Republic of Mozambique ____________

Ministry of Health

National Immunization Program

Introduction Plan for Inactivated Polio Vaccine (IPV), Rotavirus Vaccine and Measles Second Dose (MSD) Vaccine

in to the National Immunization Program

August, 2014

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Contents

List of tables.................................................................................................................5List of figures................................................................................................................6List of Annexes.............................................................................................................6List of Acronyms...........................................................................................................6References...................................................................................................................6Executive summary of the introduction plan.................................................................7

1. Justification for introduction of IPV and national decision-making process....................13

2. Overview of IPV.............................................................................................................162.1.1 Vaccine preference........................................................................................162.1.2 Country licensure status................................................................................162.1.3 Target population and vaccine supply...........................................................16

3. Introduction and implementation considerations..........................................................193.1.1 Policy development........................................................................................193.1.2 National coordination mechanism to ensure the successful introduction......193.2 Affordability and financial sustainability.............................................................213.2.1 Cost of IPV, Rotavirus and MSD vaccines joint introduction and funding......213.2.2 Country Immunization Financing and Sustainability......................................263.2.3 Financial Sustainability Strategies.................................................................283.2.3.1.1 Opportunities...........................................................................................283.2.3.1.2 Threats....................................................................................................293.2.4 Strategies and actions for financial sustainability..........................................293.2.4.1 Mobilizing additional resources (local and external sources).....................293.2.4.2 Increasing reliability of resources...............................................................303.2.4.3 Improving program efficiency.....................................................................313.3 Overview of cold chain capacity at district, regional and central levels.............323.3.1 Cold Chain Capacity at central level for Joint introduction of Rotavirus, MSD and IPV in 2015..........................................................................................................323.3.2 Cold Chain Capacity at Provincial level for Joint Rotavirus, MSD and IPV introduction in 2015....................................................................................................343.3.3 Cold Chain Capacity at District level for Joint Rotavirus, MSD and IPV introduction in 2015....................................................................................................373.3.4 Cold Chain Capacity at Health Facility level for Joint Rotavirus, MSD and IPV introduction in 2015....................................................................................................383.4 Waste management and injection safety..........................................................393.5 Health worker training and supervision.............................................................40

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3.6 Risks and challenges........................................................................................414. Situational analysis of the immunisation programme....................................................42

4.1 General context of the country..........................................................................424.1.1 Country profile...............................................................................................424.1.2 The EPI Program in Mozambique..................................................................424.2 Geographical, economic, policy, cultural, gender and social barriers to immunization..............................................................................................................444.2.1 Routine Immunization Coverage...................................................................444.2.2 Polio Eradication Activities.............................................................................464.2.2.1 Routine OPV..............................................................................................464.2.2.2 NIDs and sub-NIDS....................................................................................464.2.2.3 AFP/Polio Surveillance...............................................................................474.3 Findings from recent programme reviews.........................................................504.4 Stock management...........................................................................................56

5. Monitoring and evaluation............................................................................................575.1.1 Updating of monitoring tools..........................................................................575.1.2 Adverse Event Following Immunisation (AEFI) monitoring and reporting......57

6. Advocacy, communication, and social mobilisation.......................................................59

7. List of Annexes..............................................................................................................62

8. List of acronyms............................................................................................................75

9. References....................................................................................................................76

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List of tables

Table 1: IPV vaccine preferences and estimated date of introduction...................................15

Table 2. Multi-year forecast for IPV Supplies at national level..............................................16

Table 3. Mozambique’s Immunisation Schedule for Infants and Pregnant women after IPV, 17

Rotavirus and measles second dose introductions................................................................17

Table 4 Cost and funding for joint introduction of rotavirus, MSD and IPV vaccines into the NIP in Mozambique..............................................................................................................22

Table 5: Roll Out Process Cost for IPV, Rotavirus & MSD Vaccine introduction.....................23

Table 6: Cost and funding for roll out process of joint introduction of rotavirus, MSD and IPV vaccines...............................................................................................................................24

Table 7: Government expenditure on routine vaccination from 2011-2013..........................27

Table 8. Cold chain capacity required at regional / provincial vaccine stores........................32

Table 9. Cold chain capacity at +5oc required the regional / provincial levels........................34

Table 10. Cold chain gap analysis at regional / provincial vaccine stores for joint IPV, Rota and MSD introduction.................................................................................................................34

Table 11. Cold chain additional investment and running costs at regional / provinvial vaccine stores for joint IPV, Rota and MSD introduction...................................................................35

Table 12: CC investment at district level for the joint introduction of IPV, Rota and MSD and in 2015.....................................................................................................................................36

Table 13: Additional CC investment at Health Facility level for the joint introduction of IPV, rotavirus, MSD and in 2015..................................................................................................37

Table 14: Estimated target population for EPI 2015-2019.....................................................42

Table 15: EPI Coverage through Surveys, DHS 2003, MICS 2008 and DHS 2011 by Province. .44

Table 16: AFP surveillance for 2011, 2012, and 2013............................................................47

Table 17: Effective vaccine management assessment results, May 2012...............................49

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List of figures

Figure 1: Distribution of resources for the rollout process for joint IPV, Rota and MSD introduction.........................................................................................................................24

Figure 2: National coverage of BCG, DPT/HepB3, Polio 3, measles and PCV from 1981-2013 43

List of Annexes

7. List of Annexes..............................................................................................................647.1 Annex C – IPV Introduction Timeline of Activities............................................647.2 Annexes D1 – D2..............................................................................................65

List of Acronyms

8. List of acronyms

References

9. References

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Executive summary of the introduction plan

Brief justification for the introduction of IPV and key complementary considerations that have been taken into account, including comprehensive approaches for disease control.

Wild Poliovirus type 2 (WPV2) was eradicated in 1999, but was associated with the continuing emergency of cVDPV2. This led to the recommendation of coordinated global cessation of use of the type 2 component of oral polio virus (OPV2). In this context, WHO recommends that for all countries currently using OPV only, at least 1 dose of inactivated polio vaccine (IPV) should be added to the schedule by 2015. Mozambique has been using an OPV-only schedule in its routine EPI since EPI program inception in 1979. OPV coverage over time, however, has been low in several rural areas as demonstrated by several survey data, resulting in population immunity gap and putting the country at risk of emergence of cVDPVs.

AFP/Polio surveillance performance indicators reached certification standard (non-polio AFP rate of 1.0/100,000 children less than 15 years and 80% stool adequacy rate) in 2003 and have since been maintained at that level. After WHO raised this rate to 2.0/100,000 in children less than 15 years in 2005, Mozambique only managed to attain this new rate in 2009. AFP stool adequacy rates have been at the minimum 80% or above since 2004 except in 2008 when it fell below this minimum. However, progress made at the national level for AFP surveillance masks sub-optimal performance at the sub-national level. Since the country started lab confirmation of polio cases over 14 years ago, no indigenous or imported wild poliovirus has been reported. However, 2 cases of circulating vaccine derived poliovirus (cVDPVs) were detected in 2011, in 2 districts of Zambézia province.

Within the context of the above mentioned, Mozambique has been strengthening its routine immunization through Mid‐Level Managers’ training modules and implementation of RED strategy approach for immunization. National Immunization Days (NIDs) was conducted countrywide in 2005. Sub-NIDs were implemented in 2011, in response to cVDPVs. Mozambique also ensures improved case management of vaccine preventable diseases integrated in the IMCI package. Surveillance system is being strengthened through training of surveillance focal persons and clinicians in health facilities on disease surveillance. Supervision and technical support is provided particularly to weak performing districts, with support of STOP team members. Risk assessments are conducted on quarterly basis to identify districts with significant surveillance gaps for action. The feedback bulletin, also produced quarterly, provide recommendations to provinces on the actions to be taken to improve routine immunization and surveillance performance.

Outline of the benefits to the population of introducing IPV and the costs to the programme of its introduction and how the country plans to sustain those costs.

Mozambique is applying for IPV vaccine to be introduced in its National Immunization Programme (NIP). The vaccine to be administered to children under 1 year of age, it is expected raise country’s population immunity against polio, prevent the occurrence of cVDVP2 and accelerate the achievement of Polio eradication. The opportunity of IPV introduction will also be used to strengthen routine immunization so as to meet coverage targets and control vaccine-preventable diseases, as well as to strengthen VPD surveillance system in the context of integrated disease surveillance and response.

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The joint introduction of IPV, rotavirus and MSD vaccines, excluding the roll out process will cost $ 68.8 million over the next five years. These costs are related to IPV, Rotavirus and MSD vaccines and respective injection safety materials. The bulk of the vaccines and associated costs will be borne by GAVI. The Mozambican will co-financing $1.8 million ($1.7 million for rotavirus vaccine, as IPV and MSD are fully financed by GAVI, and $0.1 million for clearing and stock management of the three vaccines). Both Rotavirus and MSD vaccines have already been approved by GAVI and the government has also secured its co-financing for Rotavirus vaccine. The MOH of Mozambique will start co-financing rotavirus vaccine from June 2016.

The rollout process in terms of cold chain expansion, training, update of M&E tools, social mobilization materials and vaccine and related materials distribution (including receiving and stock management) will cost an additional $ 3.35 million, being $1.76 million for CC investment (vaccine stores, CC equipment, installation and running costs) and $1.59 million for vaccine introduction roll out process.

The 1.76 million CC investment is secured through $ 0.9 million for USAID and $0.86 million through GAVI vaccine introduction grant – VIG ($885,000 Rotavirus and $885,000 MSD) already approved and to be disbursed in 2014. There is a balance of $906,000 after using the 2 vaccine introduction grants in cold chain. The $1,59 million related to training, communication and social mobilization, vaccine clearance and stock management, vaccine delivery, monitoring and evaluation, supportive supervision, waste management and program management are secured through the $824,500 IPV vaccine introduction grant + $906,000 balance from previous grants (Rotavirus and MSD) + $230,756 from MoH and local partners, totalling $1.73 million. The final available balance is $0.37 million, which will be used to strengthen routine immunization and cover some items in the CCUP.

Overview of how the vaccine will be introduced (national or phased introduction) and key milestones and activities, such as when the vaccine will be introduced and when preparatory activities should begin.

The introduction of IPV vaccine will be on a campaign mode, at national scale. To ensure a successful introduction, particular attention will be given to social mobilization and training of health care workers. It is expected that IPV and Rotavirus vaccines will be introduced in July 2015, followed by measles second dose (MSD) three months later, in October 2015. Key activities up to the launching will include:

1. Briefing of stakeholders on IPV, in May 2015; 2. Proposal development (June and 15th August 2014) and ICC approval/endorsement

(22nd August 2014); 3. Proposal submission to GAVI (15th September 2014); 4. Adapt IEC materials and develop communication plan; revise immunization monitoring

tools; and adapt training materials (July-September 2014); 5. Printing of IEC and training materials (October 2014); Printing of monitoring tools

(October – December 2014); distribution of IEC and training materials (November – December 2014) distribution of monitoring tools (February – March 2015);

6. Develop new vaccine introduction plans at various levels of the system – July 2014 at central level, as it is a pre-requisite for GAVI approval of new vaccine funding – November and December 2014 at provincial and district level, respectively;

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7. Training of health workers at various levels of the system - November and December 2014, that is, at least 6 months prior to IPV launching at central and provincial levels, noting that the training of supervisors is a pre-requisite for vaccine shipment to the country - March 2015 for district supervisors, that is, 3 months prior to launching - May-June 2015 at service delivery level, that is, between 2 and 1 months prior to launching;

8. Vaccine reception and distribution – vaccine reception at the national vaccine store by March 2015, and that it will be pre-positioned at service delivery level at least 1 month prior to its launching;

9. Launching of IPV vaccination – July 2015, countrywide. It will be a joint introduction with rotavirus vaccine, already approved by GAVI;

10. Conducting post-introduction evaluation (PIE) for all 3 vaccines (IPV, Rotavirus & MSD) – April 2015, that is, 9 months after IPV /Rota and 6 months after MSD introduction, as the latter will be introduced 3 months after the formers).

Overview of the capacity of the immunization programme to introduce IPV, including all aspects of supply chain and logistics, health workforce capacity, etc.

All the three concerned vaccines will be stored at + 5°C. There is enough capacity at the entry point (central vaccine store) to accommodate all EPI vaccines stored at + 5oC, until 2016. However, with expected introduction of HPV in 2016, a gap is observed in storage capacity at +5oC ranging from 913 litres in 2017 to 4,026 litres in 2019, the last year of current EPI cMYP life span. Mozambique will address this gap by allocating a WICR-60m3 in 2017, as defined in the country’s CCUP in attachment. This will increase the available CC storage at +5oC by 14,815 litres.

At regional/provincial vaccine stores, it was demonstrated that 7 out of 11 provinces will require additional positive net storage capacity. These provinces are namely Nampula, Zambézia, Niassa, Cabo-Delgado, Manica, Gaza and Maputo Province. All 7 provinces will be allocated WICR by 2016. Nampula and Zambézia will receive WICR-40m3 each, while the remaining 5 provinces will received WICR-20m3 each, as per the CCUP. Before 2016, the storage gaps varying between 102 litres in Niassa and 1,190 litres in Maputo province will be covered through allocation of VLS 400 refrigerators.

The cold chain gap analysis at district level shows that a total of 117 district vaccine stores out of the 148 will require additional cold chain storage capacity at + 5oC for accommodating the vaccines already existing in the program, including and rotavirus, MSD and IPV vaccines to be introduced in 2015. To address the gap, will be installed 87 refrigerators VLS 400 and 30 refrigerators MK304, all to be procured in 2014, under the CCUP funding.

The CC gap analysis at health facility level shows that a total of 67 health facilities will require additional CC storage capacity at + 5oC. These will be equipped with MK144 refrigerators, which are part of 640 refrigerators procured under the CCUP funding.

