FINANCIAL SUSTAINABILITY PLAN OF THE EXPANDED … · REPUBLIC OF GUINEA Work – Justice -...

REPUBLIC OF GUINEA Work – Justice - Solidarity

MINISTRY OF PUBLIC HEALTH National Coordination Unit for EPI/PHC/ME

Immunization Section

FINANCIAL SUSTAINABILITY PLAN OF THE EXPANDED PROGRAM ON

IMMUNIZATION 2005 – 2013

JANUARY 2005

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TABLE OF CONTENTS

ACRONYMS AND ABBREVIATIONS .................................................................................. 3 Executive Summary ................................................................................................................... 4 INTRODUCTION...................................................................................................................... 8 Section I: National context and its impact on the organization and financing of the health system....................................................................................................................................... 11 I.1 General political and economic context.............................................................................. 11 I.11. Geographical data ............................................................................................................ 11 I.1.2. Socio-demographic data.................................................................................................. 11 I.1.3. Political and institutional situation.................................................................................. 12 I.1.4. Economic situation.......................................................................................................... 13 I.1.5 Main characteristics of the economy ............................................................................... 13 I.2. Organization and funding of the health system ................................................................. 14 I.2.1 Organization of the health system.................................................................................... 14 I.2.2. Place of health in the National Poverty Reduction Strategy........................................... 15 I.2.3. The role of EPI in national health policy ........................................................................ 16 1.2.4. Financial resources and health-sector funding ............................................................... 16 Section II: Main program characteristics ................................................................................ 20 2.1 Organization and Management .......................................................................................... 20 2.2 Vaccine supply, storage and distribution ........................................................................... 21 2.3 Disease surveillance ........................................................................................................... 21 2.4. Program results.................................................................................................................. 21 2.5. Main constraints and difficulties ....................................................................................... 22 2.6 Program goals and strategies.............................................................................................. 22 2.6.1. Goals............................................................................................................................... 22 2.6.2 Strategies ......................................................................................................................... 23 Section III: Baseline and present program costs and financing ............................................... 26 Section IV: Resource requirements and program funding/Analysis of funding gaps.............. 33 SECTION N° V: Strategic Plan and financial sustainability indicators .................................. 40 5.1 Fund-raising strategies and steps........................................................................................ 40 5.2 Strategies and steps to improve management .................................................................... 41 5.3 Institutional and human capacity-building......................................................................... 42 Consolidated table of steps and strategies to be implemented ................................................. 43 Internal fund-raising ............................................................................................................... 43 SECTION VI: Comments of the parties .................................................................................. 46 ANNEXES ............................................................................................................................... 47 Methodology and preparation of the EPI Financial Sustainablility Plan .......................................... 47

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ACRONYMS AND ABBREVIATIONS ADS Auto-disable syringes

AIDS Acquired Immune Deficiency Syndrome

BCG Bacille de Calmette et Guérin

CC Cold chain

DAFA Directorate of Administrative and Financial Affairs

DTP Vaccine for diphtheria, tetanus and pertussis

DTP-HepB Tetravalent vaccine for diptheria, tetanus, pertussis and Hepatitis B EPI Expanded Program on Immunization

EPI/PHC/ED Expanded Prog. on Immunization/Primary Health Care/Essential Drugs

FIC Fully immunized child

FSP Financial Sustainability Plan

GAVI Global Alliance for Vaccines and Immunization

GDP Gross Domestic Product

HepB Hepatitis B vaccine

HIPC Heavily Indebted Poor Countries

HIV Human Immune Deficiency virus

IC Immunization coverage

ICC Inter-agency Coordinating Committee

ICCD Integrated Coverage of Childhood Diseases

IDA International Development Association

JICA Japanese International Cooperation Agency

MATD Ministry of Territorial Administration and Decentralization

MEAS Measles vaccine

MEF Ministry of the Economy and Finance

MPA Minimum Package of Activities

MPH Ministry of Public Health

MTEF Medium-term Expenditure Framework

NGO Non-governmental organization

NHDP National Health Development Plan or Program

NID National Immunization Day

NPHD National Public Health Directorate

OPV Oral polio vaccine

PTHC Prefectural Technical Health Committee

RDC Rural Development Community

RTHC Regional Technical Health Committee

TCC Technical Coordinating Committee

TT Tetanus vaccine

UNDP United Nations Development Program

UNFPA United Nations Fund for Population Activities

UNICEF United Nations Children’s Fund

USAID United States Development Agency

WHO World Health Organization YF Yellow fever vaccine

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Executive Summary

In 1988, Guinea launched the National Primary Health Care Strategy (EPI/PHC/ED), based on the Bamako Initiative which features immunization as one of its essential components.

The activities of the Expanded Program on Immunization (EPI) form part of primary health care. Ever since this date, EPI has developed erratically, sometimes featuring periods of strong increases in coverage rates followed by setbacks. Nevertheless, real progress has been made with regard to immunization coverage, which rose from 5% in 1986 to over 60% in 2003 as far as DPT3 is concerned.

I. Challenges Regardless of the progress made, it has not been possible to reach internationally agreed goals. This poor showing is due to various difficulties and constraints, most of which were identified by the external EPI review conducted in 2000. To list only a few:

• Obsolete cold chain equipment (intermediate level and periphery);

A dearth of EPI financing from the State and partners;

Insufficient social mobilization for EPI.

To this should be added other challenges, such as:

The need to improve injection safety;

The introduction of new, more expensive vaccines into routine EPI;

The epidemiological situation, characterised by the persistence or flare-up of transmissible diseases.

These major challenges place ever greater pressure on the State’s own resources and make it even more difficult to choose between the various national priorities and public health.

As far as programme implementation is concerned, the major difficulties are mobilizing resources, disbursing funds and ensuring that they are used rationally.

In terms of EPI expenditure, financing from the State and partners increased between 2001 and 2003, primarily due to the HIPC funds which the country received during this period.

There is a need to ensure rational use of internal and external financing with a view to taking up the challenges which lie ahead and securing a sufficient volume of sustainable funding for immunization activities.

II. Goals Consequently, the Financial Sustainability Plan of the Expanded Program on Immunization comes at the right time to meet a relevant concern: taking up the above-mentioned challenges. In this connection, the plan sets the following goals:

o Engaging in advocacy efforts with a view to securing medium- and long-term funding commitments by determining common responsibilities and priorities for the government and development partners;

o Enhancing the effectiveness of fund mobilization and use;

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o Establishing a framework for cooperation between the ministries of finance and public health, on the one hand, and between the Government and development partners, on the other hand;

o Improving financial management through timely fund disbursement and regular follow-up by all partners;

o Boosting the flow of resources towards service providers;

o Enhancing the reliability, effectiveness and efficiency of fund use.

III. Context a. Opportunities

The following factors have facilitated the preparation of the EPI Financial Sustainability Plan:

o The Government's clear desire to ensure a regular supply of vaccines and consumables, as reflected by the signing of the protocol of agreement on the Vaccine Independence Initiative with UNICEF;

o The inclusion of the health sector among the priority sectors of the Medium-term Expenditure Framework in the State budget;

o The establishment of democracy, political stability, and the existence of republican institutions;

o The will to move ahead with decentralization and devolution;

o The adoption of a sectoral approach by the Ministry of Health for the implementation of the National Health Development Plan;

o The application of a policy of cost coverage in EPI/PHC/ED structures and the will to ensure community involvement in health centres;

o The existence of an Inter-agency Coordinating Committee (ICC).

b. Past costs and financing 2001-2003:

When viewed from the perspective of past costs, EPI funding rose 35% between 2001 and 2003. A breakdown shows a predominance of shared costs with regard to staff, transportation and buildings. The latter category increased to 59.7% of expenditure in 2001, from 49.5% in 2002 and 47% in 2003.

In terms of strategies, routine immunization accounts for the lion’s share of expenditure, ranging from 92.6% in 2001 to 78.7% in 2003. The next biggest cost item is immunization campaigns, which absorbed 7.4% of spending in 2001, rising to 21.3% in 2003. Outreach strategies accounted for 0.6% in 2001, as against 1.5% in 2002, and 0.7% of total program cost in 2003.

In terms of funding sources, the Government was the main donor during 2001-2003, followed by WHO and JICA in 2001. In 2002 and 2003, UNICEF provided the second largest volume of funding, after the national government.

Nevertheless, the point should be made that WHO and UNICEF should be considered as executing agencies for their own activities and for certain partners like USAID.

