSP Cost Projections In developing the Financial Sustainability Plan, future costings and sources of finance have been forecast for future programme costs for the period 2003 – 2012 utilising the baseline information from 2002 compiled in Section 3. The forecast were projected for the Vaccine Fund Period 2003-2007 and the Post Vaccine Fund period 2008-2012. Figure 4.1 : Projections of Future Resource Needs by Cost Categories 3,000,000 Other optional information Shared personnel costs 2,500,000 Measles Polio Other capital costs 2,000,000 Cold chain equipment Vehicles 1,500,000 Other recurrent costs Transportation 1,000,000 Personnel Injection supplies 500,000 New Vaccines Traditional vaccines 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 The Total Projected Costs are summarised in the following table. Table 4.1: 2003 $,000 2,516 2004 $,000 1,846 2005 $,000 1,841 2006 $,000 1,898 2007 $,000 1,717 2008 $,000 1,748 2009 $,000 1,844 2010 $,000 1,943 2011 $,000 1,931 2012 $,000 1,957 To maintain consistency in the cost forecast for the EPI programme over the projection period a number of assumptions have been made. These assumptions are: ! Population growth rate is 4.2% ! Current coverage rates are expected to be maintained or improved ! Current structure is maintained subject to phased enhancement set out below ! Implementation of strategic policies to improve the services provided by the EPI programme ! Current exchange rates are assumed and all values are expressed in US$ ! A scenario for the introduction of Pneumococcal vaccine from 2007 is costed separately. An explanation of the assumptions made for each cost category and detailed analysis of the individual costings and schedules are provided in Appendices E and F. Version: Final Page: 29 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 4.2. Strategic Initiatives Planned for and incorporated in the Forecast Period 2003 - 2012 The information compiled in the Section 3 highlighted three strategic issues that needed to be addressed: ! Reduction in vaccine wastage ! Strengthening of the cold chain ! Improvement in service delivery The projections for future programme costs and financing are therefore based upon addressing these strategic issues are as follows: 4.2.1. Reduction of Vaccine Wastage: Vaccine currently accounts for 64% of recurrent programme costs. Wastage levels are unacceptably high. In the future the primary focus in instituting cost saving must be the reduction of these wastage levels. A targeted reduction of vaccine wastage over a period of five years is set out in the following table: Table 4.2: Projected Vaccine Wastage Savings Vaccines Reconstituted Vaccines BCG Measles Yellow Fever Other Injection Vaccines DPT/Hib Tetanus (TT) Hep B Other Vaccine Polio (OPV) Vial Size 20 10 10 10 20 10 20 Current Wastage Target Wastage 30% 30% 30% 15% 15% 15% 15% Estimated Savings In 2008 Doses Savings 55,061 $4,033 74,092 $10,558 58,275 $43,347 73,768 52,815 17,830 50,015 $169,285 $2,161 $6,048 $4,775 $240,207 55% 60% 56% 21%-33% 27% 21% 26% To achieve these savings the forecast has costed the following actions: ! Recruitment of two additional staff with exclusive responsibility for vaccine wastage reduction. ! Additional training in management information systems, and management. ! Improvement of computer hardware and information management systems. ! Changes in service delivery. Version: Final Page: 30 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 4.2.2. Strengthening the Cold chain. As has been highlighted there is insufficient capacity in the cold chain, equipment is overdue for replacement and often no longer functional. A substantial proportion of the solar fridges are fifteen year old and have become unserviceable as replacement batteries and other key parts are no longer available. Provision has therefore been made for: ! Adopting a policy of solarisation ! Provision of central cold store facility ! Replacing outdated equipment 4.2.3. Improvement in Service Delivery It is proposed that there be a change in policy on service delivery. This new policy will focus on the delivery of enhanced vaccination services utilising the existing community based health service. Provision has therefore been made for: ! Recruitment of additional Public Health Officers (PHOs) to work in association with existing Community Health Nurses to provide immunisation services. ! Provision of motorcycles for mobilisation of the PHOs and distribution of the vaccine from safe storage located at the fixed health facilities to the community. ! Training the CHNs and newly recruited PHOs. This has the additional benefit of freeing up scarce nursing resource and the use of