Vaccine procurement and ordering – for traditional vaccines, the EPI program will forecast vaccine needs and procurement process will be through the Centre for Pharmaceutical and Medical Supplies (Central de Medicamentos e Artigos Médicos - CMAM) on an annual basis. For all new vaccines, including IPV, Rotavirus and MSD, the procurement will be through UNICEF mechanisms, also on annual basis. The reception of the procured vaccines at central level will be split in 4 consignments per year. Regional and provincial vaccine stores will order

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the requirements from national level also on quarterly basis. Districts and Health Facilities will make monthly orders.

Vaccine distribution – vaccines will be distributed according to requirements to regions and provinces each 4 months, and to districts and Health Facilities on a monthly basis. IPV, rotavirus and MSD vaccines will be transported with the other freeze-sensitive EPI vaccines through the existing routine immunization transportation system from national to regional and from there to provincial level. Three refrigerated trucks have been procured using PROSAUDE funds, for the purpose of transporting vaccine from central to regional/provincial levels. To facilitate the rapid nation-wide rollout of IPV, rotavirus and MSD vaccines, the first quarter of supplies will be distributed in a campaign mode whereby budget will be allocated to regional/provincial vaccine stores to deliver vaccines to districts. The districts will also receive budget to deliver the vaccines to all health facilities. At these last two levels, normal trucks and 4X4 will transport vaccines in cold boxes.

Vaccine monitoring – IPV, rotavirus and MSD vaccines will be incorporated into routine EPI monitoring systems. Coverage will be monitored using both routine Health Information System (HIS) and surveys. HIS will also monitor wastage rate of theses vaccines, and computerized monitoring tools, such as the SMT at national and provincial levels and the DVDMT at district level will be used.

Health worker training needs were identified through the routine National Health Information System (NHIS), supportive supervision visits and program assessments EPI review in 2006, surveillance review in 2010, Effective Vaccine Management Assessment (EVMA) in 2009 and 2012, the post-introduction evaluations (PIE) for Pentavalent in 2012 and PCV-10 in 2013, and the KAP study on immunization and new vaccine introduction in late 2012.

To address some of the identified weaknesses, EPI Manager and logisticians (4) at national level, EPI managers (11) and logisticians (11) at provincial level and district EPI managers in 80/148 districts have been so far refreshed on EPI logistics (Cold chain and vaccine management, including the implementation of the vaccine stock management tools – SMT and DVDMT), between 2013 and May 2014. The next refreshment training will be conducted in the fourth quarter of 2014 for the remaining 64 districts. WHO guidelines on vaccine management and CC management were adapted and made available to EPI officers at various levels of the system. Vaccine temperature monitoring devices, fridge tags were also purchased and distributed.

HSS funds have also been allocated to cover training of EPI staff on vaccine and CC management at district and health facility levels (including the training of CC assistants to handle unforeseen problems in the cold chain vaccine stores and health facilities), and to provide resources for national, provincial and district levels to conduct supportive supervisory visits to lower levels

In addition, there has also been training on RED strategy for improved district micro planning and on the use of data quality self-assessment tool (DQS) in order to enable districts to regularly assess and improve the quality of data they produce. However, due to limited resources, these trainings have chiefly targeted managers at provincial level, for them to support districts. Few districts (55 out of 148) have benefited of this training in the last 2 years due to funding limitations. Mozambique has planned part of the GAVI-HSS funds to support training of health staff on RED strategy and quality EPI data management, including the use of the DQS

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tool, with focus at district and health facility levels, while making available resources for national and provincial levels to conduct regular supportive supervisory visits to lower levels.

With support provided by STOP team member deployed in the field between 2012 and 2013, there has also been training on integrated disease surveillance and response for 13 provincial surveillance focal persons and 88 health staff (in 44 districts out of 148, in provinces of Zambézia, Tete and Inhambane). There is regular dissemination of quarterly surveillance feedback bulletin, to further strengthens the health workers capacity. In health clinics, there has been sensitization of clinicians on disease surveillance with emphasis on case detection and reporting of priority and epidemic prone diseases.

In order to support the improvement of the national surveillance system, the country has been strengthened through technical and logistical support provided by WHO in addition to a STOP team member who was regularly present in the field between 2012 and 2013. Fund have been planned under GAVI-HSS to extend the training to other districts and to clinicians and surveillance focal person at health facility level. The training will include the private clinics.

Most recently, there has also been training opportunity for health workers at all levels with the introduction of PCV vaccine in 2013, and in some districts with HPV demo project. Packages of training modules for PCV and HPV introduction were adapted from WHO Headquarters materials and Regional guidelines. These included vaccination schedule, vaccine management, and interpersonal communication, amongst others. Training tools included (but not be limited to) presentations, vaccination eligibility flow-charts, training videos, registers and vaccination cards. This will also be done for IPV introduction and this time, health workers will also be trained on AEFI, to include risk communication.

Summary of preparatory activities completed or to be undertaken.

Of preparatory activities, Mozambique has conducted the CC inventory, assessed the storage capacity at various levels of the system and developed a CCUP, which include a replacement of depleted cold chain, the expansion of CC at all levels to also accommodate new vaccines to be introduced in the next 5 years and expansion of fixed vaccination posts to more health facilities. Briefing of stakeholders and development of the IPV introduction plan at national scale is also completed.

Activities yet to be undertaken include development of IEC and training materials and monitoring tools, training of health workers, vaccine reception and distribution, launching and conducting of post introduction evaluation (PIE).

Brief description of main risks/challenges associated with the introduction of IPV and outline of the mitigating strategies put into place to address these risks.

Risks and challenges - Although the target group for IPV is similar to other vaccines in the vaccination schedule, instruction for health workers regarding eligibility criteria for receiving IPV may be challenging (not before 14 weeks and nor after 9 months). An eligibility flowchart will be developed to aid health workers to apply the correct vaccination schedule to each eligible child, as per their vaccination status. Continuous supervision will be organised and strengthened to support health care workers on site.

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Communicating to parents about eligibility proved to be a challenge during the introduction of PCV. This difficulty is expected to be even greater for a dual vaccine introduction (IPV and rotavirus). Furthermore, MSD will be introduced only three months later, in order to mitigate the challenging risk linked to eligibility of children less than 1 year versus 18 months. A comprehensive communication and social mobilisation strategy will be developed drawing on lessons learned from other countries with dual vaccine introduction experience. Targeted and tailored communication messages will be developed, pre-tested and piloted before being broadcasted.

The risk of freezing vaccine and using vaccine in subsequent vaccination session or beyond 6 hours after the vial is open, will be mitigated through specific emphasis during training regarding IPV storage temperature and its open vial policy. Additionally, stickers will be affixed in all refrigerators containing IPV, and hand-outs and pocket guides will be provided to health workers for easy reference.

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1. Justification for introduction of IPV and national decision-making process

The eradication of wild poliovirus type 2 (WPV2) in 1999, coupled with the continuing problem of neurovirulent circulating type 2 vaccine-derived polioviruses (cVDPV2s), whose behaviour can be similar or identical to that of WPVs, with significant paralytic attack rates and sustained person-to-person transmission. The emergency of cVDPV2 led to the recommendation that there should be a coordinated global cessation of use of the type 2 component of oral polio virus (OPV) as soon as possible.

Therefore, in the context of the comprehensive polio endgame strategy, WHO no longer recommends an OPV-only vaccination schedule, and recommends that for all countries currently using OPV only, at least 1 dose of inactivated polio vaccine (IPV) should be added to the schedule. The primary purpose of the IPV dose is to maintain immunity against type 2 poliovirus during and after the planned global withdrawal of OPV2 and switch from tOPV to bOPV, setting the stage for eventually ending bOPV use in 2019-2020. According to WHO, adding an IPV dose will boost both humoral and mucosal immunity against poliovirus types 1 and 3, which may also hasten the eradication of these WPVs.

In the particular case of Mozambique, the country has been using an OPV-only schedule in its routine EPI since EPI program inception in 1979. OPV coverage over time, however, has been low in several rural areas as demonstrated by survey data, resulting in an immunity gap and putting the country at risk of emergence of cVDPVs. In fact, in 2011 2 cases of cVDPVs were detected in 2 districts of Zambézia province.

It is in the context of the situation described above and in compliance with WHO recommendations that Mozambique is applying for introduction of one dose of IPV into its routine immunization schedule, in order to prevent occurrence of cVDPVs and raise population immunity against poliovirus types 1 and 3. The opportunity of IPV introduction will also be used to strengthen routine immunization so as to meet coverage targets and control vaccine-preventable diseases, thus helping to accelerate achievement of the Millennium Development Goal (MDG) 4, the target of which is a two-thirds reduction in child mortality globally by 2015.

There is an interagency coordination committee (ICC) which oversees the immunisation programme in Mozambique. The ICC is composed of the following partners: MOH (Leader), WHO, UNICEF, USAID, FDC and Village Reach. Concerning the decision-making process, the ICC was briefed on the current advances in polio eradication via the Endgame Strategic Plan 2013-2018, with emphasis on the rationale for the introduction of IPV, the withdrawal of OPV (starting with type 2 OPV2), the programmatic and financial implications of IPV introduction, the opportunity it offers for routine immunization strengthening, vaccine safety and availability, as well as the associated funding opportunity offered by GAVI.

All EPI partners above mentioned have somehow been actively involved in the decision making process for IPV introduction at country level, either through their participation in the IPV technical working group or in the ICC meetings. For instance, WHO and UNICEF have provided evidence-based information on the rational for IPV introduction as already mentioned above. They also supported MoH to conduct CC assessment and develop the Cold Chain Upgrade Plan (CCUP) in 2012, which was updated in 2013, used to demonstrate that IPV can be

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accommodated in terms of storage capacity. Further, they technically supported the development of the IPV introduction plan.

The USAID has made available financial resources through UNICEF for procurement and installation of necessary CC equipment and temperature monitoring devices, in line with the CCUP.

FDC and Village Reach, two Civil Society Organizations that support the EPI program at the provincial and district levels, provided their valuable inputs in terms of vaccine distribution strategy at peripheral levels and strategies to reach hard to reach populations, based on their own experience gained in the provinces and districts where they have been providing support in the areas vaccine and gas distribution and of social mobilization, in the context of universal access to basic health interventions. All of these inputs were taken into account by the ICC during the decision to introduce IPV.

The decision was taken for the country to start to develop the IPV introduction plan and to draft the proposal in order to submit to GAVI within the set submission deadlines. The IPV introduction plan will be endorsed by the ICC at its meeting held on 22nd August 2014.

Mozambique has a National Immunization Technical Advisory Group (NITAG); however, it is currently undergoing structural changes including transition of members. Its current level of activity and its involvement in the IPV application process has therefore been very limited.

In relation to technical and operational feasibility of introducing IPV, the country will build on its previous experience with new vaccine introduction. For instance, with regard to its pentavalent (DPT-HepB-Hib) vaccine, the country introduced the Hepatitis B component in 2001 and the Hib component in 2009. PCV-10 was introduced in April 2013 and an HPV demo project started in May 2014. All these vaccines and respective injection safety supplies were successfully introduced countrywide with support from GAVI. Lessons learned from these experiences, as well as the findings and recommendations from the new vaccines Post Introduction Evaluations (PIEs) both internal and external, will be capitalized on so as to continuously improve the new vaccine introduction process.

As an example, the post introduction evaluation (PIE) from the aforementioned 2013 PCV-10 introduction demonstrated that although the introduction was successful overall, that there were several areas requiring further improvement, specifically:

Planning at the province and district level, Training of health workers regarding the diseases that can be prevented by vaccine Timely updating of tools for use at the health facility Vaccine Management at the health facility to reduce stock outs and wastages Existence of AEFI Protocols Vaccine coverage estimates at the health facility Social mobilization

The country has already started to address these queries, as explained in the chapter 4.3 below.

The human papilloma virus (HPV) vaccine was piloted in three districts in May and June 2014. Assuming acceptability, the plan is to roll out the vaccine in the rest of the country in 2016. The introduction of rotavirus is scheduled for July 2015.

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To make use of the strengthened cold chain capacity, enhanced infrastructure and training of health personnel that stemmed from the recent PCV-10 introduction, HPV pilot, a joint introduction of rotavirus and IPV in 2015 is seen as the most appropriate and cost-effective option for Mozambique. In addition, three months after the joint introduction of the two new vaccines, Mozambique will introduce a second dose of measles. The rationale for not including measles second dose in the joint IPV and rotavirus introduction is to ensure that clear instructions are given to health care workers and key communication primary audiences (mainly mothers and care givers), about the importance of the vaccinations. Introducing too many vaccinations and doses simultaneously, could cause confusion among target groups and health personnel, and potentially resulting in mismanagement and lower coverage.

2. Overview of IPV

2.1.1 Vaccine preference

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Table 1: IPV vaccine preferences and estimated date of introduction

Preferred IPV vaccine Month and year of first vaccination

Preferred second presentation

Preferred third presentation

10 dose stand-alone IPV

July 2015 5 dose stand-alone IPV*

1 dose stand-alone IPV

* The country is aware that for now this product is not available. However, it would prefer this product if it becomes available in the future. This means that if this option is not available by the time of introduction, then the third product becomes the next preference.

The planned month of nationwide introduction of IPV and rotavirus is July 2015. The exact date is yet to be identified. Mozambique opts for WHO pre-qualified stand-alone IPV in 10 dose vials. The preference of the 10 dose vial is based on a balance between optimizing storage capacity and minimizing wastage and cost, since the preservative (2 phenoxy-ethanol) in the stand-alone IPV vaccine is not WHO pre-qualified and the vaccine should be discarded after maximum six hours after opening. While optimization of the storage capacity looks clear for the 10 dose vial option, the optimization of the wastage was considered based on the comparison with measles wastage rate at country level which has ranged from 25% to 30% in the last three years. The least preferred vial is the single dose because it will occupy too much storage capacity particularly for outreach activities.