The cost per fully immunized child for DTP3 stayed almost the same in 2001 and 2003 (USD 32.30). In 2002, however, it went up to USD 36.20.

c. Estimated resource requirements and funding needs for 2005-2013

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Estimated program cost comes to USD 124,136,802, of which USD 80,218,187 is secured funding, leaving a gap of USD 43,918,615. The bulk of the funding comes from the traditional partners such as WHO and UNICEF and above all GAVI, particularly following the introduction of the new pentavalent vaccine in 2006. However, it should be noted that in each case, WHO and UNICEF must be viewed as fund-raisers and executing agencies.

The national government’s estimated contribution for 2005-2013 is low compared to its contribution during 2001-2003.

IV. Data source Data was collected on the basis of the reports of activities submitted by the EPI/PHC/ED Coordination Unit and information received from the various partners.

FSP goals were set taking the following factors into consideration:

NHDP estimates

Available resources and likely resources from partners

Improvement of overall EPI management by:

- Ensuring an adequate supply of essential vaccines;

- Implementing the ”reach each district” strategy;

- Relying increasingly on performance contracts with private health agents and structures involved in immunization;

- Overhauling cold chain facilities at all levels;

- Relaunching supervisory activities;

- Monitoring immunization activities by level, taking wastage rates for all antigens into consideration.

The State intends to continue its efforts to raise funds for EPI. Activities will focus on the following:

Actually applying texts on the use of funds generated by cost coverage in health care centres: this would make it possible to cover overheads relating to refrigerators in health centres, fuel for outreach strategies, essential drugs, management aids and staff incentives

Preparing, adopting and disseminating legislative and regulatory texts on the functioning of the mutual insurance companies;

Speeding up the decentralization process via the preparation, adoption and dissemination of legislative and regulatory texts;

Getting the private health sector involved in immunization activities. With this in mind, the Ministry of Health intends to introduce model contracts in existing and future structures to cover the delivery of health care and promote immunization of their clients;

Securing funding from national and foreign NGOs for the financing of systematic immunization activities and campaigns in their operating areas;

Applying the convention between the Government and UNICEF on the Vaccine Independence Initiative (VII);

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Pursuing efforts to combat corruption, improve management of public funds and apply the principles of good governance;

Enlisting the backing of certain traditional EPI partners, particularly JICA and UNICEF, in their traditional operating areas, with regard to logistics and cold chain facilities;

Taking advantage of budgetary support, the financing form that certain bilateral and multilateral partners prefer at present. Part of the funding from the partners concerned could be earmarked for immunization activities, especially routine EPI;

Encouraging staff involved at all levels of the health pyramid to shoulder more responsibility, by means of performance contracts;

Introducing systematic monitoring of efforts to optimize fund use, by means of the following indicators:

- Reduction of drop-out rates

- Monitoring of vaccine wastage rates

- Disbursement rate for funds earmarked for EPI.

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INTRODUCTION

At the National Health Conference in 1984, the Republic of Guinea pledged its full support to a health system primarily based on primary health care designed to provide essential care to the bulk of the population with its full support.

Implementing this policy through the EPI/PHC/ED program has made it possible to achieve remarkable progress, as reflected by immunization coverage rates. For DTP3 for example, coverage rates for 2000, 2001, 2002 or 2003 are as follows: 43%, 64%, 50% and 69%.

Immunization is deemed the most cost-effective means of combating EPI target diseases. As a result, it remains the primary means of fighting such diseases.

The activities of the Expanded Program on Immunization form part of the EPI/PHC/ED program. To date, 390 health centres and CMCs offer immunization activities for the benefit of the public.

EPI goals for the next 10 years, as defined in the NHDP, are as follows:

Ensuring an adequate supply of essential vaccines;

Reaching nationwide vaccine coverage rates of 90% for children under 1 and for pregnant women, including in poor, isolated areas;

Eradicating polio over the short term.

The following strategies will be used to achieve these goals:

• Incorporating new vaccines into routine EPI (HepB, Hib);

• Introducing specific measures to reach poor, isolated areas;

• Allocating part of the funds released by debt relief for EPI;

• Enlisting partners’ support for the funding of immunization activities, especially as far as the investment component is concerned.

The real progress made reflects the will of the Health Department to strengthen fund mobilization efforts for the financing of the health system in general and EPI in particular.

Significant progress has been made thanks to these efforts. Nevertheless, in terms of program operation, there are still major concerns with regard to financing:

• The EPI budget accounts for only a small share of the overall health budget;

• There is a shortage of rolling stock and cold chain equipment;

• Certain antigens are subject to frequent shortages;

• There are not enough staff members to service poor, isolated areas.

There are also a number of challenges, including the following:

• Partners do not coordinate activities sufficiently;

• The epidemiological situation is worrying: cases of wild polio viruses and yellow fever have appeared;

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• There is a need to secure EPI funding once GAVI support has been phased out.

These challenges are placing ever greater pressure on the State’s own resources and are making it increasingly difficult to choose between the different national priorities and public health.

The Government absolutely must secure internal and external financing to meet these challenges, thereby guaranteeing adequate and sustainable funding for immunization activities.

The EPI Financial Sustainability Plan is a tool designed to take up this challenge. It aims to do the following:

• Determine the joint responsibilities and priorities of the Government and the development partners;

• Optimize fund mobilization and use;

• Provide a framework for coordination and negotiation between the Ministries of Health and Finance on the one hand, and between the Government and the development partners, on the other hand.

Certain aspects of the current climate are conducive to the preparation of such a plan:

• The important role played by community funding, via cost coverage in immunizing health care structures;

• The Government’s clear determination to ensure a regular supply of vaccines and consumables, as reflected by the signature of a protocol of agreement on the Vaccine Independence Initiative (VII) with UNICEF;

• The implementation of the National Poverty Reduction Strategy, of which immunization is an important component;

• The existence of a functional ICC.

The FSP consists of the following six sections:

Section I: National context and its impact on the organization and financing of the health system Section II: Main program characteristics Section III: Baseline and present program costs and financing Section IV: Resource requirements and program funding/Analysis of funding gaps Section V: Strategic plan and financial sustainability indicators Section VI: Comments by the parties

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SECTION I:

NATIONAL CONTEXT AND ITS IMPACT ON THE ORGANIZATION AND FUNDING

OF THE HEALTH SYSTEM

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Section I: National context and its impact on the organization and financing of the health system I.1 General political and economic context I.11. Geographical data

The Republic of Guinea is located in West Africa, between 7° and 12° latitude north and 8° and 15° longitude west, with a coast line of 300 km on the Atlantic Ocean. It is bordered by Guinea-Bissau to the north-east, by Senegal and Mali to the north and north-east, by Côte d’Ivoire to the east and by Liberia and Sierra Leone to the south. The country features a tropical climate, alternating between dry seasons (from November to April) and rainy seasons (from May to October), depending on region and altitude. It should be noted that the country has one of the densest hydrographic networks in the area.

Guinea has a surface area of 245,857 sq.km. and is divided up into four natural regions:

o Lower Guinea, a region where coastal plains cover 18% of the country’s land area and the climate is characterised by heavy rainfall ranging from 3000 to 4000 mm per year;

o In Middle Guinea, 22% of the land area consists of mountains, and annual rainfall varies between 1000 and 15000mm;

o In Upper Guinea, plateaux and wooded savannas account for 40% of total land area, and between 1000 and 1500mm of rain falls every year;

o Lastly, Forest Guinea features mountains and dense forests covering 20% of the land area, with rainfall ranging between 2000 and 3000mm per year.

I.1.2. Socio-demographic data

In demographic terms, Guinea’s population was estimated at 8,225,754 inhabitants in 2001, on the basis of estimates relying on the 1996 census. This population is unevenly distributed throughout the national territory: two-thirds live in rural areas while one-third lives in urban areas. More than half of the urban population lives in Conakry, a city with an annual estimated growth rate of 6%1.

Guinea has a consolidated average fertility rate of 6 for the country as a whole. This makes it one of the fastest growing countries in the area, with a natural rate of increase of 2.8% per year. Life expectancy at birth is 54, with an overall mortality rate of 14.2 per 1000 and an infant mortality rate of 98 per 1000 live births. The maternal mortality rate is 528 per 100,000 live births.

In terms of education, the educational reform introduced following the educational policy statement adopted in 1989 has led to real progress in this field, as reflected by the raw school attendance rate, which rose from 26.81% in 1990 to 57% in 20002. It is worth noting that during the same period, the

1 EDS 1992 2 SRP. P.25.

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school attendance rate for girls went from 7.3% in 1990 to 44.3% in 20003. These improvements were the outcome of major investments in infrastructures and the recruitment of more teachers. Nevertheless, the adult literacy rate remains relatively low, varying between 40% and 50% depending on the region. This rate is also characterised by a pronounced gender imbalance, with literacy rates of 41% and 22% for men and women, respectively.