ambulances for emergency and other uses and ensure that EPI activities are not hindered when the ambulances are unavailable. A detailed analysis of the costing of recurrent and capital cost for the Vaccine Fund Period 2003- 2007 and the Post- Vaccine Fund Period 2008-2012 are provided overleaf. Explanation of the assumptions made for each cost category and detailed analysis of the individual costings and schedules are provided in Appendices E and F Version: Final Page: 31 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Table 4.3: Cost Projections [A] 1 1.1 1.2 2 3 4 5 Subtotal [B] 6 7 8 Subtotal Capital Costs Vehicles Cold chain equipment Other capital costs 88,865 88,865 62,424 166,726 9,838 238,988 84,897 66,277 3,668 154,841 32,473 28,908 3,741 65,122 37,491 3,816 41,307 28,472 3,892 32,364 68,921 27,231 3,970 100,123 93,733 30,529 4,050 128,312 35,853 21,758 4,131 61,742 29,203 4,213 33,416 Recurrent Costs Vaccines Traditional vaccines New Vaccines Injection supplies Personnel Transportation Other recurrent costs 2003 997,973 71,630 926,343 61,939 9,959 12,835 381,529 1,464,234 2004 844,814 72,251 772,563 65,856 11,619 16,365 376,179 Vaccine Fund Period 2005 2006 859,748 73,941 785,807 70,685 12,177 22,356 396,547 1,361,513 852,481 73,070 779,411 73,476 12,177 25,175 395,703 1,359,013 2007 847,800 72,537 775,263 76,404 12,177 25,678 403,597 1,365,656 2008 845,323 72,269 773,054 79,470 12,177 26,192 406,339 1,369,502 Post Vaccine Fund Period 2009 2010 2011 880,827 75,304 805,523 82,808 12,177 30,329 420,512 1,426,653 917,822 78,467 839,355 86,286 12,177 34,622 433,671 1,484,577 956,370 81,762 874,608 89,910 12,177 35,314 438,924 1,532,694 2012 996,538 85,197 911,341 93,686 12,177 36,021 442,738 1,581,159 1,314,832 [C] 9 10 Supplemental Immunization Activities Polio Measles 435,688 385,225 820,913 140,076 23,970 164,046 137,957 24,449 162,406 140,716 202,529 343,245 143,531 25,437 168,968 146,401 25,946 172,347 149,329 26,465 175,794 152,316 26,994 179,310 155,362 27,534 182,896 158,469 28,085 186,554 Subtotal [D] 12 13 14 Optional Information Shared personnel costs Shared transport costs Other optional information 53,578 20,864 67,651 142,093 56,194 24,573 47,294 128,061 58,769 26,926 76,347 162,042 61,481 27,299 42,457 131,237 64,193 26,224 50,260 140,677 67,173 26,082 80,947 174,203 68,057 28,625 45,056 141,738 68,278 29,541 53,336 151,155 69,162 30,483 54,403 154,047 69,382 31,450 55,491 156,322 Subtotal Total Requirements 2,516,106 1,845,927 1,840,803 1,898,616 1,716,607 1,748,416 1,844,307 1,943,353 1,931,379 1,957,451 Version: Final Page: 32 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 4.3. Probable Sources of Finance & Funding Gap Based on the cost projections from 2003 – 2012 an assessment has been made on the future sources of finance and the degree of certainty associated with prospective funding as below: Figure 4.2: Projections of Secure and Probable Financing by Source and Funding Gap $3,000,000 Funding Gap $2,500,000 HIPC (EU) $2,000,000 Republic of China (Taiwan) Catholic Relief Services $1,500,000 WHO $1,000,000 Unicef GAVI-VF $500,000 National Government $0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Table 4.4 Secure + Probable Funding Funding Gap 2007 $1,716,607 $0 2008 $1,206,409 $542,007 2009 $1,228,105 $616,203 2010 $1,246,717 $696,636 2011 $1,254,582 $676,797 2012 $1,260,459 $696,991 An assessment of the future sources of funding are presented in the table below. It is apparent that the EPI programme is heavily dependent on GAVI support up to 2008 and thereafter there is a substantial funding gap. Secure + Probable Funding National Government GAVI-VF Unicef WHO Catholic Relief Services Republic of China (Taiwan) HIPC (EU) MRC 2003 $ 226,996 1,162,597 680,091 416,456 2004 $ 250,876 1,225,670 172,023 82,023 2005 $ 265,839 1,295,038 171,203 81,203 2006 $ 272,722 1,173,972 261,622 171,622 2007 $ 276,235 1,163,008 174,484 84,484 2008 $ 581,282 176,174 86,174 2009 $ 593,903 177,897 87,897 2010 $ 604,577 179,655 89,655 2011 $ 612,535 181,448 91,448 2012 $ 620,072 183,277 93,277 29,965 14,974 27,519 18,677 18,396 12,780 18,407 22,830 19,151 13,833 207,454 2,516,106 100,362 1,845,927 1,840,803 1,898,616 1,716,607 350,000 1,206,409 350,000 1,228,105 350,000 1,246,717 350,000 1,254,582 350,000 1,260,459 Total Funding Gap - - - - - $542,007 $616,203 $696,636 $676,797 $696,991 Version: Final Page: 33 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 4.4. Projected Key Indicators A review of the key indicators during and post GAVI support indicate that programme efficiencies resulting from the vaccine wastage reduction, improvement in service delivery resulting in enhanced coverage result