2.1.2 Country licensure status

Mozambique accepts the Expedited Procedure for national registration of WHO pre-qualified vaccines without requiring full in-country licensure. National vaccine licensure will therefore not be needed for IPV. However, formal communication to the Pharmaceutical Department at the Ministry of Health requesting permission to use the vaccine nationwide is necessary and it takes approximately 3 months, but for this case of IPV it has already started to be prepared even prior to GAVI’s approval of funding for this proposal. UNICEF procures all GAVI-funded vaccines in Mozambique and will also procure the IPV. Currently, only the stand-alone IPV is WHO pre-qualified. Mozambique is therefore seeking GAVI support to introduce the stand-alone IPV.

2.1.3 Target population and vaccine supply

The target population for IPV is all surviving infants. The vaccine will be introduced into the national routine immunization programme in July 2015, and the estimated coverage and IPV supplies for the period of July to December 2015 and the next years up to 2019, is presented in the table below.

Table 4 below gives an overview of Mozambique’s dose allocation needs, listing the target population and estimated coverage up to 2019. The data presented are based on the WHO EPI Log Forecast tool for Mozambique. Penta3 coverage is used as a proxy for expected IPV coverage. The vaccine is scheduled to be introduced with rotavirus in July 2015, hence the lower coverage for the same year.

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Table 2. Multi-year forecast for IPV Supplies at national level

2015 2016 2017 2018 2019Total 5-years

Total Population

25,727,911

26,423,623

27,128,530

27,843,933

28,571,310

135,695,307

Total annual birth cohort:

1,106,2

74

1,136,1

89

1,166,5

00

1,197,2

61

1,228,5

38 5,8

34,763

Total annual surviving infants:

1,035,5

48

1,063,5

51

1,091,9

23

1,120,7

18

1,149,9

95 5,4

61,736 Target Coverage for Penta3 94% 95% 96% 97% 98%Target Coverage for IPV* 47% 95% 96% 97% 98%

Target Number for IPV

486,708

1,010,3

73

1,048,2

46 1,087,097

1,126,995

4,759,420

IPV liquid

1,300,0

00

2,438,6

00

2,260,0

00

2,343,5

00

2,429,4

00 10,7

71,500 No. of syringes required for IM injections

721,500

1,353,4

00

1,254,3

00

1,300,7

00

1,348,3

00 5,9

78,200

Safety boxes SB_5l 7,300

13,600

12,600

13,100

13,500

60,100

*The target coverage for IPV in 2015 correspond to ½ of the pentavalent target as the introduction is expected to be in July 2015

IPV immunogenicity is highest after 14 weeks of age because of reduction in maternal antibodies. IPV will therefore be given intramuscularly as a single dose at the minimum age of 14 weeks in addition to OPV3/Penta3 and PCV3. Children who are behind in their vaccination schedule will receive the IPV dose at the first contact with the vaccination service after 14 weeks of age. For children starting their DTP schedule later than three months, the IPV will be administered at the first immunization contact along with the first DTP dose. IPV will be administered in the same thigh as PCV, in this case in the right thigh, 2 cm apart from each other, during the same vaccination session. As for Rotavirus it will follow the current schedule for routine DPT-HepB-Hib, but only 2 doses will be administered. These guidelines will be communicated clearly to health workers and supervisors throughout Mozambique. For more information, please see section 3.6 on training.

Table 3 below illustrates the immunization schedule for infants and pregnant women after introducing IPV, rotavirus and measles second dose into the Mozambican routine vaccination programme. Vaccines to be introduced in 2015 are in italic bold.

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Table 3. Mozambique’s Immunisation Schedule for Infants and Pregnant women after IPV, Rotavirus and measles second dose introductions

Immunisation for infants Immunisation for pregnant women and WCBA

Age Visit Antigen Visit Interval AntigenBirth 1 BCG, OPV0 1 0 (as earlier as

possible)TT1

6 weeks 2 DPT-HepB-Hib1, PCV1, OPV1, Rota 1

2 4 weeks after 1st dose

TT2

10 weeks 3 DPT-HepB-Hib2, PCV2, OPV2, Rota 2

3 6 months after 2nd dose

TT3

14 weeks 4 DPT-HepB-Hib3, PCV3, OPV3, IPV1

4 1 year after 3rd dose

TT4

9 months 5 Measles First Dose 5 1 year after 4th dose

TT5

18 months

6 Measles Second Dose (MSD)

- - -

In case the child arrives to the vaccination service after 14 weeks of age, the IPV will be administered at the first encounter after 14 weeks.

1

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3. Introduction and implementation considerations

3.1.1 Policy development

The single dose IPV will be administered intramuscularly at 14 weeks of age together with DPT-HepB-Hib3, PCV3, and OPV3. In case the child arrives to the vaccination service after 14 weeks of age, then IPV will be administered at the first immunization contact after 14 weeks and before 9 months of age. If an infant is to receive IPV, PCV and pentavalent during the same visit, the IPV and PCV vaccines will be given at a minimum two centimetres apart in the right thigh and the pentavalent vaccine will be given in the left thigh.

Mozambique does not have a documented risk of vaccine-associated paralytic polio prior to four months of age and is therefore not considering alternative, flexible immunization schedules for IPV before 14 weeks of age.

There will be no IPV catch-up vaccination campaign as per WHO recommendations. This means that children who have already received Penta3 when IPV is introduced will not be eligible for IPV. The reason is that they will be sufficiently immunised against all three types of polio through tOPV. Therefore, only children born after the introduction of IPV will be eligible for the IPV vaccine. This will be highlighted in health worker training sessions.

Mozambique’s comprehensive Multi-year Plan 2014-2018 (cMYP), which was updated in September 2013, has recently been revised in July 2014 and updated to include IPV and MR vaccines. The review also allowed the program to align Mozambique’s EPI cMYP with the new Health Sector Strategic Plan (Plano Estratégico do Sector da Saúde, PESS), which ends in 2019. The cMYP was initially aligned with the PESS but the PESS was extended after approval of the cMYP.

The existent plan to introduce rotavirus has also been modified and aligned with the new introduction plan for IPV in order to allow for a dual introduction.

3.1.2 National coordination mechanism to ensure the successful introduction

The detailed timeline (annex C) outlines the key processes for the successful introduction of IPV. In developing the timeline for the joint introduction of IPV and rotavirus, key lessons learned from recent vaccine introduction, particularly PCV-10, were taken into consideration.

To ensure a successful introduction, particular attention will be given to social mobilization and training of health care workers. Mozambique has introduced several vaccines in the near past and it is crucial that health personnel understand the benefits of the additional vaccines and know how to administer them.

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It is expected that IPV will be introduced in July 2015. Based on the chosen introduction date, a timetable has been developed to implement a number of new vaccine introduction activities, amongst which the main ones include: 1) Briefing of stakeholders on IPV to decide on its introduction, occurred in May 2015.

2) Proposal development and ICC approval – the proposal development happened between June and 15th August 2015 and the ICC endorsement on 22nd August 2015.

3) Proposal submission to GAVI for IPV funding, is expected to be by 15th September 2014.

4) Adapt IEC materials and develop communication plan for educating communities; revise immunization monitoring tools; and adapt training materials – the development of all these materials will be ready at least 8 months prior the launching, that is, will be developed in Between July and September 2015 and printed in October 2015.

5) Printing and distribution of IEC and training materials and monitoring tools – having IEC materials ready at least 8 months ahead, will allow 2 months (November and December 2015) for distribution through different levels of the system, so that at service delivery level the materials will be pre-positioned at least 6 months prior launching. This will allow that communication (IEC) with communities on new vaccine will occur for at least 6 months. Training materials will be printed at the same time as the IEC materials. Monitoring tools, will be pre-positioned at service delivery level at least 3 months (in February and March 2015) prior the launching (noting that they will take much more time for printing given the high nr of data collection forms, register and vaccination cards and high quantities necessary for each of them).

6) Develop new vaccine introduction plans at various levels of the system. This will occur one year prior to launching for central level, as it is a pre-requisite for GAVI approval of new vaccine funding. At provincial and district level, it will happen at least 6 months prior to launching, in November and December 2015.

7) Training of health workers at various levels of the system, will occur at least 6 months at central and provincial levels prior to IPV launching. Even though this seems to be a too long interval between training and launching, the training of supervisors is a pre-requisite for vaccine to be shipped to country level. Training of district supervisors will occur 3 months (in March 2015) prior to launching, and at service delivery level and between 2 and 1 months (May-June 2015) prior to launching.

8) Vaccine reception and distribution. It is expected that vaccine will be received at the national vaccine store, at least 3 months (by March 2015) prior to the launching, and that it will be pre-positioned at service delivery level at least 1 month prior to its launching.

9) Launching of IPV vaccination, is expected to be on July 2015, countrywide. It will be a joint introduction with rotavirus vaccine, already approved by GAVI.

10) Conducting of post-introduction evaluation (PIE), which will happen at the same time for all 3 vaccines (9 months – April 2015 – after IPV /Rota and 6 months after MSD introduction, as the latter will be introduced 3 months after the formers).

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At national level, there is an interagency coordination committee (ICC) which oversees the immunisation programme in Mozambique. The ICC is composed of the following partners: MOH (Leader), WHO, UNICEF, USAID, FDC and Village Reach. The ICC will monitor and evaluate all EPI activities including the dual introduction of the IPV and rotavirus and latter of MSD vaccines using indicators developed and agreed upon by the Committee. In this case, the introduction process will be closely monitored paying due attention to operational aspects such as the training of health workers, supply of vaccine and injection equipment, cold chain and logistics, advocacy and social mobilization, and adaptation of forms, register and cards. The implementation will be monitored through selected indicators, which include the number of districts having introduced new vaccine and MSD, the coverage rate, dropout rate, vaccine wastage rate, the adverse events following immunization, stock, consumption, supply of vaccines, injection safety and cold chain equipment and waste disposal. At sub-national level, provinces and districts, similar committees will be created lead by Provincial and District Directorate of Health, respectively, for monitoring of introduction process in its different phases (preparatory, launching and vaccination) at these levels. It is noted that monitoring and evaluation is part of ICC terms of reference.

At national level were created three sub-committees, namely advocacy, IEC and social mobilization sub-committee, logistic sub-committee and training / monitoring (overlook development of training materials and training of health workers and updating and printing of monitoring tools) sub-committee. This will be replicated at provincial and district level as well, but only one sub-committee will be installed as this only needs to ensure that all materials and instruction received from central level are delivered and implemented timely.

3.2 Affordability and financial sustainability

3.2.1 Cost of IPV, Rotavirus and MSD vaccines joint introduction and funding

The joint introduction of IPV, rotavirus and MSD vaccines into the National Immunization Program, excluding the roll out process will cost $ 68.8 million over the next five years. These costs, which were calculated based on the WHO-EPI Forecast tool, are related to IPV, Rotavirus and MSD vaccines and respective injection safety materials, clearing and stock management. The bulk of the vaccines and associated costs will be borne by GAVI, if this IPV country`s application is approved. The Mozambican government’s investment will be limited to a total co-financing amount of $1.8 million (USD 1.7 million for rotavirus vaccine only, as IPV and MSD are fully financed by GAV, and $0.1 million for clearing and stock management of the three vaccines – see table 4). Both Rotavirus and MSD vaccines have already been approved by GAVI and the government has also secured its co-financing for Rotavirus vaccine. Therefore, there is no funding gap for vaccines and related injection safety supplies. The MOH of Mozambique will start co-financing rotavirus vaccine from June 2016.

The rollout process in terms of cold chain expansion, training, update of M&E tools, social mobilization materials and vaccine and related materials distribution (including receiving and stock management) for this joint introduction of IPV, rotavirus and MSD vaccine, will cost an additional $ 3.35 million, being $1.76 million for CC investment (vaccine stores, CC equipment, installation and running costs) and $1.59 million for vaccines introduction roll out process.

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With regards to CC investment, the ICC and other stakeholder’s involvement have been crucial in advocacy and resource mobilization of the $1.76 million required for this joint introduction of IPV, rotavirus and MSD vaccine. Out of the $ 1.76 million requirements, the country has already secured USD 0.9 million for CC investment, which is part of the 1.3 million grant provided by USAID in response to the CCUP recently developed in May, 2013. The remaining $ 0.86 million requirements for CC investment will be covered using GAVI new vaccine introduction grant (noting that the country is entitled to receive $824,500 VIG for IPV, $885,000 VIG for Rotavirus and $885,000 VIG for MSD, the last two already approved and to be released in 2014) . The country has been approved for GAVI-HSS grant to be released in 2014 and it had already planned and budgeted $864,000 for the construction of vaccine stores in the first year GAVI-HSS grant. However, given the delay in the disbursement of GAVI-HSS funds, the country is now considering using VIG to cover the $864,000 in replacement of the HSS grant.

Considering the above described, the CC investment is fully covered and there still a balance of $906,000 ($899,856-USAID + $885,000-VIG + $885,000-VIG – $1,763,856 million) that will be used to cover other activities of the roll out process (activities related to new vaccine introduction process) and to cover other CC requirements as per the CCUP (noting that the total cost of the Cold Chain Upgrade Plan - CCUP is 4.5 million and covers CC requirements up to 2023).

The cost of joint introduction of Rotavirus, MSD and IPV is presented in the tables below, for both vaccine and related injection safety supplies, and the vaccine introduction rollout process.