Naturally, this situation has a bearing on the adoption of certain types of behaviour that are conducive to the promotion of hygiene and health. Finally, it should be noted that Guinea was ranked 157th out of 175 countries in the 2003 Human Development Index.

I.1.3. Political and institutional situation

1.1.3.1 Brief overview of the country’s political situation

Guinea is governed by a Fundamental Law adopted on 23 December 1990, the preamble of which states that the country adheres to the principles of law enshrined in the Universal Declaration of Human Rights and the African Charter on Human and People’s Rights. The text also affirms the right to work and to health, and the right of the State to ensure the well-being of its citizens.

Since then, republican institutions have gradually been set up: the National Assembly, the Supreme Court, the Economic and Social Council and the National Communication Council.

The Fundamental Law protects freedom of speech and belief, as reflected by the existence of 42 political parties and a host of newspapers, at least ten of which appear regularly. The country is politically stable, and civil society is actively involved in all fields through associations and NGOs.

At the head of the country is the President of the Republic, the guarantor of republican institutions. The last presidential elections for a seven-year term were held in December 2003.

1.1.3.2 Political and administrative organization

As far as its political and administrative organization is concerned, Guinea launched a major territorial reform in 1986, marked by devolution and decentralization.

In terms of devolution, legislative and regulatory texts make provision for three levels.

The first level of devolution is the regional one: seven administrative regions were established in addition to the region of Conakry, which constitutes a special zone with a specific status.

The second level is the prefectural entity, the body truly responsible for the implementation of the Government’s overall and sectoral programs and policies. There are 33 prefectures in the country as a whole.

The third level is the sub-prefecture, which is the local echelon for designing and implementing development-related efforts and operating the machinery of the State.

3 SRP (op. cite)

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As far as decentralization is concerned, the reform of the State has led to the definition of a legal framework via the creation of decentralized communities in rural and urban areas.

On the basis of these texts, the country currently has 38 urban communes, including five in the city of Conakry, and 302 rural development communes (RDCs). These territorial entities are financially autonomous and are administered by a deliberative body (the Communal Council for urban communes and the Community Council for rural communes). The executive body is the mayor for the urban communes and the President of the RDC for the rural communes.

It should be noted that initial reluctance to embrace the policies of devolution and decentralization has been reduced by means of consultation campaigns organized by the Government. Now, the people are determined to become actively involved in running development programs.

I.1.4. Economic situation

After three decades of economic policy based on the centralized planning model, Guinea found itself facing major internal and external imbalances when the socialist regime ended. Accordingly, in 1986 it launched a vast program of economic and financial reform based on the overall goal of reducing poverty through steady, sustainable growth. The main characteristics of these reforms were to be the following:

o The State’s gradual withdrawal from the productive sectors;

o A more healthy economic and financial position;

o Private-sector support via the improvement of the institutional and regulatory framework for doing business;

o Continued efforts to develop basic infrastructures and investments in the rural sector.

To accompany this process, these reforms were reinforced from 1996 onwards by rigorous steps in the following areas:

o A restrictive budgetary policy aimed at putting the Government’s finances back on an even keel;

o A tight-money policy aimed at containing inflation and aligning exchange rates for the parallel market with bank rates.

Even though, on the whole, these policies made it possible to reduce macroeconomic imbalances and ensure a stable economic and financial climate from 1996 to 1999, economic growth was slower than expected.

I.1.5 Main characteristics of the economy

During the 90s, Guinea averaged 4% annual growth in real terms. This growth primarily came from the mining, agricultural and industrial sectors. The mining sector, especially bauxite, accounts for 80% of overall export earnings and represents 16% of GDP. Agriculture, which contributes 18% to GDP, grew at an average clip of 4.5%. Industry, which increased its contribution to GDP from 29% to 31% during this period thanks to reforms, developed at a 3.2% pace. However, services’ share of GDP fell from 50% to 47% during the period under review.

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According to the conclusions of the latest Public Expenditure Review conducted in 2003 by the Ministry of Economy and Finance with the support of the World Bank, the economic situation has significantly worsened over the last three years. Not only has economic growth been slower than expected but budgetary policy has been expansionist, as reflected by increased spending on security and defence. This has led to faster money supply growth, boosting monetary inflation. Moreover, internal imbalances have worsened and the gap between official and parallel exchange rates has widened.

With regard to the future, the country faces major cash-flow problems which may compromise the implementation of the National Poverty Reduction Strategy adopted in 2002. The provisional tranche of the HIPC funds expired in June 2003, while the debt relief from the ADB came to an end in December 2003. The volume of outside funding is expected to decline. In view of this situation, securing funding for health care, which is one of the essential components of the National Poverty Reduction Strategy, is a major concern.

I.2. Organization and funding of the health system I.2.1 Organization of the health system

The health system in Guinea is composed of the public and private sub-sectors.

The public sub-sector features a pyramidal structure with the health stations at the bottom, moving upwards through the health centres, the prefectural hospitals and regional hospitals, and ending with the national hospital at the top.

The private sub-sector includes medical structures on the one hand and pharmaceutical structures on the other.

The medical private sub-sector can be broken down into nurses’ and midwives’ offices, doctors’ practices and clinics.

Pharmaceutical and biomedical structures consist of points of sale, private dispensaries, wholesale companies and laboratories for biomedical analysis.

It should be noted that the infrastructures in the sector primarily consist of health establishments divided up between the public and private sectors.

The following table shows the number of public-sector structures by type.

Table 1: Situation of public-sector medical structures

Type Number

Operational health stations 550

Health centre / CSA 394

Prefectural hospital / CMC 30

Regional hospital 7

National hospital 2

Source: EPI/PHC/ED Review March 2004,

The status of these infrastructures varies owing to problems with construction, the technologies used and maintenance.

The level of equipment generally matches the level set out in the health sheet; any differences primarily pertain to operational status.

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At present, the private health sector consists of 19 clinics, 2 company hospitals, 219 doctors’ practices, 11 dentists’ offices and 16 midwives’ offices.

The informal sector is developing rapidly and uncontrollably. Although it provides health care, no information is available on the rates charged and above all on the quality of service, a factor which jeopardises the long-term survival of the official structures.

The pharmaceutical and biomedical sector is made up of 230 dispensaries, 40 points of sale and 10 laboratories.

With regard to human resources, the survey of health-sector staffing gives an in-depth look at overall staffing with a breakdown by region, prefecture and type of health-care establishment. The survey also shows the primary characteristics of the staff employed (breakdown according to skills, gender, age, seniority, etc.).

The following is a summary of the report entitled “The situation with regard to health-care personnel”.

According to this document, the Ministry of Health employs a total of 6679 persons, broken down into health-care staff (82.2%) and support staff (17.8%).

Out of this total, 52.1% are women and 47.9% are men, a proportion that varies depending on region, prefecture and profession. Conakry and Kindia have the highest women/men ratio – 2.54 and 1.36 respectively. The most men are employed in the regions of Boké and N’Zérékoré (nearly three men for every two women).

A look at the age and seniority pyramid shows that over the next seven years, nearly 25% of all staff will have retired. The categories most affected are public health technicians (73%), midwives (52.1%), X-ray technicians (50%), laboratory technicians and pharmacists’ assistants. Already today, there are not enough persons in these categories, and this problem will become worse in the future if nothing is done. This being so, additional staff will have to be recruited.

I.2.2. Place of health in the National Poverty Reduction Strategy

In 2002, Guinea drew up a National Poverty Reduction Strategy of which health is one of the main components. The general goal assigned to the health sector within the framework of this strategy is “to ensure that all men, women and children in the country have access to quality health care without geographical, economic or socio-cultural obstacles”.

Some specific goals are as follows:

o Reduce the gross mortality rate from 12/1000 in 2005 and 9/1000 by 2010 as compared with 14.2/1000 in 1999;

o Reduce the infant mortality rate from 70/1000 in 2005 to 50/1000 by 2010 as compared with 98/1000 in 1999;

o Reduce the maternal mortality rate from 300 per 100,000 in 2005 and 200 for 100,000 by 2010 as compared with 528 per 100,000 in 1999.

With a view to stepping up the implementation of the health component of the National Poverty Reduction Strategy, the government finalized a National Health Development Plan (NHDP) in 2004, which gives high priority to immunization.

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I.2.3. The role of EPI in national health policy

The overall aim of the NHDP is to further the country’s overall socioeconomic development by improving public health status.

The specific goal is to introduce an accessible health-care system by 2010 that is capable of meeting public health needs and helping to reduce poverty.