in substantially reduced costs per DPT/Hib child over the forecast period 2003 – 2012. Additional benefits of the programme can be seen from the key indicators in the table below: Table 4.6: Projected Key Indicators Population Surviving Infants DTP-Hib (liquid) Coverage Recurrent Cost of DPT- Hib Child Recurrent & Capital Cost of DPT- Hib Child Cost Per Capital - Recurrent NIP Costs Cost Per Capital - SIA % Government Funding of Recurrent NIP Activities % Vaccines in Cost of Recurrent NIP Activities 2003 1,566,517 58,650 89% $30 $31 $0.93 $0.52 2004 1,632,311 61,114 92% $25 $29 $0.81 $0.10 2005 1,700,868 63,681 95% $24 $26 $0.80 $0.10 2006 1,772,305 66,355 95% $23 $23 $0.77 $0.19 2007 1,846,741 69,142 95% $22 $22 $0.74 $0.09 15% 68% 2008 18% 64% 2009 2,005,125 75,072 95% $21 $22 $0.71 $0.09 18% 63% 2010 2,089,341 78,225 95% $21 $22 $0.71 $0.09 19% 63% 2011 2,177,093 81,510 95% $21 $21 $0.70 $0.08 19% 62% 2012 2,268,531 84,934 95% $21 $21 $0.70 $0.08 Population Surviving Infants DTP-Hib (liquid) Coverage Recurrent Cost of DPT- Hib Child Recurrent & Capital Cost of DPT- Hib Child Cost Per Capital - Recurrent NIP Costs Cost Per Capital - SIA % Government Funding of Recurrent NIP Activities % Vaccines in Cost of Recurrent NIP Activities 1,924,305 72,046 95% $21 $22 $0.71 $0.09 40% 62% 39% 62% 38% 62% 38% 62% 37% 63% It can be concluded that the benefits that accrue to the EPI programme and the health system in general are substantial. Version: Final Page: 34 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 4.5. Scenario B: Projections for inclusion of Pneumococcal Vaccine in 2007 It is assumed that on completion of the clinical trials of the Pneumococcal vaccine introduction will take place from 2007. It is anticipated that since the Pneumococcal vaccine will be a new vaccine it could qualify for further GAVI support. Due to lack of accurate information it was assumed that the cost per dose was in the region of twice the cost of the DPT/Hib or approximately $50 for a 10 dose vial. With the introduction of the Pneumococcal vaccine projections of future resource needs by cost categories and the impact on the funding gap are illustrated as follows: Figure 4.3 : Scenario B Projections of Future Resource Needs by Cost Categories 3,000,000 Other optional information Shared personnel costs 2,500,000 Measles Polio Other capital costs 2,000,000 Cold chain equipment Vehicles 1,500,000 Other recurrent costs Transportation 1,000,000 Personnel Injection supplies 500,000 New Vaccines Traditional vaccines 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Projected costs for Scenario B are summarised in the following table: Table 4.7: 2003 $,000 2,516 2004 $,000 1845 2005 $,000 1,841 2006 $,000 1,899 2007 $,000 2,219 2008 $,000 2,167 2009 $,000 2,280 2010 $,000 2,398 2011 $,000 2,405 2012 $,000 2,451 Figure 4.4: Scenario B Projections of Secure and Probable Financing by Source and Funding Gap $3,000,000 Funding Gap $2,500,000 HIPC (EU) $2,000,000 Republic of China (Taiwan) Catholic Relief Services $1,500,000 WHO $1,000,000 Unicef GAVI-VF $500,000 National Government $0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Table 4.8 Secure + Probable Funding Funding Gap 2007 $2,218,904 - 2008 $1,636,081 $531,049 2009 $1,675,823 $604,785 2010 $1,713,240 $684,738 2011 $1,740,699 $664,399 2012 $1,766,993 $684,073 Version: Final Page: 35 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Table 4.9: Projected Financing Scenario B - Including Introduction of Pneumonicocal Vaccine [A] Secure Funding National Government Sub-National Government Donor Pool (if applicable) GAVI-VF Unicef WHO Catholic Relief Services Republic of China (Taiwan) HIPC (EU) MRC Total 2007 193,698 1,353,963 18,396 1,566,057 2008 199,013 12,780 211,793 2009 208,599 18,407 227,006 2010 216,110 22,830 238,941 2011 220,773 19,151 239,924 2012 224,876 13,833 238,709 Funding Gap 652,846 1,955,337 2,053,601 2,159,037 2,165,174 2,212,357 [B] Secure + Probable Funding National Government GAVI-VF Unicef WHO Catholic Relief Services Republic of China (Taiwan) HIPC (EU) MRC 2007 276,235 1,665,305 174,484 84,484 18,396 2,218,904 2008 581,282 429,672 176,174 86,174 12,780 350,000 1,636,081 2009 593,903 447,718 177,897 87,897 18,407 350,000 1,675,823 2010 604,577 466,522 179,655 89,655 22,830 350,000 1,713,240 2011 612,535 486,116 181,448 91,448 19,151 350,000 1,740,699 2012 620,072 506,533 183,277 93,277 13,833 350,000 1,766,993 Total Funding Gap - 531,049 604,785 684,738 664,399 684,073 As anticipated programme costs would increase considerably however the forecast remains uncertain given that there is no reliable information on the expected price for this new vaccine. Version: Final Page: 36 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 4.6. Key Indicators for Scenario B A review of the key indicators following the introduction of the Pneumococcal vaccine indicate that programme efficiencies enable the introduction of the new vaccine whilst maintaining the cost per DPT – Hib child at a level considerably lower that the current estimated cost. Table 4.10: Scenario B Projected Key Indicators Population Surviving Infants DTP/Hib (liquid) Coverage Recurrent Cost of DPT/Hib Child Recurrent & Capital Cost of DPT/Hib Child Cost Per Capital - Recurrent NIP Costs Cost Per Capital - SIA % Government Funding of Recurrent NIP Activities 2007 1,846,741 69,142 95% $30 $30 2008 1,924,305 72,046 95% $27 $28 2009 2,005,125 75,072 95% $27 $28 2010 2,089,341 78,225 95% $27 $29 2011 2,177,093 81,510 95% $27 $27 2012 2,268,531 84,934 95% $27 $27 $1.01 $0.09 $0.93 $0.09 $0.93 $0.09 $0.93 $0.09 $0.92 $0.08 $0.91 $0.08 14% 31% 30% 30% 29% 29% It should be noted that the detailed financial analysis provided in the Appendix relates to the EPI programme excluding the costs associated with the introduction of the Pneumococcal vaccine discussed above. Version: Final Page: 37 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 SECTION 5 5. Sustainable Financing Strategic Plan and Indicators 5.1. Key objectives for the Financial Sustainability Plan If the perceived function of the Financial Sustainability Plan is seen to be solely to secure funding from the Global Alliance for Vaccinations and Immunisation, then its true importance is lost. From the government’s perspective, the real value of the FSP is to start the process of moving The Gambia EPI programme on its way towards financial sustainability, which is defined by GAVI as follows: Although self-sufficiency is the ultimate goal, in the nearer term sustainable financing is the ability of a country to mobilize and efficiently use domestic and supplementary external resources on a reliable basis to achieve current and future target levels of immunization performance in terms of access, utilization, quality, safety and equity. The FSP will assist The Government of The Gambia and in particular, senior health officials and senior management of the EPI programme to ensure the successful delivery of immunisation services in The Gambia. The Government intends to use the Financial Sustainability Planm as a strategic framework to implement change and deliver continuous programme improvement. 5.2. Requirements for Success To start the process of moving The Gambia on its way towards financial sustainability of EPI delivery it must achieve the following: ! To secure ongoing GAVI and other donor funding ! To be used as an advocacy tool for the following: o The Government of The Gambia in their dealing with their development partners. o The Department of State for Health and Social Welfare in their negotiations with other governmental departments. o Senior management of the EPI programme for resource mobilisation, programme strengthening and deepening. ! To form the basis for strategic planning for the EPI programme of The Gambia. ! To establish targets and monitor the performance of EPI delivery at all levels. ! Continual improvement in the effective delivery of immunisation services. ! Efficiency savings set out in the plan. Version: Final Page: 38 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 5.3. Strategic Plan to Achieve Sustainable Financing In order to achieve these goals the actions outlined below must be achieved: Table 5.1: Strategic Plan Objective Required Actions Responsibility Progress indicator Submission accepted Timely Reporting. Monitoring of achievement of FSP objectives Clear plan for sustainable funding. Clear plan for sustainable funding. Means of Verification Approval of funding Approval of Funding To secure ongoing GAVI and other donor funding To secure current Complete, approve MHSW round of GAVI and deliver FSP to ICC Funding GAVI. To secure future Implementation of DHS GAVI funding FSP and reporting as EPIM required To identify and target partners for ongoing funding of EPI services To be used as an advocacy tool To secure new Advocacy at senior sources of funding level with potential strategic partners. To negotiate with other government departments To secure additional donor funding MHSW DHS EPIM DP MHSW DHS EPIM MHSW DHS EPIM Substantially increased donor support. Substantially increased donor support. Use finance and Secured funds Inclusion in budget. costings to secure to meet all budgetary approval requirements of and support for EPI FSP. activities To strengthen and To ensure all staff in DHS FSP targets Targets monitored deepen