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Table 4 Cost and funding for joint introduction of rotavirus, MSD and IPV vaccines into the NIP in Mozambique

FUNDED FUNDING GAP

2015 2016 2017 2018 2019 Total Resource Require/ in USD Gov Gov Co-

FinanceGAVI - NVS

GAVI-VIG

(IPV)

GAVI-VIG

(Rota)

GAVI-VIG (MSD)

USAID UNICEF UNICEF WHO Funded Funding Gap

JOINT IPV, ROTAVIRUS AND MSD INTRODUCTION USD $ USD $ USD $ USD $ USD $ USD $ USD $ USD $ USD $ USD $ USD $ USD $ USD $ USD $ USD $ USD $Cost for Rotav irus Vaccine $4,436,872 $5,644,134 $5,555,488 $5,830,316 $6,114,542 $27,581,352 $1,705,705 $25,875,647 $27,581,352 $0

Cost for MSD Vaccine $289,038 $490,707 $473,315 $495,369 $519,521 $2,267,950 $2,267,950 $2,267,950 $0Cost for IPV Vaccine $4,595,500 $8,620,451 $7,989,100 $8,284,273 $8,587,929 $38,077,253 $38,077,253 $38,077,253 $0Cost for Injection Safety Materials - MSD $45,291 $76,821 $74,155 $77,595 $81,325 $355,187 $355,187 $355,187 $0Cost for Injection Safety Materials - IPV $41,562 $77,903 $72,196 $74,889 $77,579 $344,129 $344,129 $344,129 $0Vaccine Ship, Clearing & Stock Management Costs $14,598 $27,461 $31,187 $36,228 $42,093 $151,567 $151,567 $151,567 $0Cold Chain additional invest costs-Central level $108,125 $108,125 $108,125 $108,125 $0Cold chain additional invest costs-Reg. & Prov. $2,229 $356,533 $2,229 $2,229 $2,229 $365,448 $365,448 $365,448 $0Cold chain additional invest costs-District level $129,018 $129,018 $129,018 $129,018 $0Cold Chain Additional Invest/ Costs-H Facility level $52,434 $52,434 $52,434 $52,434 $0

Cold Chain Additonal Running Costs all levels $16,484 $32,366 $37,387 $37,484 $37,582 $161,303 $161,303 $161,303 $0Construction of Vaccine Stores - Reg. & Prov. $864,000 $864,000 $223,042 $640,958 $864,000 $0Installation of CC Equip all Levels $38,909 $43,563 $352 $352 $352 $83,528 $83,528 $83,528 $0Rollout Process (training, s. mob, vac. delivery , etc.) $1,591,782 $1,591,782 $70,756 $824,500 $536,526 $100,000 $60,000 $1,591,782 $0

TOTAL COST $11,253,716 $16,233,939 $14,343,534 $14,838,734 $15,463,151 $72,133,075 $70,756 $1,857,272 $66,920,165 $824,500 $759,567 $640,958 $899,856 $100,000 $60,000 $72,133,075 $0

RESOURCE REQUIREMENT FUNDING SOURCE

TOTAL COST FOR VACCINES & INJECTION SAFETY $9,408,263 $14,910,016 $14,164,254 $14,762,441 $15,380,896 $68,625,870Government Co-Financing $0 $415,962 $409,423 $429,688 $450,632 $1,705,705GAVI Financing $9,408,263 $14,494,054 $13,754,832 $14,332,753 $14,930,263 $66,920,165

TOTAL COST FOR CC INVESTMENT $239,074 $1,296,462 $148,093 $40,065 $40,163 $1,763,856Country Financing $239,074 $432,462 $148,093 $40,065 $40,163 $899,856GAVI Financing $0 $864,000 $0 $0 $0 $864,000

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The remaining aspects of the roll out process totalling $1,591,782 related to training, communication and social mobilization, vaccine delivery, monitoring & evaluation and supervision, waste management and program management as presented in the table 8 below, will be covered through the third GAVI vaccine introduction grant ($824,500 IPV-VIG). Taking into account that there is a balance of $906,000 after using the other two VIG to cover the CC needs, the country should have available for now $1,730,500 ($824,500 IPV-VIG + 906,000 balance). This covers all required resources for introduction roll out process and leaves a balance of $138,718. However, taking into account that the introduction of these vaccines should be a country owned process, MoH and local partners will cover some items of the above mentioned needs in a total of $230,756 ($70,756 – MoH + $100,000-UNICEF + $60,000-WHO) as demonstrated in the tables 4 and 5. This will allow to increase the available balance to $369,474. This amount will be used to strengthen routine immunization and cover some items in the CCUP, as mentioned earlier. Detailed budget of the roll out process is presented in the annexe D (tables 1 to 12).

Table 5: Roll Out Process Cost for IPV, Rotavirus & MSD Vaccine introduction

INTRODUCTION OF ROTAVIRUS VACCINE TOTAL Provinces 11 Districts 148 Nr Total US 1,360

TOTAL MZM TOTAL USD Funded $ Gap $Training 13,968,225 476,731 476,731 - Training 64,000 2,184 2,184 - Adapt Trainig Materials 293,000 10,000 10,000 - Training Central Level 1,010,100 34,474 34,474 - Training Provincial Level 3,771,125 128,707 128,707 - Training District Level 8,830,000 301,365 301,365 - Communication and Social Mobilization 9,014,000 307,645 307,645 - Communication & Social Mobilization Central Level 1,536,000 52,423 52,423 - Communication & Social Mobilization Provincial Level 2,298,000 78,430 78,430 - Communication & Social Mobilization District Level 5,180,000 176,792 176,792 - Vaccine Delivery 4,319,750 147,432 147,432 - Vaccine Delivery Central to Provinces 407,000 13,891 13,891 - Vaccine Delivery Provinces to Districts 508,750 17,363 17,363 - Vaccine Delivery Distrits to Health Facilities 3,404,000 116,177 116,177 - Monitoring & Evaluation 7,720,778 263,508 263,508 - Revise M&E tools 60,000 2,048 2,048 - Print M&E tools 1,318,500 45,000 45,000 - Integrated Disease Surveillance 5,014,549 171,145 171,145 - Post Evaluation Introduction (PIE) 1,034,730 35,315 35,315 - Technical Assistance 293,000 10,000 10,000 - Supportive Supervision 6,776,145 231,268 231,268 - Central level Supervision (Central to Provincial / District levels) 687,763 23,473 23,473 - Provincial level Supervision (Provinces to District / H Facility levels) 2,719,163 92,804 92,804 - District level Supervision (Districts to H Facility level) 3,369,220 114,990 114,990 - Waste Management 2,730,300 93,184 93,184 - Build Incinerators 2,197,500 75,000 75,000 - Fuel for Incinerators & Open Burning Waste 532,800 18,184 18,184 - Program Management 2,110,000 72,014 72,014 - Overheads 2,110,000 72,014 72,014 -

TOTAL 46,639,198 1,591,782 1,591,782 0

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Table 6: Cost and funding for roll out process of joint introduction of rotavirus, MSD and IPV vaccines

Component /activityTotal Resource Requirements in

MZM

Total Resource Requirements in

USDGovernment Common

FundGAVI New Vaccine

Grant - IPV

GAVI New Vaccine Grant

- RotavirusWHO USAID-

UNICEF HSS Funded Funding Gap

MZM US$ US$ US$ US$ US$ US$ US$ US$ US$Training 13,968,225 476,731 12,184 0 464,547 0 0 0 0 476,731 0

Adapt Trainig Materials 64,000 2,184$ 2,184$ 2,184$ -$ Print Training materials 293,000 10,000$ 10,000$ 10,000$ -$

Central Level 1,010,100 34,474$ 34,474$ 34,474$ -$

Prov incial level 3,771,125 128,707$ 128,707$ 128,707$ -$

District Level 8,830,000 301,365$ 301,365$ 301,365$ -$

Communicaction & Social Mobilization 9,014,000 307,645 0 0 130,853 76,792 0 100,000 0 307,645 0

Central Level 1,536,000 52,423$ 52,423$ 52,423$ -$ Prov incial level 2,298,000 78,430$ 78,430$ 78,430$ -$

District Level 5,180,000 176,792$ 76,792$ 100,000$ 176,792$ -$

Vaccine Delivery 4,319,750 147,432 31,254 0 8,857 107,321 0 0 0 147,432 0

Central Level 407,000 13,891$ 13,891$ 13,891$ -$

Prov incial level 508,750 17,363$ 17,363$ 17,363$ -$

District Level 3,404,000 116,177$ 8,857$ 107,321$ 116,177$ -$

Monitoring & Evaluation 7,720,778 263,508 9,133 0 73,230 121,145 60,000 0 0 263,508 0

Rev ise M&E tools 60,000 2,048$ 2,048$ 2,048$ -$

Print M&E tools 1,318,500 45,000$ 7,085$ 37,915$ 45,000$ -$

Integrated Disease Surveillance 5,014,549 171,145$ 121,145$ 50,000$ 171,145$ -$ Post Evaluation Introduction (PIE) 1,034,730 35,315$ 35,315$ 35,315$ -$ Technical Assistance 293,000 10,000$ 10,000$ 10,000$ -$

Supportive Supervision 6,776,145 231,268 0 0 0 231,268 0 0 0 231,268 0

Central level Superv ision (Central to Provincial / District levels) 687,763 23,473$ 23,473$ 23,473$ -$

Prov incial level Supervision (Provinces to District / H Facility levels) 2,719,163 92,804$ 92,804$ 92,804$ -$

District level Supervision (Districts to H Facility level) 3,369,220 114,990$ 114,990$ 114,990$ -$ Waste Management 2,730,300 93,184 18,184 0 75,000 0 0 0 0 93,184 0

Build Incinerators 2,197,500 75,000$ 75,000$ 75,000$ -$

Fuel for Incinerators & Open Burning Waste 532,800 18,184$ 18,184$ 18,184$ -$

Program Management 2,110,000 72,014 0 0 72,014 0 0 0 0 72,014 0

Overheads 2,110,000 72,014$ 72,014$ 72,014$ -$

TOTAL 46,639,198 1,591,782$ 70,756$ -$ 824,500$ 536,525$ 60,000$ 100,000$ -$ 1,591,782$ -$

The driving cost for the joint IPV, rotavirus and MSD vaccines introduction rollout are training of health workers (30%), communication and social mobilization (19%) and monitoring & evaluation (17%). It is noted that integrated disease surveillance is responsible for 65% of the weight in the M&E. Other items have a weight of 15% or less (Figure 1).

Figure 1: Distribution of resources for the rollout process for joint IPV, Rota and MSD introduction

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3.2.2 Country Immunization Financing and Sustainability

The EPI program financing is largely influenced by the entire health sector financing trends. Therefore, for better illustration and understanding, it will first be analysed the global health sector financing and then narrowed down to the immunization financing.

The State Budget (OE) in the health sector consists of the ordinary revenues of the state and direct budget support, and the Common Fund - fund for budget support to the health sector, inserted in the Sector Wide Approach (SWAp), which is applied in the same mechanisms than OE. The weight of health in total government expenditure has declined in relative terms, from nearly 14% in 2006 to about 7% in 2011 (REO 2006, 2011), although health remains a priority of the Government of Mozambique.

The second source of funding is the vertical funds, intended to support the fight against specific diseases. Of these, the funds of the United States Government (USG) and the Global Fund to Fight HIV, TB and Malaria (GF) represent over half of the total financial resources of the sector, and are often used in the form of contracts with NGOs, or in kind (IFE 2012).

Finally, the third source of funding is private spending, which accounted for about 13% of total spending, representing payments made to private providers, pharmacies and co-payments for services in the National Health System (NHS). This source also includes medical assistance, which deducts 1.5% of basic salary to civil servants and is used in the NHS Health. Funding through the insurers are not yet properly explored, despite its rapidly growing in recent years (PESS, 2014-2019).

In Mozambique, the total expenditure on health has increased consistently over the years and is estimated to have represented 6.2% of GDP in 2009, or about 1,000 MT (US $27) per capita. However, this level of funding is still far below regional averages and recommendations of the WHO and the World Bank to finance a basic package of health services.

In recent years there has been a growing trend of total expenditure on health, with an increase from US $ 402 to US $ 759 million from 2007 to 2012. This growth was driven in part by the considerable increase in OE funds, but mainly by the increase of external funds more specifically vertical projects (Off budget), which more than doubled between 2007 and 2012.

Although, overall, the funding has shown an increasing trend in recent years, the Mozambique Health Sector still has a major dependence on external resources, being important to draw attention to the fact that a proportion of state budget (SB) comes directly from the Partners as well as the Balance of Payments. According to the Survey on Foreign Funds 2012 and Activity Reports and Budget Execution, the State Budget (OE) had a smaller contribution (36%) compared to donors / development partners (including funds PROSAUDE, on budget and off budget) which accounted for 64% of spending on health in 2012.

The costing exercise of the National Health Sector Strategic Plan (PESS) 2014-2019, which provides the essential financial needs in order to fulfil the goals of coverage of health services and the system itself, showed that the financial requirements for the implementation of the PESS 2014-2019 amount to US $ 7.81 billion. Meanwhile, the scenario of internal and external funds

25

for the period of execution of this PESS drawn from the main planning documents of the ministry (State Budget & the MTEF) and the information provided by the partners through the external funds survey (IFE), shows a financial gap of US $ 1.47 billion for the entire duration of the PESS.

Meanwhile, it is expected that the investment for the public health programs will grow 23% in the 2014-2019 period, being that the maternal and child health program (21%), malaria program (22%), nutrition program (16%) and EPI program (14%) the ones bearing the greater weight in the total costs (figure 7).

Furthermore, it appears that the greater weight of the costs of public health programs in general go to communication activities, media and outreach, with a weight of 32%, followed by the costs of program management (meetings and other activities of program planning) with 22% and infrastructure and equipment with 19%.