The main strategic thrust of this national health policy is integrated disease and maternal mortality control. The document stipulates that “disease control efforts aim to create conditions conducive to a reduction in morbidity and mortality and complications linked to priority diseases, in accordance with the Millennium Development Goals, selected in connection with the National Poverty Reduction Strategy”.

Disease control goals are as follows:

o Reduce infant and child mortality from 177 per 1000 to 90 per 1000 by 2015;

o Reduce infant mortality from 98 per 1000 to 50 per 1000 per 2015;

o Reduce maternal mortality from 528 per 100,000 live births in 1999 (EDS 2) to 220 per 100,000 live births by 2015;

o Reduce malaria-related mortality by 40% by 2015;

o Reduce tuberculosis-related mortality by 50% by 2015;

o Keep the rate of HIV/AIDS infection below 5%;

o Reduce the prevalence of stunted growth from 26% to 13% for children under 5 by 2015.

The best way to achieve these goals is immunization, as provided by the Expanded Program on Immunization (EPI).

1.2.4. Financial resources and health-sector funding

Health-sector funding comes from four main sources: the State, local authorities, the public and donors.

The State primarily covers payment of officials’ wages, part of vaccine procurement, other overheads for centralized and decentralized structures, as well as part of basic and advanced training. It also invests in health centres and hospitals.

Local authorities (communes, prefectures, regions) bear a relatively small share of the cost burden, which is limited to paying the salaries of part of the contractually employed staff.

The public pays part of the cost of health infrastructures and, through the cost coverage system, part of the operating costs of health-care establishments, in particular the purchase of pharmaceutical products, staff incentives, maintenance and upkeep expenses, and management aids. To this must be added an unknown but significant volume of household spending on health care, complementary examinations and purchase of medicine.

Donors mainly finance infrastructure or equipment-related expenditures, basic or advanced training, the procurement of logistics equipment and part of vaccine procurement within the framework of EPI.

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For 1998, health-care funding, in terms of real expenditure, was as follows:

Table 2: Operating expenses for the Ministry of Public Health, 1998 (in millions of Guinean francs)

Source Estimate Percentage Executed Percentage

State 17,884 90.2 14,630 79.8

Local authorities 19 0.1 5,779 0.03

Outside aid 1,560 7.8 978 5.3

Public 365 1.9 2,709 14.8

Total 19,828 100 18,322,779 100

Source: Administrative Affairs Division, Ministry of Health, 1999

The amount of outside aid corresponds to the training and supply of medicine provided by certain foreign institutions and NGOs.

The above breakdown shows that the State covers the lion’s share of the operating budget for health, leaving aside household expenditure on other, non-public sources of health care.

Health’s share of the national budget for the period under review was 3.5%, well below the 10% recommended by the World Health Organization.

Studies have shown that spending out of the national budget focuses on salaries, which account for a very large share (nearly 90%).

Notwithstanding its budget-related difficulties, the State has made real efforts in the health field, even if the desired goals were not met.

For example, out of the HIPC funds made available, 9.23% were earmarked for health in 2001, as against 22.41% in 2002 and 22.12% in 2003.

In terms of GDP, health’s share of the State budget has varied somewhat, ranging from 1.1% in 2000 to 1.6% in 2001 and 1.2% in 2002.

As far as the health budget is concerned, EPI’s share of vaccine procurement from 2001 to 2004 is as follows:

o From the perspective of allocations, 12.41% in 2001, 14.41% in 2002, 11.87% in 2003 and 8.13% in 2004.

This drop in allocations is linked to economic cycles related to the country’s invasion by rebel forces and the resultant rise in security-related expenditure.

o Allocations for vaccine procurement stood at 35.43% in 2001, 100% in 2002 and 99.49% in 2003.

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SECTION II:

MAIN CHARACTERISTICS OF THE EXPANDED PROGRAM ON IMMUNIZATION

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Section II: Main program characteristics 2.1 Organization and Management 2.1.1 Organization The Expanded Program on Immunization, or EPI, has been a reality in Guinea since 1979. However, the redoubled efforts made from 1986 did not start to pay off until 1988, when the first EPI/PHC/ED health centres were established. EPI activities in Guinea form a part of the EPI/PHC/ED program. The latter is aimed at improving immunization coverage and ensuring the sustainability of such coverage by guaranteeing the supply of vaccines and essential drugs, broadening health coverage, strengthening the management capacities of EPI actors at all levels and above all encouraging community involvement. The program offers immunization incorporated into several other components of mother and child health, in a minimum package of activities at the level of the health centre (HC). The number of immunizing structures follows the number of infrastructures built, renovated or integrated.

EPI is a section of the Preventive Division and forms an integral part of the National Coordination Unit of the EPI/PHC/ED program.

2.1.2 Management In structural terms, the institutional framework for the EPI/PHC/ED program consists of the following: an EPI/PHC/ED National Coordinator, an EPI National Director, an accountant, and an Essential Drugs Officer.

The management unit is responsible for coordinating all activities and managing resources. It is assisted at the central level by a support team for decentralization, an epidemiological statistics unit, a logistics and supply unit, and a supervisory unit.

2.1.3 Working commissions In addition, four commissions composed of non-EPI members have been set up.

Commission for EPI Logistics and Supply Commission for Community Involvement and Social Mobilization Commission for Training and Supervision SNIS Commission for Monitoring and Evaluation

Coordination at the regional and prefectural levels is handled by the Regional Health Directors (RHD) and the Prefectural Health Directors (PHD), respectively.

Over a 15-year period (1988- 2003), the number of public establishments made operational, built or renovated and outfitted in accordance with the prevailing standards comes to 394 health centres/CSA, 550 health stations, 32 prefectural hospitals/CMC, seven regional hospitals and two national hospitals.

The private sector also immunizes under the supervision of the public services.

20

Table 3: Immunization calendar Antigen Age at immunization Geographical

coverage

BCG At birth Entire country

OPV Birth, 6, 19 and 14 weeks Entire country

DTP 6, 10 and 14 weeks Entire country

ROUVAX 9 months Entire country

YF 9 months Entire country

TT Women of child-bearing age, pregnant or not (15-45 ans ) Entire country

2.2 Vaccine supply, storage and distribution

At the central level, requirements in terms of vaccines and consumables are estimated then communicated to the Ministry of Public Health, followed by the Ministry of Economy and Finance, with a view to the signing of a contract with the Health Department.

Regional warehouses are supplied on a quarterly basis. The PHDs and HCs are supplied every month.

2.3 Disease surveillance

Surveillance of EPI target diseases (AFP, measles, maternal land neonatal tetanus, pertussis, diphtheria, tuberculosis and yellow fever) is integrated into surveillance of other potentially epidemic diseases.

Reporting is done on a weekly basis. Information is analysed at the various levels and followed up by ripostes.

For purposes of transmitting epidemiological surveillance data to a higher level, the RHDs, PHDs and some HCs are linked to the EPI/PHC/ED Coordination Unit via a VHF radio communication network.

2.4. Program results

– Immunization coverage by antigen from 1990 to 2003

Table 4 : Immunization coverage as a % (administrative data) 2000 Year

Antigen 1998 1999

NS* RD** 2001 2002 2003

BCG 69 76 82 71 75 71 80

DTP3 56 46 43 57.3 64 58 69

POLIO3 56 43 43 57.3 64 58 69

MEASLES 58 52 40 59 59 61 75

YF 17 47

TT2+ 48 - 38 42 52 53 58 * NS: National Survey ** RD: Routine Data

A look at this table shows that DTP3 immunization coverage, which stood at 69% at of 31 December 2003, was still a long ways from the goal of 80%. The corresponding gap for measles and YF coverage rates was 28%, which means that a lot remains to be done.

21

In 2002, immunization coverage rates were below the 50% mark for all EPI antigens with the exception of the YF antigen, which had just been introduced.

In 2003, support from partners included participation in training supervision, logistics and financial assistance with the implementation of the outreach strategy, technical support with monitoring, all of which made it possible to boost immunization coverage rates for all EPI antigens.

2.5. Main constraints and difficulties

2.5.1 From an organizational perspective

- Insufficient number of staff unevenly distributed in health groups;

- Lack of coordination by partners in the field;

- Irregular meetings of the EPI/PHC/ED Logistics Committee;

- Delays with regard to deliveries of vaccines, medicine and management aids to health structures;

- Lack of clearly defined terms of reference for EPI managers.

2.5.2 From a management perspective

Despite all that has been done to ensure better management of activities, implementation-related problems still exist:

- Training scheduling and implementation is not coordinated with the central level. Unplanned trips by field agents have a negative impact on program operation.

- Means of transportation (supervisory vehicles and motorcycles) and cold chain equipment are in poor condition and must be replaced.