EPI EPI work towards the EPIM achieved. at senior level. programme successful delivery of the FSP Targets. To form the basis for strategic planning for the EPI programme of The Gambia Develop a strategic Develop clear plan MHSW Sector wide Development of plan for health health facility approach health provision in DHS delivery. development, FP developed accordance with infrastructural strategic plan. improvement, equipment and staffing in conjunction with key partners. To establish targets and monitor the performance of EPI delivery at all levels. To establish annual Establish clear targets MHSW Targets set, Unfavourable performance targets for coverage, reduced DHS communicated, performance drop out and vaccine EPIM and monitored. identified and acted wastage reduction upon. Monitor targets at Senior management MHSW Reports issued Targets achieved or central, divisional to receive, review and DHS and exceeded. and health centre act on monthly EPIM unfavourable level. reports on all key performance targets. acted upon. Version: Final Page: 39 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 Progress Means of indicator Verification To achieve continual improvement in the effective delivery of immunisation services. To maintain and Gradual improvement DHS Coverage Improved coverage. enhance coverage of service delivery EPIM reports. through PHO/CHN implementation of policy of community based delivery. To reduce drop out Monitor drop out EPIM Drop Out Reduction in drop rates and investigate PHO/CHN analysis reports. out rates. unfavourable levels. Causes of drop Document causes and out documented take corrective action. and addressed To achieve efficiency savings set out in the plan. To reduce vaccine Immediate DHS Monthly Action taken to management enhance EPI wastage improvement in management reports to senior processes. reporting management. Recruitment of Require name Immediate Staff recruited and appropriately & dept. Recruitment retained. qualified personnel and training. responsible only for vaccine wastage reduction. National VWMRT Standardised Systematic audit to measurement and timely reporting validate accuracy. monitoring of vaccine provided to Immediate usage v actual delivery director and management action at Facility level. senior on unfavourable management on wastage. monthly basis. Identify causes of DHS Reduction in Comparison of wastage and deliver EPIM reported reduction in wastage solutions to reduce VWMRT wastage at against annual wastage. CHN / PHO targeted targets. facilities. To strengthen trained human resources for the effective delivery of EPI services To maintain DHS Staffing norms Staffing lists from Establish clear EPIM set and facilities minimum levels of staffing norms for monitored staffing for the EPI delivery of EPI services at all levels Develop incentive DHS Incentive Divisional Health package for staff EPIM packages Team Annual delivering EPI developed and reports services implemented Objective Required Actions Responsibility MHSW – Minister for Health and Social Welfare FP – Funding Partners DP – Diplomatic Personnel PS – Permanent Secretary to Department of State for Health and Social Welfare DHS – Director of Health Services EPIM - EPI Manager VWRMT - Vaccine Wastage Reduction Management Technician CHNs – Community Health Nurse PHOs - Public Health Officers Version: Final Page: 40 Printed: 11:20 AM 3/12/2004 The Republic of The Gambia – Department of State for Health & Social Welfare Financial Sustainability Plan Submitted to GAVI November 2003 The successful implementation of the key strategic changes recommended are the requirements for the success of this Financial Sustainability Plan. Since the instigation of the Financial Sustainability Plan advocacy has commenced to secure long term funding for the EPI programme. To date this has secured proposed funding of US$350,000 grant aid from HIPC(EU) which has been allocated to funding the EPI programme. A further US$100,000 is anticipated in loans to the government which has been recorded as a government contribution to the FSP. 5.4. Conclusion Figure 5.1: Projections of Secure and Probable Financing by Source and Funding Gap $3,000,000 Funding Gap $2,500,000 HIPC (EU) $2,000,000 Republic of China (Taiwan) Catholic Relief Services $1,500,000 WHO $1,000,000 Unicef GAVI-VF $500,000 National Government $0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 As can be seen from the final graphic representation of future probable funding their achievement will place The Gambia well under way to achieving financial sustainability as government works to bridge the future funding gap. 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