With regards to immunization financing, there are very few partners providing financial support to EPI program, namely WHO, UNICEF, USAID (usually channelled through WHO or UNICEF), and two Civil Society Organizations (CSOs, namely Foundation for Community development (FDC) and Village Reach. Part of the funds allocated to EPI are from the Common Basket Fund, also called PROSAUDE Fund. The main NGO’s supporting health sector at district level in several provinces is the World Vision, Save the Children, MSF and a number of other small local NGO’s.

An analysis of the Overall Expenditure and Financing for Immunization from all sources (Government and donors) as reported in the APR 2011, APR 2012 and APR 2013, shows that total routine EPI expenditures increased by 100% from $13.0 million in 2011 to $26.1 million in 2013. However, it should be noted that 90% of this increase ($ 11.8 million) is due to the weight of new and underused vaccines (NUV), for which GAVI supports 91% ($10.8 million).

Parallel to the increase in the routine immunization expenditure, it is also important to note that the Government expenditure on routine immunization has increased by 2.7 million ($ 0.9 million for co-financing of NUV and 1.8 million for other routine recurrent expenditures inclining traditional vaccines & injection safety devices) between 2011 and 2013 (from $3.4 million to $6.1 million), representing 79% increase in Government allocations to EPI program.

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Table 7: Government expenditure on routine vaccination from 2011-2013

Gov. Expenditure on Vaccine & Inj. Safety Devices

Total Expenditure on Vaccines & Inj. Safety Devices

Gov. Expenditure on Routine Immunization

Total Expenditure on Routine Immunization

2011 $2,121,765 $8,681,765 $3,420,723 $13,034,2192012 $2,611,824 $8,619,896 $4,771,068 $13,870,8492013 $3,994,362 $20,444,213 $6,130,857 $26,094,958Amount Increase (2011 to 2013) $1,872,597 $11,762,448 $2,710,134 $13,060,739% increase (2011 to 2013) 88% 135% 79% 100%

The 100% increase in total immunization expenditures and 79% in Government expenditure on immunization between 2011 and 2013 highlights the importance and priority the Government and its Partners gives to immunization program. This level of commitment can be considered an indication that the foreseen increase in the available resources as per the PESS 2014-2019, will reflect in the increased allocation to EPI financing.

3.2.3 Financial Sustainability Strategies

The Government of Mozambique through the MOH and its health development partners intends to take a number of steps that will have positive effects on the overall costs and financing of the plan. To achieve that, the opportunities and threats in raising and effectively managing donor funds are analysed.

3.2.3.1.1 Opportunities

After a decade of higher annual economic growth to 6%, the Gross Domestic Product (GDP) per capita was $ 545.5 in 2011. Prospects are still good, with projected growth rates of 7-8%, due mainly to mega-projects of the extractive industry and the public investment in the area of infrastructure. It is expected that this growth will translate into increased fiscal space (expense) for the health as well as creating more opportunities for generating individuals and families’ income, and consequent improvement of living conditions and health, well as GDP (PESS 2014-2019).

Furthermore, opportunities for funding exist at international and national levels. The signing of the IHP+ (Compact), and the existence of strong SWAP and other coordination mechanisms (MNCH SWAP, ICC, NCC, etc.) offer opportunities for resource mobilization and its more efficient use. Donors have in the past offered substantial resources for immunization, reflecting their high level of confidence in the programme. EPI programme receives significant commitment from the Government of Mozambique. This commitment has been demonstrated through a 79% increase the Government financing to EPI between 2011 and 2013, as demonstrated above.

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3.2.3.1.2 Threats

Despite availability of opportunities in Mozambique for improved EPI financing and efficient service delivery, there are some threats the government of Mozambique needs to overcome for better mobilization of resources for immunization financing. The successful implementation of the cMYP and the introduction of new vaccines depend on how the government and the EPI get around these threats.

The recent proliferation of Global Health Initiatives that target specific interventions outside of immunization limits government’s ability to secure budgetary support from many traditional donors. The donors instead prefer to channel their funds through these initiatives. Furthermore, there are a number of cost-effective health and other social interventions competing with immunization for the limited government resources, such as Malaria, HIV/AIDS, TB, amongst others.

A country like Mozambique with per capita income of $545 (in 2011, The WB indictors), provides limited scope to mobilize resources domestically. There are untapped opportunities for the integration of the EPI programme implementation with other child survival initiatives leading to synergy and saving of limited resources. The vast terrain of Mozambique makes access health care in certain areas of the country difficult thereby leading to high implementation costs (outreach & mobile brigades). There is a problem of proper vaccine management at all levels of the EPI delivery system to an extent that it could in the long run lead to wastage of scarce resources.

3.2.4 Strategies and actions for financial sustainability

There are basically three strategies to be employed, which include the mobilization of additional resources (from both local and external sources); ensuring increased reliability of resources and improving the efficiency of the program.

3.2.4.1 Mobilizing additional resources (local and external sources)

Firstly, the programme aims at increasing the proportion of resources assigned by the Ministry of Health to the Expanded Program on Immunization. The increase should be in proportion to the increase in the Ministry of Health's budget and to Mozambique's economic growth. For this to happen, the program will work with the Health Planning Department within the MoH to improve fund allocation to the immunization program through active participation in the development and M&E of both the national health strategic plan (PESS) and the MoH annual plan of action, in order to advocate for the EPI cMYP and the immunization annual PoA.

There is a potential for future improvements and sustainability in state funding of the health sector, resulting from the potential increase in government revenue from the natural resources sector. Meanwhile, HIPC and Debt relief initiatives also offer an opportunity for Ministry of Health to advocate for an increased budget allocation to the health sector. These improvements and sustainability in state funding of the health sector will be achieved through advocacy, engaging in permanent dialogue with the Ministry of Planning and Ministry of Finance, as well as engaging the influential people within the National Parliament for approval of pro-health legislation and policies.

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Secondly, the MOH through its vaccine procurement department will aim at obtaining more competitive prices for traditional EPI vaccines and related injection supplies. This will be done through, direct negotiations with vaccine manufacturers and other relevant firms, taking into account that GAVI is already tackling this issue for new and underutilized vaccines at global level. The present support from GAVI is expected to guarantee supplies up to the end of 2019. Meanwhile, additional partners locally shall be sensitized to support vaccine supplies from the outset.

Thirdly, the program aims to advise and advocate for local governments to mobilize resources for their constituencies to cover some selected cost items, especially for Information, Education and Communication and social mobilization activities. The strategy shall aim to integrate the immunization and MCH program activities within those already being carried out by the local governments for efficiency gains. This might include, for instance, having local authorities using its structure already in place to mobilizing communities for increased utilization of immunization services, or even to provide transport or fuel for outreach.

Furthermore, avenues for resource mobilization and partnerships with the private sector will be sought. This has proven successful with mass immunization campaigns. For instance, making use of the social responsibility law passed by parliament, advocate with the private sector on the cost effectiveness of investment in the health sector area, with particular emphasis to immunization. Further, the country shell also explores possibilities of taxation in phone call or electricity in order to increase financing for health sector, which would reflect in increased immunization program financing.

Lastly, the potential of health insurance has also not been exploited to a large extent in the country. Once this potential is exploited in future, this will be an additional source for health financing.

3.2.4.2 Increasing reliability of resources

The financial forecasts for immunization should be incorporated into the MTEF and LTEF planning and budgeting cycles, and updated regularly. The strategy to have an increasing proportion of the vaccine expenditure covered by the Government increases the reliability of the resources required. In addition, the Ministry of Health shall protect its contribution to vaccine purchase within its health sector expenditures.

As stated above, at the national level, resources saved from debt relief and HIPC initiatives and reallocated to health sector should be proportionally increased by the MOH to the EPI programme. The program will advocate for that to happen by conducting a cost-effectiveness analysis of the EPI program and presenting that to the MOH and partners (e.g. SWAP). Furthermore, the programme will work with the Health Planning Department, Ministry of Health to improve fund appropriation by building capacity for financial management at all levels. In addition, improvements in cash flow and accountability measures at the implementing units shall be the focus to enable faster release of resources and an increase in its allocation.

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3.2.4.3 Improving program efficiency

The EPI program will seek to ensure efficient utilization of its resources with the best possible outcomes. There are a number of issues that lead to inefficiencies within the MOH in general and EPI in particular. Low numbers and skills of health workers is a health sector-wide problem, which leads to poor resource management. Inadequately trained personnel coupled with brain drain are key weaknesses that hamper the implementation of health programs. Therefore, providing staff that could efficiently deliver services is key to the success of the implementation of MoH programs. In addition, the EPI will work with the MoH to explore better ways to ensure staff retention and motivation.

High vaccine wastage and poor maintenance of equipment also lead to poor utilization of limited resources. Therefore, putting in place strategies to work towards limiting these inefficiencies shall free such resources and be a strong advocacy tool to attract additional resources. In this regard, the MOH with support from its internal partners has conducted a cold chain inventory and an effective vaccine management assessment, which informed the cold chain and vaccine management improvement plans.

In addition, the EPI program and the MOH will seek to strengthen the monitoring and evaluation capacity of the program. At present, monitoring information especially for vaccine receipts, utilization and wastage are not accurately recorded in a manner that can guide management decision. This has recently started to be implemented at central level and it is being replicated at the provincial and District level. The utilization of the vaccine management tools (SMT at national and provincial levels and DVDMT at district level), the training of the users along with supportive supervision will allow for this to happen. The MOH has recently deployed an EPI logistician in each province to support basically EPI logistic including effective vaccine management.

Moreover, the EPI program is committed at improving the program efficiency through fostering integration and sharing of resources with other related programs whenever possible at all levels, particularly at service delivery level. For instance, Reach Every District (RED) Strategy, is aiming at more efficient use of resources through better planning, which will improve its efficiency. One of the main aspects of RED strategy is integration during outreach activities, meaning that during outreach EPI activities, other interventions, such as MCH activities, deworming, Vitamin A, mosquito treated bed nets, etc., as described in the basic service package will be offered to the population.

The delivery of supplies is another area to explore for efficiency gains through integration with other programs. Integrated Monitoring & supervision will also be considered. This means that in all these areas there shall be co-participation in the allocation and utilization of resources which will improve efficiency for EPI and other MCH program.

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3.3 Overview of cold chain capacity at district, regional and central levels

3.3.1 Cold Chain Capacity at central level for Joint introduction of Rotavirus, MSD and IPV in 2015

Mozambique is applying in this application for introduction of IPV vaccine into the NIP in 2015. Considering that the country has already been previously approved for the introduction of rotavirus and MSD vaccines also in 2015, the analysis here presented will consider joint introduction of Rotavirus, MSD and IPV vaccines.

All the three concerned vaccines will be stored at + 5°C. The analysis of the net positive cold chain storage capacity shows that annual volume requirement for all vaccines provided in the national immunization program and including the three new vaccines (in this case Rotavirus, MSD and IPV) at + 5°C is of 68,695 litres, while the currently net storage capacity installed is of 32,808 litres. Therefore, the total amount of vaccines the country needs for 2015 can be shipped in 2.09 times, this is, 2 consignments. Considering that the national vaccine shipment plan contemplates 4 consignments per year in 2015 (17,174 litres per shipment), this leaves a positive balance in storage space at +5oC of 15,634 litres (see table 8 below). It should be noted that in 2015, the Rotavirus, MSD and IPV vaccine quantities have been adjusted to 50% of the expected annual target for penta3 and MCV1, considering that the introduction is planned for July 2015.

The positive balance at +5oC continues in 2016, even though it reduces considerably to 1,178 litres with expected introduction of HPV vaccine into the national immunization program. The big reduction in the CC storage capacity at + 5oC noted from 15,634 in 2015 to 1,178 liters in 2016 is explained by the fact that Rotavirus, MSD and IPV were considered for 100% of the expected target, along expected increase in coverage as well as the expected introduction of the HPV countrywide (noting that HPV demo is taking place in 2014 and 2015). At this stage, as per the analysis presented above, there is no need to increase the storage capacity at + 5oC at the national vaccine store in 2015 with introduction of Rotavirus, MSD and IPV and in 2016 with introduction of HPV.

However, from the following year (2017) it is observed a gap in storage capacity at +5oC ranging from 1,087 liters in 2017 to 4,210 liters in 2019 (see table 8), the last year of current EPI cMYP life span. The country will address this gap by allocating a WICR-60m3 in 2017, as defined in the country’s CCUP in attachment. This will increase the available CC storage at +5oC by 14,815 litres to a total installed capacity of 47,623 litres (32,808 initially existing + 14,814 additionally installed). In this new context, considering the now available 47,623 litres from 2017, the country’s 148,072 litres volume required in 2019 can be shipped in 3.1 consignments (see table 8). Taking into account that the country plan considers 4 shipments per year (37,018 litres per shipment), this leaves a positive storage balance at +5oC of 10,605 litres. Therefore, the WICR-60m3 to be allocated in 2017 at the central vaccine store will be enough to accommodate vaccines to be provided in the national immunization program until the end of the life span of the current EPI cMYP in 2019 and beyond.