- There is no national EPI communication strategy;

- The basic health infrastructures built when the program was launched must be overhauled or rebuilt according to the prevailing norms; the premises of the EPI/PHC/ED Logistics Unit have yet to be finished;

- There are not enough EPI staff members at the central and peripheral levels;

- Not enough officers have received EPI management training.

2.5.3 From a funding perspective

The State has managed to increase its contribution to EPI program allocations but the fund disbursement rate remains quite low. EPI funding relies heavily on outside aid.

Program coordination does not cover the mechanism for vaccine procurement by the State. It should further be noted that the majority of health centres have a low self-financing capacity as far as replacement of cold chain equipment and motorcycles is concerned.

2.6 Program goals and strategies 2.6.1. Goals

2.6.1.1 Overall goal

The overall goal of the EPI strategic plan is to reduce morbidity and mortality rates due to vaccine-preventable diseases through the immunization of children aged 0-11 months and pregnant women in Guinea.

22

To reach this goal, the Ministry of Public Health is assisted by the following main technical and financial partners: UNICEF, WHO, GAVI, the European Union, USAID, Rotary Club International and JICA, as well as by the communities.

2.6.1.2 Specific goals

Reaching and maintaining an immunization coverage rate of at least 80% for all EPI antigens in 80% of all health districts ;

Introducing new vaccines like HepB and Hib in 2006;

Optimizing management efficiency by reducing wastage rates for vaccines and consumables;

Introducing an effective system for surveillance and control of EPI target diseases (eradicating polio by 2005);

Eliminating neonatal tetanus by 2006, controlling measles by 2006;

Drawing up an EPI communication strategy.

Table 5: Coverage goals by antigen from 2003 to 2013

Year Antigen

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

BCG 79 80 85 90 90 92 92 93 95 95 95

OPV3 69 75 80 80 85 85 90 90 90 90 90

DTP3 69 75 80 80 85 85 90 90 90 90 90

MEAS 75 80 85 90 90 90 90 90 90 90 90

YF 47 70 75 80 80 85 85 90 90 90 90

TT2+ 58 65 85 90 95 96 97 97 97 98 98

DTP- Hb3-Hib - - - - 85 85 90 90 90 90 90 Sources: Forecasts by the National EPI Department

2.6.2 Strategies

Strategies are worked out in response to current obstacles to normal increases in immunization coverage.

i.With regard to the increase in immunization coverage and its extension to all districts

The emphasis will be placed on the following key points:

Ensuring the availability of vaccines at all levels of the health pyramid. To this end, the recent signature (November 2004) of a cooperation agreement between the Guinean Government and UNICEF covering the supply of high-quality vaccines at an affordable price will make it possible not only to improve supply channels but also to reduce the very high wastage rates sometimes due to overly long channels;

Increasing funding for immunization activities, especially with regard to vaccines and consumables. A close correlation has been observed between the volume of funding for immunization and EPI performance. For example, the decline in the volume of outside funding and the State’s budgetary allocation for EPI from 1994 onwards led to a sharp drop in DTP3 immunization coverage, which plummeted from 73% to 53% in 1996;

23

Training health agents in EPI management, including vaccines;

Replacing cold chain equipment, which has become obsolete (most of the refrigerators are over ten years old);

Replacing vehicles used for supervisory and outreach strategies;

Drawing up an EPI social communication strategy.

ii. Organization of services

The strategies worked out to strengthen coordination/EPI management are as follows:

Strengthening EPI officials’ management skills on all levels;

Reinforcing EPI supervisory activities at all levels;

Incorporating a financial component into the health information system;

Improving the supply of immunization services at all levels.

iii. Improvement of surveillance

The strategies worked out to strengthen epidemiological surveillance of EPI target diseases are as follows:

Retraining/retraining health centre agents, laboratory assistants and clinical practitioners in EPI target disease surveillance;

Supplying laboratories with equipment to diagnose EPI target diseases;

Strengthening the mechanism for the transmission of reports on epidemiological surveillance and immunization activities;

Perfecting the system for investigating EPI target diseases; Improving feedback on all levels; Encouraging the community to become more involved in the surveillance of EPI target diseases.

24

SECTION III:

BASELINE AND CURRENT PROGRAM COSTS AND FINANCING

25

Section III: Baseline and present program costs and financing In 2000, Guinea conducted an external review of its immunization program with the technical and financial backing of various partners, including WHO, UNICEF, USAID and the World Bank. A large share of this review was devoted to analysing EPI costs and financing.

Two major conclusions can be drawn on the basis of the review’s findings.

1) There is a clear correlation between funding volume and EPI performance. From 1994 onwards, the drop in the volume of outside funding, combined with a decline in State funding, led to a fall in DTP3 immunization coverage, which went down from 73% to 56% in 1998.

2) Apart from specific costs (vaccines and cold chain equipment), it is difficult to ascertain the costs of the immunization program owing to its inclusion in the EPI/PHC/ED program.

Nevertheless, a cost analysis based on the information collected from the different departments and certain partners deemed to be the major contributors to the immunization program allows us to draw up tables on pre-GAVI and GAVI costs and financing.

It is important to note that among the partners, WHO and UNICEF must be viewed as agencies which mobilize and manage funds from other partners (e.g. USAID); as a result, the amounts indicated do not appear as their actual contributions.

4.1 Pre-GAVI program costs and financing

For 2001, the year before GAVI funding came on stream, the total cost of the Expanded Program on Immunization (EPI) came to USD 6,729,411. In terms of type of activity, the cost of routine EPI accounted for the largest share with USD 6,191,317, or 92.6%. Immunization campaigns represented 7.4%, or USD 501,193.

When spending is broken down, shared costs take up the lion’s share with 59.7%, following by building costs (48.6%), transportation costs (9.8%) and wages (1.3%). The breakdown of other expenses out of overall expenses is as follows:

- Maintenance costs (7.8%)

- Cost of vaccines (6.2%) and injection supplies (2.5%)

- Capital costs (5.1%)

- Wages of full-time staff (0.5%).

In term of funding sources, the Government is the leading donor for the program with 67%, followed by WHO (12%) and JICA (10%).

WHO was the number two contributor after the State with a funding volume of 9%, the bulk of which went for additional immunization campaigns and operating expenses.

JICA made a significant contribution, which primarily served to purchase vaccine and cold chain equipment.

26

The overall cost of EPI vaccines and consumables was borne by JICA (95.2%) and UNICEF (4.8%).

Other contributors included local authorities (8%), USAID (less than 1%) and Rotary (less than 1%).

A look at EPI funding for 2001 shows that as far as vaccines were concerned, Guinea is entirely dependent on outside aid, merely financing the construction of health centres, staff and other recurrent costs.

4.2. Program costs and funding with GAVI support

GAVI’s input in Guinea began in 2002 with funds earmarked for the strengthening of field activities. In practical terms, EPI activities were revitalized in 2003 with funding from the Vaccine Fund channelled through GAVI.

Overall costs for immunization activities came to USD 9,080,771 in 2003, up some 35% when compared with 2001.

A breakdown by type of activity reveals that the construction of health centres took up the largest share with around 46.9%. Immunization campaigns came in second with around 21.3%. Vaccines and consumables accounted for approximately 14%, while maintenance costs represented 7.8%.

A look at funding sources shows the State in the lead with some 65%, followed by UNICEF (11%), WHO (10%), local authorities (7%) and the Vaccine Fund (GAVI) (4%). USAID’s share went from less than 1% in 2001 to 3% in 2003.

It should be noted that, unlike 2001 when vaccines were entirely covered out of outside funding, more than 69.4% of routine EPI vaccines in 2003 were purchased out of the State budget. GAVI funding went to finance the newly introduced yellow fever vaccine, AD syringes and the corresponding safety boxes, accounting for 30.6% of the overall cost of routine vaccines.

27

FSP Section 3 – Breakdown of past costs - GUINEA (in USD)

Cost heading 2001 2002 2003

Recurrent costs USD (%) USD (%) USD (%)

Vaccines 417 516 6.2% 497 688 5.9% $ 1 055 991 11.6%

- Traditional vaccines 417 516 431 370 733 070

- new and under-used vaccines - 66 318 322 921

Injection supplies 169 818 2.5% 181 704 2.2% 211 078 2.3%

Staff 34 108 0.5% 35 240 0.4% 36 227 0.4%- Wages of full-time staff (central, provincial and local levels) 34 108 35 240 36 227- Per diems for the outreach strategies/mobile teams - - -

Transportation 110 262 1.6% 170 219 2.0% 187 900 2.1%

Fixed strategy and vaccine delivery 73 361 113 252 125 015

Outreach and mobile strategy 36 901 56 967 62 885

Maintenance and overheads 622 794 9.3% 660 464 7.8% 680 713 7.5%

Short-term training 26 537 84 577 1.0% 8 865 0.1%

Social mobilization and IEC 40 103 0.6% 3 000 0.0% - 0.0%

Disease control and surveillance 339 568 5.% 266 934 3.2% 245 032 2.7%Other costs of the outreach strategy (excluding per diems, transportation and ice) - 0.0% 73 023 0.9% - 0.0%

Other recurrent costs 100 896 1.5% 11 005 53 865

Follow-up/Evaluation 28 171 - -Supplies, consumables and management aids 72 725 11 005 53 865

Other (specify) - - -



Sub-total of recurrent costs 1 861 602 1 983 854 2 479 671

Capital costs

Vehicles 144 444 2.1% 159 544 1.9% 179 200 2.0%

Cold chain equipment 188 411 2.8% 199 098 2.4% 204 692 2.3%

Other capital costs 15 094 0.2% 15 402 0.2% 19 216 0.2%

Sub-total of capital costs 347 949 374 044 403 108

Immunization campaigns

Polio 427 737 6.4% 802 692 9.5% - 0.0%

Vaccines 427 737 493 524 -

Other operating costs - 309 168 -

Measles 73 456 1.1% 368 523 4.4% $ 1 579 428 17.4%

Vaccines - 151 219 516 255

Injection supplies - 66 670 279 370

Other operating costs 73 456 150 634 783 803

Yellow fever - 0.0% 722 670 8.6% - 0.0%

Vaccines - 601 978 -

Injection supplies - 120 692 -

Other operating costs - - -

Meningitis (FAP) - 0.0% - 0.0% - 0.0%

Vaccines - - -

Injection supplies - - -


29

Maternal and neonatal tetanus - 0.0% - 0.0% 358 696 4.0%

Vaccines - - 99 938

Injection supplies - - 98 660

Other operating costs - - 160 098

Inputs from other campaigns - 0.0% - 0.0% - 0.0%

Vaccines - - -

Injection supplies - - -


Sub-total of operating costs 501 193 1 893 885 1 938 124Shared costs and additional optional information

Shared staff costs 658 488 9.8% 686 711 8.2% 701 916 7.7%

Shared transportation costs 90 526 1.3% 141 407 1.7% 153 482 1.7%

Buildings 3 269 653 48.6% 3 336 381 39.6% 3 404 470 37.5%

Additional optional information - 0.0% - 0.0% - 0.0%






Sub-total Optional 4 018 667 4 164 499 4 259 868

GRAND TOTAL 6 729 411 8 416 282 9 080 771

Routine immunization (fixed strategy) 6 191 317 6 392 407 7 079 762Routine immunization (outreach and mobile strategy 36 901 129 990 62 885

Immunization campaigns 501 193 1 893 885 1 938 124

ROTARY

Graphique 1: Financement par Source 2001 (%)

Gouvernement national

67%

Gouvernement local8%

GAVI - FMV0%

OMS12%

UNICEF3%

Coopération Japonaise

10%

USAID0% NETHERLANDS

0%

INTERNATIONAL0% ARIVA - UE

0%

30

.



58%


GAVI - FMV2%

OMS7%

UNICEF17%


7%ROTARY

INTERNATIONAL0%

NETHERLANDS0%

USAID2%

ARIVA - UE0%

GraGraGra

ph1: Funding sources for 2001 (%)



65%


GAVI - FMV4%

OMS10%

UNICEF11%

USAID3%

ROTARY INTERNATIONAL

0%ARIVA - UE

0%


0% NETHERLANDS0%

ph 2: Funding sources for 2002 (%) ph 3: Funding sources for 2003 (%)

31

SECTION IV:

RESOURCE REQUIREMENTS AND PROGRAM FUNDING/

ANALYSIS OF FUNDING GAP

32

Section IV: Resource requirements and program funding/Analysis of funding gaps

Estimated program cost for 2005 to 2013 comes to USD 124,136,802, broken down as follows:

- Fixed strategy: USD 115,694,232

- Outreach strategy: USD 1,261,127

- Immunization campaigns: USD 7,181,443.

Costs are expected to increase sharply in 2006 with the introduction of new vaccines, especially the pentavalent vaccine, which will account for 34.8% of the cost structure in 2006, up 41.9% when compared with the previous year.

Secured financing for 2005-2013 totals USD 80,218,187 (64.4%), whereas likely financing amounts to USD 43,918,615 (35.4%). The latter figure, which primarily pertains to equipment and buildings, is covered by the national government.

Consequently, there is a need to renew rolling stock and cold chain equipment in order to revitalize activities in the field.

The funding gap can be met if estimated likely funding is factored in as well. In this connection, due note should be taken of the following:

It is likely that the plan involving the IDA credit, which is in the discussion phase, will get underway as part of efforts to combat poverty;

Negotiations are under way with the IMF for an interim program to replace HIPC funds (due to be phased out in late 2005/early 2006);

The European Union may provide some budgetary support.

A large share of secured financing comes from the Government (26.3%), GAVI (36.3%), local authorities (10.1%) and traditional partners, including WHO and UNICEF, both of which must be viewed as both fund-raisers and executing agencies.

Moreover, certain traditional partners do not appear clearly because their input covers such expenses as operating costs of the immunization campaigns organized by WHO and UNICEF. One example is ROTARY INTERNATIONAL, which helps to fund the NIDs and contributes to equipment procurement.

The Government’s level of contribution during the period remains low in comparison with past costs and funding for 2001-2003. Nevertheless, its share of secured financing, combined with probable financing, considerably increases its contribution, and the assistance of present and new partners will be necessary to cover this.

GAVI’s financial input will above all be visible starting in 2006, when the new DTP-HepB-Hib vaccine is introduced into routine immunization. It will keep its position of the leading partner for EPI financing until the end of 2010, when the State takes over. From 2010 onwards, the Government will clearly be the main contributor to the program. In any event, the support of traditional and new partners will be necessary for the implementation of the plan.

33

FSP Section 4 – Estimated future resource requirements - GUINEA (in USD) Cost heading 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Recurrent costs USD USD USD USD USD USD USD USD USD USD Vaccines 1 515 050 1 057 311 5 964 704 5 944 129 5 721 979 5 843 697 5 715 229 5 593 367 5 492 339 5 659 340

- Traditional vaccines 918 878 657 011 474 930 439 165 446 924 465 254 475 752 487 590 499 665 511 893 - New and under-used vaccines 596 172 400 300 5 489 774 5 504 964 5 275 055 5 378 443 5 239 477 5 105 777 4 992 674 5 147 447

Injection supplies 176 813 196 983 286 406 306 605 318 288 333 334 345 221 356 237 367 526 378 833 Staff 36 952 42 914 39 407 39 704 44 501 41 308 42 655 42 977 47 628 45 266

- Wages of full-time staff (central, provincial and local level) 36 952 42 914 39 407 39 704 44 501 41 308 42 655 42 977 47 628 45 266 - Per diems for the outreach strategy/mobile teams - - - - - - - - - - Transportation 191 626 346 484 187 495 222 990 376 482 399 046 283 428 461 284 442 086 310 846 Fixed strategy and vaccine deliveries 127 495 230 526 124 746 148 362 250 485 265 497 188 573 306 906 294 133 206 815 Outreach and mobile strategy 64 131 115 958 62 749 74 628 125 997 133 549 94 855 154 378 147 953 104 031 Maintenance and overheads 710 515 1 026 933 877 333 947 557 1 003 904 1 085 298 1 071 335 1 042 149 1 027 932 1 033 946 Short-term training 40 793 41 609 42 441 43 290 44 156 45 039 45 939 46 858 47 795 48 751 Social mobilization and IEC 14 655 14 948 15 247 15 552 15 863 16 180 16 504 16 834 17 171 17 514 Disease control and surveillance 58 689 66 226 62 683 63 109 71 123 65 658 67 850 68 311 76 072 72 003 Other costs of the outreach strategy (excluding per diems, transportation and ice) 24 828 25 324 25 831 26 347 26 874 27 412 27 960 28 519 29 090 29 672

Other recurrent costs 56 360 57 488 58 637 59 810 61 007 62 226 63 471 64 740 66 035 67 356 Follow-up/Evaluation 9 578 9 770 9 965 10 164 10 368 10 575 10 787 11 002 11 222 11 447 Supplies, consumables and management aids 46 782 47 718 48 672 49 646 50 639 51 651 52 684 53 738 54 813 55 909 Other (specify) - - - - - - - - - - Other (specify) - - - - - - - - - - Other (specify) - - - - - - - - - -