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Table 8. Cold chain capacity required and cost at +5oC at central vaccine store

    Formula 2014 2015 2016 2017 2018 2019

A

Annual positive volume requirement, including new vaccine (specify:__________) (litres)

Sum-product of total vaccine doses multiplied by packed volume per dose

38,228 litr

68,695 litr

126,519 litr

135,582 litr

142,122 litr 148,072 litr

BExisting net positive cold chain capacity (litres)

# 32,808 litr 32,808 litr 32,808 litr 32,808 litr 32,808 litr 32,808 litr

C

Estimated minimum number of shipments per year required for the actual cold chain capacity

A/B 1.17 2.09 3.86 4.13 4.33 4.51

DNumber of consignments / shipments per year

Based on national vaccine shipment plan

4 4 4 4 4 4

E Gap in litres ((A/D) - B) - 23,251litr - 15,634 litr - 1,178 litr 1,087 litr 2,723 litr 4,210 litr

F Selected CC Equipment *   WICR-60m3

G Net additional positive capacity installed US $ 14,815 litr

H Estimated additional cost of cold chain US $ $108,125 $108,125

IEstimated additional running cost of cold chain

  $4,923 $4,923 $4,923 $14,769

JEstimated Installation Cost of CC Equipment

US $ 6,173 per unit $0 $0 $0 $6,173 $0 $0 $6,173

TOTAL CC COST $129,067

It is noted here that the scenario presented above for the joint introduction of Rotavirus, MSD and IPV is different from the one presented at the time the country applied for Rotavirus and MSD. The letter was developed considering 2 consignments per year, while the former was developed considering 4 shipments per year. This adjustment allowed the shift of the gap in CC storage at + 5oC from 2015 to 2017, as seen in table 8 above. This alternative scenario has been developed to allow the country to introduce Rotavirus and MSD as previously planned for 2015, adding IPV which is also planned for 2015, while at the same time allowing the country to accommodate the delay in the release of the GAVI-HSS funds for the first year, in which the country planned the construction of the buildings for installing the WICR at regional and provincial levels, as per the CCUP.

The estimated additional cost of the cold chain storage in the central vaccine store for the joint introduction of Rotavirus, MSD and IPV vaccines is of $108,125 in addition to the installation and running costs of $6,173 and $14,769, respectively, totalling $129,067 (see table 8 above). As demonstrated above, despite the introduction be in 2015, this investment in CC is required by 2017, time by which the gap starts.

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It is noted that there is already a guaranteed financing of USD 1.3 million of USAID through UNICEF to finance the CCUP at various levels. In the case of central vaccine store, this funding contemplates 4 WICR-60m3 and 1 WIFR-60m3 to replace the cold and freezer rooms that are old and to increase the current positive and negative storage capacities to accommodate new vaccines and possible campaign needs. The WICR-60m3 to be installed, is part of the said CCUP.

3.3.2 Cold Chain Capacity at Provincial level for Joint Rotavirus, MSD and IPV introduction in 2015

Following the same reasoning as presented above for the central level store, based on the net annual positive storage capacity required for the annual amount of vaccines, including rotavirus, MSD and IPV vaccine to be received by each province, and taking into account 4 annual shipments form central store to provincial stores, it was demonstrated that 7 out of 11 provinces will require additional positive net storage capacity. These provinces are namely Nampula, Zambézia, Niassa, Cabo-Delgado, Manica, Gaza and Maputo Province (the table 9 below illustrates the analysis).

Taking into account the existing capacity in each province, the net positive storage capacity gap by 2019 varies from 937 litres in Niassa to 2,660 litres in Zambézia province. Even though in some instance the gap can be addressed using refrigerators (for example in Niassa, Cabo-Delgado and Gaza provinces with 937, 1,243 and 1,335 litres gap respectively), the country has selected WICR-20m3 (5,128 litres) as a minimum capacity to be installed at provincial level, according to CCUP in attachment. According to the same plan, the provinces of Sofala and Nampula, will function in the future as regional stores for central and northern zone respectively. Therefore, in this analysis it has been selected WICR-40m3 for each of the provinces (see table 9 above), as per the CCUP. It is noted that the storage gap at provincial requiring WICR selected starts in 2016 (see bale 10). Before 2016, the storage gaps varying between 102 litres in Niassa and 1,190 litres in Maputo province will be covered through allocation of VLS 400 refrigerators (table 10).

With the above mentioned, were selected 2 WICR-40m3 (for Nampula and Zambézia provinces) and 5 WICR-20m3, one for each one of the remaining 5 provinces requiring WICR (see tables 9 and 10).

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Table 9. Cold chain capacity at +5oC required at regional / provincial levels Cold chain capacities required at the sub-national/intermediate vaccine storesTable 6.1: Capacity and cost (for positive storage) - Regional & Provincial levels

Intermediate stores 2019

Formula Sofa

la

Nam

pula

Zam

bezi

a

Nia

ssa

Cabo

-D

elga

do

Tete

Man

ica

Inha

mba

ne

Gaz

a

Map

uto

Prov

ince

Map

uto

City

A

Annual positive volume requirement, including new vaccine (specify:__________) (litres)

Sum-product of total vaccine

doses multiplied by

packed volume per dose

11,462 litr 28,017 litr 26,839 litr 9,136 litr 10,676 litr 13,864 litr 12,268 litr 8,900 litr 7,981 litr 9,396 litr 7,028 litr

B Existing net positive cold chain capacity (litres)

# 4,400 litr 5,057 litr 4,050 litr 1,347 litr 1,426 litr 4,400 litr 1,050 litr 4,910 litr 660 litr 300 litr 1,915 litr

C

Estimated minimum number of shipments per year required for the actual cold chain capacity

A/B 2.61 5.54 6.63 6.78 7.49 3.15 11.68 1.81 12.09 31.32 3.67

D Number of consignments / shipments per year

Based on national vaccine

distribution plan

4 4 4 4 4 4 4 4 4 4 4

E Gap in litres ((A/D) - B) 1,534 litr- 1,947 litr 2,660 litr 937 litr 1,243 litr 934 litr- 2,017 litr 2,685 litr- 1,335 litr 2,049 litr 158 litr-

F Selected CC Equipment WICR

0 WICR-40m3 WICR-40m3 WICR-20m3 WICR-20m3 0 WICR-20m3 0 WICR-20m3 WICR-20m3 0

Selected CC Equipment Refrigerator

2 VSL 400 (216 litr)

3 VSL 400 (216 litr)

VSL 400 (216 litr)

VSL 400 (216 litr)

2 VSL 400 (216 litr)

2 VSL 400 (216 litr)

4 VSL 400 (216 litr)

02 VSL 400 (216 litr)

3 VSL 400 (216 litr)

3 VSL 400 (216 litr)

G Net additional positive capacity installed

0 9.524 litr 9.524 litr 5.128 litr 5.128 litr 0 5.128 litr 0 5.128 litr 5.128 litr 0

H Estimated additional cost of cold chain - WICR 1 US $ $0 $61,736 $61,736 $46,389 $46,389 $0 $46,389 $0 $46,389 $46,389 $0 $355,418

Estimated additional cost of cold chain - Refrigerator 1

$2,229 $3,343 $1,114 $1,114 $2,229 $2,229 $4,458 $0 $2,229 $3,343 $3,343 $25,631

I Cost of Vaccine Store Building **

US $ $0 $144,000 $120,000 $120,000 $120,000 $0 $120,000 $0 $120,000 $120,000 $0 $864,000

J Estimated additional running cost of cold chain - WICR 1

$0 $11,709 $11,709 $7,983 $7,983 $0 $7,983 $0 $7,983 $7,983 $0 $63,335

Estimated additional running cost of cold chain - Refrigerator 1

$244 $731 $244 $244 $487 $146 $974 $0 $487 $731 $390 $4,676

Estimated Installation Cost of Refrigerators

US $ 176 per unit $352 $528 $176 $176 $352 $352 $704 $0 $352 $528 $528 $4,048

K Estimated Installation Cost of WICR

US $ 6,173 per unit $0 $6,173 $6,173 $6,173 $6,173 $0 $6,173 $0 $6,173 $6,173 $0 $43,211

1. The time at which all WICRs and Refrigerators will be installed at provincial level a nd the estimate of the running costs are presented in the tables X and Z below.

$1,360,319TOTAL CC COST

$68,011

$381,049

$47,259

Table 10. Cold chain gap analysis at regional / provincial vaccine stores for joint IPV, Rota and MSD introduction

Cold chain gap analysis & additional cost for subnational stores for the next five yearsAdditional cold chain storage capacity refrigeration Number and type of equipments needed for refrigeration

Level Name of store 2014 2015 2016 2017 2018 2019 2014 2015 2016 2017 2018 2019Region Sofala 3,129 litr- 2,128 litr- 239 litr- 37 litr 228 litr 400 litr VSL 400 VSL 400

Region Nampula 1,949 litr- 496 litr 5,114 litr 5,787 litr 6,257 litr 6,675 litr 3 VLS 400 WICR-40m3

Prov ince Zambezia 1,668 litr- 206 litr 3,745 litr 4,261 litr 4,620 litr 4,941 litr VLS 400 WICR-40m3

Prov ince Niassa 536 litr- 102 litr 1,306 litr 1,482 litr 1,605 litr 1,714 litr VLS 400 WICR-20m3

Prov ince Cabo-Delgado 478 litr- 267 litr 1,675 litr 1,880 litr 2,023 litr 2,150 litr 2 VLS 400 WICR-20m3Prov ince Tete 3,170 litr- 2,201 litr- 373 litr- 107 litr- 79 litr 245 litr VSL 400 VSL 400

Prov ince Manica 147 litr- 710 litr 2,327 litr 2,563 litr 2,727 litr 2,874 litr 4 VLS 400 WICR-20m3

Prov ince Inhambane 4,120 litr- 3,498 litr- 2,325 litr- 2,154 litr- 2,035 litr- 1,929 litr- Prov ince Gaza 48 litr 606 litr 1,658 litr 1,811 litr 1,918 litr 2,014 litr VLS 400 2 VLS 400 WICR-20m3

Prov ince Maputo Province 534 litr 1,190 litr 2,428 litr 2,609 litr 2,735 litr 2,848 litr 3 VLS 400 3 VLS 400 WICR-20m3

Prov ince Maputo City 1,291 litr- 800 litr- 126 litr 261 litr 356 litr 439 litr VSL 400 VSL 400 VSL 400

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Table 11. Cold chain additional investment and running costs at regional / provinvial vaccine stores for joint IPV, Rota and MSD introduction

Cold Chain additional investment costs Cold Chain additional annual running costsLevel Name of store 2014 2015 2016 2017 2018 2019 2014 2015 2016 2017 2018 2019Region Sofala $1,114 $1,114 $2,229 $0 $0 $0 $49 $97 $97 $244Region Nampula $3,343 $61,736 $65,079 $0 $146 $3,073 $3,073 $3,073 $3,073 $12,440Prov ince Zambezia $1,114 $61,736 $62,850 $0 $49 $2,976 $2,976 $2,976 $2,976 $11,952Prov ince Niassa $1,114 $46,389 $47,504 $0 $49 $2,045 $2,045 $2,045 $2,045 $8,227Prov ince Cabo-Delgado $2,229 $46,389 $48,618 $0 $97 $2,093 $2,093 $2,093 $2,093 $8,470Prov ince Tete $1,114 $1,114 $2,229 $0 $0 $0 $0 $49 $97 $146Prov ince Manica $4,458 $46,389 $50,847 $0 $195 $2,191 $2,191 $2,191 $2,191 $8,958Prov ince Inhambane $0 $0 $0 $0 $0 $0 $0 $0Prov ince Gaza $1,114 $2,229 $46,389 $48,618 $49 $97 $2,093 $2,093 $2,093 $2,093 $8,470Prov ince Maputo Prov ince $3,343 $3,343 $46,389 $49,733 $146 $146 $2,142 $2,142 $2,142 $2,142 $8,714Prov ince Maputo City $1,114 $1,114 $1,114 $3,343 $0 $0 $49 $97 $97 $146 $390

$4,458 $17,830 $356,533 $2,229 $2,229 $2,229 $381,049 $195 $779 $16,662 $16,759 $16,857 $16,954 $68,011

The CC investment for provincial vaccine stores amounts at $381,049 for positive storage ($355,418 for WICR and $25,631 for refrigerators). Given that none of the provinces has space for installing the WICRs, buildings will have to be considered in each of 2 regions and 5 provinces. According to the CCUP1, each regional vaccine store will occupy 240m2 and will cost approximately $144,000, while each provincial store will occupy 200m2 and will cost approximately $120,000. This brings the total cost of building vaccine stores to $864,000 for the 7 vaccine stores (2 regional stores, Sofala and Nampula, and 5 provincial stores). Transport and installation cost was estimated at $6,173 per unit for WICR and $176 per unit for refrigerators. Under these assumptions, Transport and installation of CC equipment at regional / provincial level will cost $47,259 ($34,211for all 7 WICR units and $4,048 for refrigerators). Finally, the additional running costs amount at $68,011 ($63,335 for WICR and $4,676 for refrigerators). At the end, the total resources requirements for CC equipment, buildings and installation at regional/provincial level amount at $1,360,319 (see table 9 above).

While $381,049 cost of CCE and $47,259 of installation cost will be financed through USAID-UNICEF funds, the country has planned to use HSS grant for which is already approved to finance the construction of the vaccine stores in provinces requiring them for installation of the WICRs. It is noted that this has already been figured in in the HSS first year plan and budget. The $68,011 running costs will be secured by MoH and its local partners in their annual funds allocation to EPI recurrent expenditures.

It is also noted that in the previous application for Rotavirus and MSD (for which the country has already been approved) the gap analysis showed that the WIRC at regional and provincial level were required form 2015. However, this analysis took into account 3 annual shipments from central store to regional and provincial stores. Noting that the implementation of the CCUP concerning regional and provincial level is a little delayed, subject to disbursement of the first year HSS grant to cover the construction of the buildings to install the WICR, the country has decided to build an alternative scenario for the joint introduction of Rotavirus, MSD and IPV vaccines, which considers 4 consignments from central to regional / provincial level. On one

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hand, this scenario shifts the need for installation of the WICRs at regional/provincial levels from 2015 to 2016, and on the other hand allows the country to introduce the Rotavirus, MSD and IPV in 2015, with small gaps in storage capacity in 2015 varying between 102 litres in Niassa and 1,190 litres in Maputo province, which will be covered through allocation of VLS 400 refrigerators, at the same time that allow for more time for the country to prepare for addressing the challenges of the WICRs installation in 2016.

It is worth noting that in the CCUP it is supposed that Sofala and Nampula function as regional vaccine stores for central and northern zones respectively. However, the plans contemplates only the purchase of 3 WICR-40m3 (2 for Sofala and 1 for Nampula) and 8 WICR-20m3 for the remaining 8 provinces, except Maputo city, which will gets its vaccine directly from the national vaccine store.

3.3.3 Cold Chain Capacity at District level for Joint Rotavirus, MSD and IPV introduction in 2015

The cold chain gap analysis at district level shows that a total of 117 district vaccine stores out of the 148 will require additional cold chain storage capacity at + 5oC for accommodating the vaccines already existing in the program, including and rotavirus, MSD and IPV vaccines to be introduced in 2015. The additional CC investment required in the 117 districts with storage gap amounts at $129,081, to which should be added the transport and installation cost ($20,592) and the running costs (36,038) for the 5 years span of the current cMYP, totalling $185,648 (see table 12 below).

Table 12: CC investment at district level for the joint introduction of IPV, Rota and MSD and in 2015

ModelTotal

Quantity

Cost / Unit

Transp. & Installatio

n Cost/Unit

Running Cost /

Per unit

Total Investment Cost

Total Transp. & Installation Cost

Annual Running Cost

Total Running Cost for 5 Years

Grand Total

VSL 400 87 $1,11

4 $176 $49 $96,918 $15,312 $4,238 $21,188 $133,418MK304 30 $1,07

0 $176 $99 $32,100 $5,280 $2,970 $14,850 $52,230

Total $129,018 $20,592 $36,038 $185,64

8

The identified gap will be addressed through allocating 87 VSL 400 and 30 MK304 refrigerators to the districts with identified storage shortage (for details see annex Z – CC gap analysis for district level). The refrigerators are already at country level and have been acquired in the context of the CCUP, using USAID grant channelled through UNICEF. It is noted that under the CCUP, the country has already ordered a total of 640 refrigerators to replace old and depleted refrigerators and expand the CC capacity at district and health facility level. The transport, installation and running costs of the refrigerators to be allocated for new vaccines as presented in the table 12 above will be covered by country internal resources, and have already been included and secured in the next year (2015) annual budget. The running costs will continue to be secured for the duration of current EPI cMYP (2015-2019).

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3.3.4 Cold Chain Capacity at Health Facility level for Joint Rotavirus, MSD and IPV introduction in 2015

The CC gap analysis at health facility level shows that a total of 67 health facilities will require additional CC storage capacity at + 5oC. As explained above, the country has procured 640 refrigerators, under the CCUP. Therefore, the gap will securely be addressed through the allocation of part of these units.

Table 13: Additional CC investment at Health Facility level for the joint introduction of IPV, rotavirus, MSD and in 2015

Model

Total Quantity

Cost / Unit

Transp. & Installation Cost/Unit

Running Cost / Per unit

Total Investment Cost

Total Transp. & Installation Cost

Annual Running Cost

Total Running Cost for 5 Years

Grand Total

MK 144 67 $782.

60 $176 $137 $52,434 $11,792 $9,179 $45,895 $110,121

At this stage, it can be concluded that the CC gap analysis at all levels of the health system indicates that a total of $ 1,785,155 will be required to address the CC gap in order to meet the needs for the already existing and the introduction of rotavirus, MSD and IPV vaccines by 2015 through 2019. From this amount, 48% (864,000) are for construction of buildings for installing the WICR at regional and provincial levels.

The selection of the CC equipment was in line with the country CCUP recently developed. As already stated above, the Government has used use different funding mechanisms, including HSS and internal donor support, to provide funds for purchasing these WICR and refrigerators, as stated in the financing sheet of the cMYP costing tool. For instance, $1.3 million of the required amount has already been secured through USAID-UNICEF fund in response to the CCUP, and has been used to procure 14 WICR for Central and provincial vaccine stores, and 640 refrigerators and 7 freezers. Installation and running costs have been already secured through local partners, has part of the USAID/UNICEF funds have been allocated for this purpose.

The remaining funds have a potential of being mobilized. For instance, the country has included the construction of buildings for installation of the WICR at regional and provincial levels in the first year GAVI-HSS plan and budget grant, expected to be disbursed yet during the ongoing year. Given the delay in the disbursement of the HSS grant, the country is considering using one of the three vaccine introduction grant (Rotavirus – $885,000, MSD – $885,000 and IPV $824,500) to cover these costs.

The running costs will continue to be secured by MoH and its local partners in their annual funding allocation to EPI recurrent expenditures for the duration of current EPI cMYP (2015-2019).

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3.4 Waste management and injection safety

Mozambique is using WHO pre-qualified auto-disable (AD) syringes for all injectable vaccines, both for new vaccines procured through UNICEF and for self-procured traditional vaccines.

The country instituted a Regulation for the Management of Bio-Medical Wastage in 2003. This regulation is operationalized through the Provincial Injection Safety Committees, which exist in every Province. The Committees assign responsible staff for bio-medical wastage (BMW) management in all District and Health Facilities. The Committees are responsible for the following activities:

Budgeting for fuel for incineration/burning of BMW Planning for a means of secure transportation of the BMW from the immunization sites Set the routes for BMW collection in accordance to fixed immunization sites Identification of temporary storage sites for the safety boxes Identification of incineration sites or sites for digging a hole for burn and bury. In the

capital cities, the BMW is incinerated at the Central or Provincial Hospitals or other Health Units with incineration facilities. In rural areas, the BMW will be disposed and burnt and buried the pre-selected sites.

Waste management regulations and procedures are expected to remain the same for the introduction of IPV. In the coming years the country has planned for improvements in waste management facilities at District level by the construction of incinerators in all/selected district hospitals, through the GAVI HSS funding mechanism.

Waste management and injection safety is being monitored regularly to identify needs for improvements. In 2004 and 2006, the injection safety assessment and the EPI Review indicated overstock of AD syringes and safety boxes, overflowing pierced and opened safety boxes, gaps in the knowledge of health workers about the national waste management policy, and inappropriate waste management practices including burning and burying as methods of waste disposal often in close proximity to the community. Both studies found a 100% use of AD syringes and safety boxes in all immunization sessions, both static and mobile.

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3.5 Health worker training and supervision

Health worker training needs were identified through the routine National Health Information System (NHIS), supportive supervision visits and program assessments (including the EPI Review in 2006), the EVMA in 2012 and the post-introduction evaluations (PIE) for Pentavalent in 2012 and PCV-10 in 2013, respectively.

Measures to identify and address capacity building needs are in place and include routine supportive supervision, EPI logistic in (CC and vaccine management training, including the use of stock management tool (SMT) at national and provincial level, and DVDMT tool at district level). Data Quality Surveys (DQS) are being implemented by provinces to assess districts and used to inform the training of health workers for data quality improvement. EPI logisticians at national level, EPI managers and logisticians at provincial level and district EPI managers in 80/148 districts have been so far refreshed on EPI logistics between 2013 and May 2014. The next refreshment training will be conducted in the fourth quarter of 2014.

New vaccine introduction provides an opportunity to address known training needs. Packages of training modules for IPV introduction are being adapted from WHO Headquarters materials and Regional guidelines. These include refreshment trainings on vaccination schedule, vaccine management, and interpersonal communication, among other sessions, designed to ensure that IPV introduction is harmonized with other recent vaccine introductions. Training tools will include (but not be limited to) presentations, vaccination eligibility flow-charts, training videos, registers and vaccination cards. Health workers will also be trained on AEFI, to include risk communication.

For IPV specifically, WHO Headquarters has developed generic training materials for health care workers at different levels. The Ministry of Health in Mozambique will revise the guidelines, adapt them to the local context, translate them and include them in the training package for IPV introduction.

Cascade training of trainers will be used to build capacity among health workers for IPV introduction. As per the recent PIE, this training strategy has been effective in building the capacity of vaccinators. There have been challenges in ensuring that the right people at the most peripheral level receive timely training. Pre-registering of eligible health workers, timely delivery of training and monitoring of training will be conducted to ensure that all eligible vaccinators benefit.

Supportive supervision will be conducted before, during and after vaccine introduction in order to identify and address capacity gaps and other vaccine introduction challenges. Appropriate supervisory checklists for different several levels (National/province and district) will be developed to support supervisors in their supervisory visits. Further, financial resources within the vaccine introduction grant will be planned and made available to provinces and districts for implementing supportive supervision.

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3.6 Risks and challenges

Although the target group for IPV is similar to other vaccines in the vaccination schedule, instruction for health workers regarding eligibility criteria for receiving IPV may be challenging. An eligibility flowchart will be developed to aid health workers to apply the correct vaccination schedule to each eligible child, as per their vaccination status. Continuous supervision will be organised and strengthened to support health care workers on site.

Communicating to parents about eligibility proved to be a challenge during the introduction of PCV. This difficulty is expected to be even greater for a dual vaccine introduction (IPV and rotavirus). Furthermore, MSD will be introduced only three months later, in order to mitigate the challenging risk linked to eligibility of children less than 1 year versus 18 months. A comprehensive communication and social mobilisation strategy will be developed drawing on lessons learned from other countries with dual vaccine introduction experience. Targeted and tailored communication messages will be developed, pre-tested and piloted before being broadcasted.

The risk of freezing vaccine and using vaccine in subsequent vaccination session or beyond 6 hours after the vial is open should not be overlooked. This will be mitigated through specific emphasis during training regarding IPV storage temperature and its open vial policy (since the preservative, 2 phenoxy-ethanol, in stand-alone IPV is not WHO pre-qualified, the vaccine should be discarded after maximum six hours after opening). Additionally, stickers will be affixed in all refrigerators containing IPV, and hand-outs and pocket guides will be provided to health workers for easy reference.

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4. Situational analysis of the immunisation programme

4.1 General context of the country

4.1.1 Country profile

The population of Mozambique was estimated to be 24.4 million inhabitants in 2013 with a natural population growth of 2.14%i and a population density of 25.6 inhabitants per square km. It is a young population; 45% of habitants are under 15 years. The average life expectancy at birth is 41.8 years. The illiteracy rate is 60%, females representing the highest rate with (71.3%). The population density, as well as the main indicators of the health status of population vary significantly between the Provinces. According to DHS 2011, the infant mortality rate is 64/1000.

Mozambique is divided into 11 provinces, which are divided into 148 sanitary districts with a total of 1392 health unitsii providing three levels of care. Maputo City has provincial status and is the country’s economic and political capital. Of the 11 Provinces, the most populous are Zambézia and Nampula, which have approximately 20% of the Mozambican population each.

In 2012, Mozambique recorded a GDP growth of 7.4%. However, the same year Mozambique ranked 185 out of 187 in the Human Development Index report iii, classifying it as one of the world’s poorest countries.

Health sector allocations in 2012-2013 were 7% of the national budget of the Government of Mozambique. In 2013, Mozambique finalised the new Health Sector Strategic Plan for 2014-2019, a policy document covering and prioritising all areas of the health sector. However, there is an annual funding gap of approximately USD 200 million to implement the new PESS. The updated cMYP has been aligned with the PESS.

4.1.2 The EPI Program in Mozambique

Mozambique Expanded Program on Immunization was launched in 1979 under the Primary Health Care Program, with the main objective of reducing mortality and morbidity from diseases that can be prevented by vaccination. Over the years, immunization program has benefited from government and political commitment at all levels.

Within the Ministry of Health, EPI is a unit in the Department of Health Promotion within the National Directorate for Health Promotion and Disease Control. The central level sets policies, standards and priorities, builds capacity, coordinates activities with partners, mobilises resources, and procures vaccines and injection safety materials in coordination with the Centre for Pharmaceuticals and Medical Supplies (CMAM). It also monitors and provides technical support to all provinces. In turn, the provinces are responsible for capacity building, monitoring, supervision and technical support to the districts. The districts and their health facilities are responsible for planning, management and delivery of EPI services. At the district level, immunization is part of primary health care and is integrated into the child survival activities.

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Various communities are involved in mobilizing community members bringing their children for immunization.

The program focuses on children under one year of age and pregnant women. Other groups such as under 5, under 15 and women of child bearing age are also targeted, within the framework of the accelerated disease control or elimination and eradication, to achieve the global targets of polio eradication, elimination of maternal and neonatal tetanus, and accelerated measles control. The targeted population for routine immunization and SIA’s and their respective percentage estimated using the 2007 census assuming a growth rate of 2.14% is as per Table 14.

Table 14: Estimated target population for EPI 2015-2019

2015 2016 2017 2018 2019

Population25,727,911

26,423,623

27,128,530

27,843,933

28,571,310

New-borns (Births)

1,106,271

1,136,187

1,166,497

1,197,258

1,228,535

Surviving Infants

1,035,470

1,063,471

1,091,841

1,120,634

1,149,908

6-59 months4,219,377

4,333,474

4,449,079

4,566,405

4,685,695

< 5 years4,399,473

4,518,440

4,638,979

4,761,313

4,885,694

Pregnant Women

1,286,396

1,321,182

1,356,427

1,392,197

1,428,566

Child Bearing Age Women

6,406,250

6,579,482

6,755,004

6,933,139

7,114,256

*Women of Child Bearing Age include pregnant women. If the latter is not taken into account, then the percentage of WCBA will be 19.9

In 2012, immunization services were offered in approximately 1190 health centres, which represented 92% of health unities in the existing health network with fixed vaccination sites. However, less than 50% of the country population is served by the existing health network. In order to reach the unreached, the country introduced new outreach strategies, namely monthly health days in 2000 and most recently, the Reach Every District (RED) strategy. However, its implementation countrywide has been challenging due to limitation in funds availability. Additionally, the country started in 2008 the implementation of the National Mother and Child Health Week, taking place twice a year countrywide that offers integrated mother and child health services in addition to immunization.