Sub-total of recurrent costs 2 826 281 2 876 220 7 560 184 7 669 093 7 684 177 7 919 198 7 679 592 7 721 276 7 613 674 7 663 527 Capital costs

Vehicles - 678 160 31 280 180 826 760 824 74 879 197 609 813 222 85 408 215 769 Cold chain equipment - 415 663 653 883 76 142 79 636 167 827 302 798 933 354 172 838 171 361

Other capital costs - 434 664 1 082 517 752 290 481 931 461 727 45 700 46 960 11 951 38 398 Sub-total of capital costs - 1 528 487 1 767 680 1 009 258 1 322 391 704 433 546 107 1 793 536 270 197 425 528 Immunization campaigns

Polio 1 220 863 1 232 143 1 286 525 - - - - - - - Vaccines 448 729 447 218 461 082 - - - - - - - Other operating costs 772 134 784 925 825 443 - - - - - - -

Measles - - 329 270 - - 123 918 - - 140 029 - Vaccines - - 108 654 - - 39 692 - - 43 499 - Injection supplies - - 58 107 - - 21 227 - - 23 263 - Other operating costs - - 162 509 - - 62 999 - - 73 267 -

Yellow fever - 877 773 - - - - - - - - Vaccines - 731 655 - - - - - - - - Injection supplies - 146 118 - - - - - - - - Other operating costs - - - - - - - - - -

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

Meningitis (FAP) - - - - - - - - - - Vaccines - - - - - - - - - - Injection supplies - - - - - - - - - -

34

Other operating costs - - - - - - - - - - Maternal/neonatal tetanus 47 111 145 576 286 498 - - 1 288 974 - - 1 470 737 -

Vaccines 7 321 64 277 43 119 - - 186 471 - - 204 356 - Injection supplies 8 972 81 299 54 537 - - 235 852 - - 258 473 - Other operating costs 30 818 - 188 842 - - 866 651 - - 1 007 908 -

Inputs from other campaigns - - - - - - - - - -

Vaccines - - - - - - - - - - Injection supplies - - - - - - - - - - Other operating costs - - - - - - - - - -

Sub-total of campaign costs 1 267 974 2 255 492 1 902 293 - - 1 412 892 - - 1 610 766 - Shared costs and other additional details

Shared staff costs 717 191 753 541 766 916 780 526 796 136 820 543 806 281 822 406 838 854 855 632 Shared transportation costs 156 552 156 552 156 552 156 552 156 552 156 552 156 552 156 552 156 552 156 552 Buildings 3 472 559 3 542 011 3 612 851 3 685 108 3 758 810 3 833 986 3 910 666 3 988 879 4 068 657 4 150 030 Other additional details - - - - - - - - - -

Other (specify) - - - - - - - - - - Other (specify) - - - - - - - - - - Other (specify) - - - - - - - - - - Other (specify) - - - - - - - - - - Other (specify) - - - - - - - - - -

Sub-total optional 4 346 302 4 452 104 4 536 319 4 622 186 4 711 498 4 811 081 4 873 499 4 967 837 5 064 063 5 162 214 GRAND TOTAL 8 440 557 11 112 303 15 766 476 13 300 537 13 718 066 14 847 604 13 099 198 14 482 649 14 558 700 13 251 269

Routine immunization (Fixed strategy) 7 083 624 8 715 529 13 775 603 13 199 562 13 565 195 13 273 751 12 976 383 14 299 752 12 770 891 13 117 566 Routine immunization (Fixed + outreach strategy) 88 959 141 282 88 580 100 975 152 871 160 961 122 815 182 897 177 043 133 703 Immunization campaigns 1 267 974 2 255 492 1 902 293 - - 1 412 892 - - 1 610 766 -

35

Graph 4: Estimated secured funding by source (in USD) from 2001 to 2013 Graph 5: Estimated likely funding by source (in USD) from 2001 to 2013

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Graphique 4: Projection du Financement Assuré par sources (en US$) de 2001 à 2013

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Coopération Japonaise USAID ROTARY INTERNATIONAL ARIVA - UE

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36

Graph 6: Estimated secured and likely funding by source (in USD) from 2004 to 2013

Graph 7: Estimated secured funding gap (in USD) from 2001 to 2013

0%10%20%30%40%50%60%70%80%90%

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Graphique 6: Projection du Financement Assuré et probable par sources (en US$) de 2004 à 2013

Gouvernement national Gouvernement local GAVI - FMV OMSUNICEF Coopération Japonaise USAID ROTARY INTERNATIONALARIVA - UE NETHERLANDS

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Graphique 7: Projection des écart du Financement Assuré (en US$) de 2001 à 2013

Financement (% Coût / Besoin Res) Écart Financier (% Besoins en Ressources)

37

Graph 8: Estimated likely funding gap (in USD) from 2004 to 2013

Graph 9: Estimated secured and likely funding gap (in USD) from 2004 to 2013

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Graphique 8: Projection des écart du Financement Probable (en US$) de 2004 à 2013


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Graphique 9: Projection des écarts du Financement Assuré et Probable (en US$) de 2004 à 2013


38

SECTION N° V:

STRATEGIC PLAN AND FINANCIAL SUSTAINABILITY INDICATORS

39

SECTION N° V: Strategic Plan and financial sustainability indicators

Immunization is recognized as the most cost-effective tool for combating diseases, barring respiratory illnesses, diarrhoeal diseases and shigella.

EPI goals for the next 10 years are as follows:

•

•

•

•

Ensure a sufficient supply of essential vaccines : DTP, polio, TT, BCG, measles, YF, HepB;

Reach overall immunization coverage of 90% of all children under one and women of child-bearing age, including in poor, isolated zones;

Eradicate polio in the short term;

Introduce the combined DTP-HepB-Hib vaccine into routine immunization to replace DTP.

For these goals to be reached, the FSB must be implemented. The latter requires the development of certain strategies with regard to:

o Fund-raising;

o Improved management;

o Institutional and human capacity-building.

5.1 Fund-raising strategies and steps 5.1.1 Internal fund-raising

The Government of the Republic of Guinea has already provided tangible proof of its commitment to disease prevention efforts, particularly as far as immunization activities are concerned. In addition to earmarking funds for staff, buildings and utilities, the State has:

• Financed the procurement since 2001 of vaccines and consumables used in routine EPI for traditional antigens;

• Shouldered a growing share of the cost burden for additional activities: polio NIDs, campaigns targeting measles, yellow fever, tetanus, meningitis, etc.;

• Committed itself to gradually replacing GAVI funding for the introduction of new vaccines, thereby ensuring the long-term viability of such efforts along with traditional vaccines.

The State intends to step up its EPI efforts with a view to further ensuring the financial sustainability of the program over the long term. In this connection, efforts will focus on the following:

• Increasing the amount of budgetary resources earmarked for the procurement of vaccines and consumables. This increase will depend on the execution rate for budgetary allocation;

• Actually applying texts relating to the use of the income generated by cost coverage by the public in the health centres, thereby making it possible to cover operating costs of refrigerators in health centres, fuel for outreach strategies, management aids and staff incentives;

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• Preparing and adopting legislative and regulatory texts on the mutual insurance companies;

• Enlisting the support of the private medical sector for immunization activities. The Ministry of Health intends to draw up model contracts with existing and future private-sector structures to cover the delivery of services and the promotion of immunization activities;

• Encouraging national and foreign NGOs to help finance systematic immunization activities and immunization campaigns in their areas of operation.

5.1.2 Outside fund-raising

Bilateral and multilateral cooperation gives the Government a major opportunity to raise outside funds for EPI:

• The State has displayed a strong political commitment to immunization at the highest level by signing several conventions, including the one on the Vaccine Independence Initiative (VII);

• The Government is making praiseworthy efforts to combat corruption, improve the administration of public funds and apply the principles of good governance.

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• Enlisting the support of certain traditional EPI partners in their usual fields of operation, in particular JIDA and UNICEF for logistics and cold chain equipment;

• Taking advantage of the facilities offered by budgetary support, the preferred funding form for certain leading bilateral and multilateral partners: World Bank, Rotary, USAID, JICA, etc. Part of the partners’ funding could be earmarked for immunization activities, in particular routine EPI;

• Improving disbursement rates for budgetary allocation.

5.2 Strategies and steps to improve management

5.2.1 Steps and strategies to enhance resource reliability

The Government plans to take the following steps:

• Increase the accountability of the staff involved at all levels of the pyramid on the basis of performance contracts. To this end, immediate superiors will monitor activities every six months with a view to assessing agents’ performance and correcting any weak points;

• Step up the process of decentralization and devolution via the preparation, adoption and dissemination of legislative and regulatory texts;

• Supervise, monitor and follow up activities;

• Monitor stocks of vaccines, consumables, supplies and management aids;

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• Monitor financing channels to ensure traceability.

5.2.2 Strategies and steps to optimize resource use

The Government plans to do the following with a view to optimizing resource use;

• Continue to extend health care to the public;

• Implement the “reach each district” strategy;

• Reduce drop-out rates;

• Reduce wastage rates;

• Follow up immunization activities on all levels (PTHC, RTHC and TCC) and through the ICC;

• Set up a Committee for Evaluation/Follow-up consisting of the partners, the Ministry of Health, the Ministry of Economy and Finance, which would come under the responsibility of an official close to the Minister of Health.

5.3 Institutional and human capacity-building

This strategy requires the following:

• A sufficient number of quality services with regard to the necessary infrastructures, equipment and logistics;

• The replacement of cold chain equipment;

• The replacement of logistics (motorcycles) to ensure the success of the outreach immunization strategy;

• The replacement of the vehicle park for the implementation of supervisory and monitoring activities on all levels;

• Staff training with a view to ensuring high-quality service delivery for both traditional vaccines and vaccines to be introduced.

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Consolidated table of steps and strategies to be implemented

Internal fund-raising

Activity Period Responsible Follow-up indicator

Funding of vaccines and consumables for routine EPI

2005 - 2013 MEF

Availability of vaccines andconsumables

Contribution to additional immunization activities

2005 - 2013 ICC Disbursement rate for the amount budgeted for additional activities

GAVI funding for the introduction of new vaccines

2005 - 2013 GAVI

Coverage rate for new vaccines in routine EPI

Actual application of texts on the use of income from cost collection

2005 - 2013 MPH

MTAD

Share of income earmarkefor EPI

Preparation and adoption of legislative and regulatory texts on the mutual insurance companies

2005 - 2013 MTAD Enabling laws and texts onthe mutual insurance companies available

Contribution of the private health sector to immunization activities

2005- 2013 MPH Number of contracts signedand share of targets covere

Contribution of NGOs in their operating areas to the funding of immunization activities and campaigns

2005- 2013 MPH

MTAD Volume of funds raised

External fund-raising


Advocacy efforts targeting partners to raise funds for EPI

2005 – 2013 MPH

Volume of funds raised forEPI

Steps and strategies to enhance resource reliability


Half-yearly monitoring of activities to evaluate agents’ performance and correct shortcomings

2005 - 2013 MPH Monitoring reports available

Follow-up of the application of texts in relation to community funding for EPI

2005 - 2013

MPH

MTAD

Volume of community funding for EPI

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Steps and strategies to optimize resource use


Expansion of public health coverage

2005 – 2013 MPH

Number of new operational structures

Implementation of the “reach each district” strategy

2005 – 2013 MPH

National immunization coverage rate

Reduction of drop-out rates 2005 – 2013 MPH

National immunization coverage rate

Reduction of wastage rates 2005 – 2013 MPH

Level of wastage rates for vaccines and consumables

Follow-up of immunization activities through various bodies (PTHC, RTHC and TCC) and through the ICC

2005 – 2013

MPH

Reports of sessions and minutes

Increase in the disbursement rate of funds earmarked for EPI

2005 – 2013 MEF

% of disbursement in relation to funds earmarked

CONCLUSION

Immunization remains the most cost-effective public health policy as well as an effective poverty reduction tool.

Despite considerable progress made in terms of the reduction of morbidity and mortality due to vaccine-preventable diseases, the EPI program is hampered by a severe shortage of resources.

The preparation and implementation of the Financial Sustainability Plan gives the Government and partners an opportunity to take up this challenge. The plan offers an ideal advocacy tool for EPI fund-raising.

Given the political will that has been displayed at the highest level and the determination of the multilateral and bilateral partners, there are grounds for hope.

Conakry, 28 January 2005 Signed by

The Minister of Public Health The Minister of the Economy and Finance Prof. Amara CISSE Mr. Mady Kaba CAMARA

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SECTION VI:

COMMENTS OF THE PARTIES

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SECTION VI: Comments of the parties

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ANNEXES

Methodology and preparation of the EPI Financial Sustainablility Plan Formation of a team A multi-sectoral team consisting of ten officers was formed to draft the EPI Financial Sustainability Plan (FSP) of the Republic of Guinea.

This team set up three working sub-groups, each responsible for reviewing documents and preparing a rough draft of one of the first three sections of the FSP.

Documentary review pertaining to:

1. The impact of the national situation and the context of the health system on the costs, funding and financial administration of the Expanded Program on Immunization.

2. Program characteristics, goals and strategy.

3. Program costs and funding for the year before GAVI support and for the year with GAVI support

Each of the sub-groups collected documents, reports and other sources of information with a view to preparing the first draft relating to its section. The sub-groups formed a one-week working committee to draft the three sections.

First drafting workshop A five-day workshop was conducted in Forécariah to present, examine and discuss the rough drafts prepared by the sub-groups with a view to making the necessary changes. Data collection At the end of the workshop, a decision was taken to conduct a survey with a view to gathering information on a sampling of urban and rural health centres, prefectural health directorates in the prefectures of Forécariah, Coyah and Dubréka and the Health Directorate of the city of Conakry as a regional entity.

The aim of the survey was to evaluate expenditure at all levels, in particular the average wages of agents conducting activities, fuel

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consumption, management aids, etc., as well as funding of EPI activities in health structures by the community, the State and other partners.

Once the survey was finished, the teams met in Conakry to analyse and process the information with a view to improving the contents of the three sections.

Through the Ministry of Health, the working group wrote to the various partners, inviting each of them to appoint a representative on the working group and to fill in and return a questionnaire on funding provided for EPI activities.

Within the country, data collection sheets were sent out to all PHD and RHD to gather data on wages, staff, vaccines and consumables, EPI equipment, rolling stock and communication by structure and by level.

Second drafting workshop A second, five-day workshop was run to process the data collected. After this workshop, an ARIVA consultant helped the FSP team to finalize the three sections.

Section 3 on the costs and funding of the Expanded Program on Immunization reviews funding from the State (BND and HIPC funds), communities and development partners.

Subsequently, a final workshop was held in Kindia to improve the draft, which was then submitted to the ICC members, the various partners involved in EPI and the representatives of the ministerial departments participating in immunization activities for comments and observations.

Finally, the working group made the necessary changes to finalize the document containing the Financial Sustainability Plan of the Expanded Program on Immunization before transmission to GAVI.

Throughout the process, the team benefited from the technical and financial assistance provided by ARIVA and WHO Geneva, as well as the support of the partners’ representatives.

Methods used to evaluate costs: baseline and current years, and estimates for 2004-2013

Estimates were made of the time and wages earmarked for immunization and of the use of logistics at the central and prefectural levels and in the health centres, along with vaccine costs and transportations, epidemiological surveillance and training and coordination and follow-up/evaluation. It was thus possible to calculate all costs on the following basis:

Staff

It was estimated that part-time EPI staff devoted from 25% to 75% to their time to EPI.

Building, rolling stock, cold chain facilities and other equipment

Capital costs (building, rolling stock, cold chain facilities and other equipment with a life of over one year) were calculated depending on whether or not they were used exclusively for EPI-related activities).

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Buildings

Construction costs were estimated on the basis of the average surface area devoted to EPI in health centres. The area occupied by the warehouse was also taken into consideration. A rate of 25% was applied.

Equipment The allocation rates applied were 100% for all cold chain equipment and motorcycles of the health centres and 25% for the equipment and rolling stock at the other levels, according to the amount of time their users spent on immunization.

Vaccines and consumables Given that no regular inventories were conducted at all levels of stock levels at year’s end and that bookkeeping procedures were inadequate, vaccine consumption was based on the quantities that the central level made available to the structures.

As far as projected future requirements are concerned, estimates were based on the projected target populations, taking due account of goals with regard to immunization coverage and wastage rates.

Estimated requirements for immunization materials were based on the number of vaccine doses administered by antigen plus 10% wastage (excluding OPV), depending on whether single or multiple doses were used.

With the help of these and other bases, it was possible to calculate all costs by heading and funding sources by donor.

Maintenance and current expenditure Overheads for buildings, maintenance and the operation of cold chain equipment and vehicles were mainly estimated by factoring in the bases proposed in the model.

Other costs Most of the other costs were taken from data provided in activity reports from the EPI/PHC/ED Coordination Unit for the various national program reviews and some information received from partners.

It should be noted that data from some partners could not be broken down individually because they use other partners as recipients and executing agencies. For example, this is the case with WHO, which channels funding from USAID.

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