The antigens offered in the immunization program include TT for pregnant women, and eventually women of child bearing age (WCBA), and BCG, OPV, Measles, pentavalent (DPT-HepB-Hib) and PCV for less than one year of age. The Hepatitis B component was introduced in 2001, the Hib component in 2009 and PCV vaccine in 2013, all under GAVI support. The country plans to introduce Rotavirus and IPV in July 2015 and Measles Second Dose (MSD) in October 2015. Since May 2014, the country has been piloting HPV demo project in three districts in order to learn lessons in preparation for the national scale up starting in 2016. The demonstration project is financed by both GAVI and the Government of Mozambique. Lastly, there plans to introduce measles/rubella (MR) vaccine countrywide also in 2016.

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4.2 Geographical, economic, policy, cultural, gender and social barriers to immunization

4.2.1 Routine Immunization Coverage

According to data from the Health Information System (DIS), vaccination coverage for different antigens provided in the NIP increased from 50% in some instances reaching 100% or more between 1981 and 2013 as shown in the graphic below (figure 2). This apparent high coverage has been justified in several ways: the population base used to calculate the target groups is smaller than the real, or there is an over-reporting of cases (the same child may be counted twice (Outreach and regular HF data.), or children are vaccinated outside the target group.

Figure 2: National coverage of BCG, DPT/HepB3, Polio 3, measles and PCV from 1981-2013

Source: National EPI database (1981-2005) and JRF (2006-2013)

Meanwhile, data from DHS 2003 and DHS 2011, showed that immunization coverage was 87.4% and 89.6% for BCG, 71.6% and 74.6% for DPT3, 69.6% and 74.3% for POLIO3, 76.7% and 81.5% for Measles, and 63% and 64% for fully immunized, respectively. Further, DHS 2011 found that 4.8% had received no vaccinations at all (2.4% in urban vs. 5.6% in rural areas). The overall dropout rate between BCG and DPT3 in 2011 was of 16.4%.

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Table 15: EPI Coverage through Surveys, DHS 2003, MICS 2008 and DHS 2011 by Province

Province BCG DPT3 OPV3 Measles Fully Im BCG DPT3 OPV3 Measles Fully Im BCG DPT3 OPV3 MeaslesFully ImNiassa 81.4 54.6 52.2 51.9 46.6 91.3 74.9 75.4 74.9 56.2 92.6 82.6 83.3 87.7 76.9 Cabo-Delgado 85.3 68.9 66.4 80.2 57.9 93.2 88.2 86.9 83.8 70.5 95.1 68.1 76.3 80.6 58.8 Nampula 83.5 61.8 62.4 69.1 53.9 82.2 63.5 63.0 67.1 51.0 88.4 75.1 69.2 83.4 66.3 Zambezia 71.9 53.0 50.0 63.3 44.7 75.1 61.7 60.2 61.7 46.8 84.0 60.3 56.8 71.5 47.3 Tete 88.3 63.6 59.9 72.0 55.0 83.0 55.5 54.0 60.0 34.2 88.7 79.9 72.0 75.8 58.0 Manica 93.1 73.6 68.5 81.5 61.6 87.0 75.4 72.8 69.2 58.3 97.0 76.6 77.2 80.3 64.6 Sofala 86.2 77.1 73.8 74.7 63.9 93.7 81.2 81.3 82.9 72.4 95.3 85.3 85.1 87.4 78.4 Inhambane 99.1 93.6 93.3 92.2 90.6 98.3 90.5 91.3 86.9 79.8 96.2 81.8 76.6 86.4 64.7 Gaza 97.1 90.4 88.0 91.7 82.3 97.3 89.4 89.9 83.4 73.9 92.7 89.0 85.9 85.6 76.3 Maputo Provincia 100.0 98.0 97.0 95.2 92.5 90.1 87.4 87.2 87.4 81.9 99.4 96.7 90.9 98.1 87.9 Maputo Cidade 99.7 97.0 94.2 96.9 91.3 97.7 89.5 86.2 93.0 81.8 96.4 90.1 80.7 95.4 76.7 National 87.4 76.1 69.6 76.7 63.3 87.5 74.1 73.3 74.1 60.1 91.1 76.2 73.2 81.5 64.1

DHS 2003 MICS 2008 DHS 2011

Mozambique does not disaggregate vaccination data into sexes, however, differences in coverage between boy and girls are not remarkable (DPT3 coverage of 74.4 for males and 73.8 for females in DHS 2003 and DPT3 coverage of 76.2 and 76.1 respectively in DHS 2011).

Equitable access to vaccination in Mozambique seems to be linked to distance to health facilities, and level of education of mothers. A low population density of 25.8 persons per square kilometre at national level means long distances to health facilities for many people in rural area, where an estimated 70% of the Mozambican population live. The Demographic Health Survey from 2011 shows that there are differences with regards to place of residence and degree of literacy. For example, children living in rural areas have 72.3% DPT3 coverage as compared to their mates in urban areas, where the coverage is 86.3%. Southern provinces (Maputo City, Maputo Province, Gaza and Inhambane) and Sofala in central zone have consistently had coverage above 80% for all antigens. On the other hand, Nampula, Zambézia, Tete and Manica are the worst performing provinces, with coverage level consistently below 80% for all antigens and also below the national average (table 15).

Moreover, DPT3 among children for mothers with secondary level education was 85.6%, with primary level education was 76.9%, and with no education was 71.5%. This may account for some of the gaps in the current EPI communication strategy targeting people with low education level or no school education at all. The outreach services to reach these populations also need to be strengthened, and strengthening equal access to vaccination is a key component of the IPV vaccination plan. This is particularly reflected in the advocacy, communication and social mobilization plan in section 6 of this proposal.

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4.2.2 Polio Eradication Activities

4.2.2.1 Routine OPV

Similarly to all other antigens provided in the NIP, routine OPV coverage has witnessed a steady increase from the early 1990s, from 50% to above 90% in 2013. However, although administrative reports of immunization coverage tend to be rather high (93.8% and 92% OPV3 coverage national level, with only 6% (9/148) and 20% (14/148) districts with OPV3 below 80% in 2012 and 2013, respectively), there are concerns about the reporting system and fluctuations in reported results, reflecting poor program data management. Therefore, different surveys conducted by accredited independent institutions such as the National Institute of Statistic have been used to assess program performance more realistically. Indeed, these surveys have consistently found low OPV3 coverage (bellow 80%) at national level, with northern and central provinces presenting the worst performance level, below the national average, while the southern provinces are the best performing, that is, above the national average (figure Z and table X above).

For instance, the last two surveys conducted in 2008 and 2011, the MICS 2008 and DHS 2011 found same level national OPV3 coverage (73.3% and 73.2%, respectively), indicating no progress in coverage level. Southern provinces (Maputo City, Maputo Province, Gaza and Inhambane) and the central province of Sofala have consistently had coverage above 80%. Six out of 11 provinces were below 80% in DHS 2011. Meanwhile, Nampula, Zambézia, Tete and Manica were consistently below 80% in both surveys (MICS 2008 and DHS 2011). Nampula and Zambézia have together 40% of total country’s population (20% each), while Tete and Manica have 9% and 7% respectively. Altogether, theses 4 provinces bear 56% of country’s population, representing a huge potential for occurrence of polio outbreaks, be it imported or circulating vaccine derived poliovirus (cVDPVs). In fact, in 2011 there were detected 2 cases of circulating vaccine derived poliovirus in 2 districts (Milange and Mopeia) of Zambézia province.

4.2.2.2 NIDs and sub-NIDS

Mozambique conducted its last national immunization days (NIDs) in 2005, in the context of the Polio Eradication Initiative (PEI), having achieved 97% administrative coverage and 95% through surveys. In 2011, two rounds of sub-NIDs were conducted in response to cVDPVs reported in Milange and Mopeia districts, in Zambézia province. Vaccination campaign was conducted the affected districts and additional 13 surrounding districts. While administrative coverage was between 90% and above (and sometimes above 100%) in all districts, post-SIA survey found a coverage of 60% in the 1st round and 83% in the 2nd round.

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4.2.2.3 AFP/Polio Surveillance

Since the commencement of polio eradication initiative in Mozambique in 1996 and with the take-off of AFP surveillance in 1997 supported by the WHO-accredited inter-country polio lab in South Africa, the country has made steady progress in terms of core performance indicators. AFP surveillance performance indicators reached certification standard (non-polio AFP rate of 1.0/100,000 children less than 15 years and 80% stool adequacy rate) in 2003 and have since been maintained at that level. Since the country started lab confirmation of polio cases over 14 years ago, no indigenous or imported wild poliovirus has been reported. However, 2 cases of circulating vaccine derived poliovirus (cVDPVs) were detected in 2011, in 2 districts of Zambézia province.

After WHO Regional Office for Africa (AFRO) recommendation in June 2005 that countries in the region should attain a minimum operational non-polio AFP rate of 2.0/100,000 in children less than 15 years, as against the previous certification rate of 1.0/100,000, Mozambique only managed to attain this new rate in 2009. AFP stool adequacy rates have been at the minimum 80% or above since 2004 except in 2008 when it fell below this minimum. However, progress made at the national level for AFP surveillance masks sub-optimal performance at the sub-national level. For instance, in the last three years, while the NPAFP rate has been situated around 3.0/100,000 children < 15 years, and stool adequacy around 87%, at sub-national level Maputo province has been the most problematic in terms of low AFP performance (NPAFP rate of 1.5 and 1.7 in 2011 and 2013, respectively). Meanwhile, stool adequacy was below 80% in at least one of these years in 5 out of 11 provinces, namely Maputo province, Gaza, Inhambane, Cabo-Delgado and Sofala. This is concerning noting that WHO recommends that for certification, countries should achieve and maintain AFP/Polio standard performance indicators at national and sub-national levels for at least three consecutive years.

It is equally of concern that the country has high number of AFP cases not classified with > 90 days after onset. This is consistent with the findings of the last surveillance review in 2010, and reflects the inability of the NPEC to conduct regular meetings to classify AFP cases due constant absence of members.

The challenges in the surveillance system are primarily related to poor understanding among health workers about the importance of surveillance and their roles in monitoring health service delivery. Other constraints are weak community based surveillance system, poor data management (timeliness, completeness, missing data and lack of regular data analysis and utilization) and absence of minimal focused technical supervision at all levels.

In order to address the constraints and the gaps in the surveillance system, the operational plan to improve surveillance of vaccine-preventable diseases integrated in the current cMYP considers the recommendations made during the different EPI and surveillance reviews and related missions in 2010, 2011 and 2012. Most of the recommendations are yet to be addressed because of financial constraints. The dual introduction and the additional funding from the VIG creates an opportunity for Mozambique to tackle these constrains and improve surveillance with special emphasis on capacity building of health personnel.

Table 16: AFP surveillance for 2011, 2012, and 2013

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2011Analysis based on data received by: 06-Jan

Population Under 15

Cases in Database No. AFP

cases

Annualised Non-polio AFP rate*

Inadequate stools

No Lab Results

>30d after onset

(n) % Confirmed VDPV Compatible Discarded Unclassified Denotified >90 daysCabo Delgado 793887 23 23 2.9 22 96% 0 0 0 20 3 0 3 1 1Maputo City 530152 12 12 2.3 11 92% 0 0 0 8 4 0 4 1 5Gaza 592078 25 25 4.2 19 76% 0 0 0 16 9 0 9 6 4Inhambane 631010 29 29 4.6 21 72% 0 0 0 18 11 0 11 8 9Manica 752417 18 18 2.4 15 83% 0 0 0 13 5 0 5 3 2Maputo Province 650081 11 11 1.5 10 91% 0 0 1 8 2 0 2 1 2Nampula 2038411 42 42 2.1 39 93% 0 0 0 29 13 0 13 3 12Niassa 636821 39 39 6.1 32 82% 0 0 0 32 7 0 7 7 5Sofala 835925 40 39 4.5 32 82% 0 0 1 28 10 1 10 7 3Tete 961965 25 25 2.6 24 96% 0 0 0 18 7 0 7 1 7Zambezia 1947223 53 51 2.6 49 96% 0 2 1 39 9 2 8 2 7Mozambique 10369971 317 314 3.0 274 87% 0 2 3 229 80 3 79 40 57* Indicate global certif ication criteria* Non-polio AFP rate is per 100 000 children 0-14 years

AFP cases with 2 stools within 14 days of onset*

CLASSIFICATION STATUS

2012Analysis based on data received by: 04-Jan

Population Under 15

Cases in Database No. AFP

cases

Annualised Non-polio AFP rate*

Inadequate stools

No Lab Results

>30d after onset

(n) % Confirmed VDPV Compatible Discarded Unclassified Denotified >90 daysCabo Delgado 808800.8 34 34 3.3 25 74% 0 0 8 23 3 0 1 9 4Maputo City 537354.5 12 12 2.3 12 100% 0 0 0 11 1 0 0 0 1Gaza 604842.8 24 24 3.9 21 87% 0 0 1 23 0 0 0 3 1Inhambane 642007.8 23 23 3.7 17 74% 0 0 0 18 5 0 4 6 5Manica 780908 19 19 2.5 19 100% 0 0 0 19 0 0 0 0 0Maputo Province 677898.9 23 23 3.2 18 78% 0 0 2 20 1 0 0 5 2Nampula 2091528 46 45 2.2 44 98% 0 0 0 43 2 1 2 1 3Niassa 662574.2 42 42 6.2 36 86% 0 0 2 38 2 0 1 6 3Sofala 856677.6 44 44 5.0 35 80% 0 0 2 37 5 0 3 9 7Tete 1002837 25 25 2.2 23 92% 0 0 3 20 2 0 1 2 4Zambezia 1999892 51 51 2.6 48 94% 0 0 0 47 4 0 1 3 5Mozambique 10665322 343 342 3.1 298 87% 0 0 18 299 25 1 13 44 35* Indicate global certif ication criteria* Non-polio AFP rate is per 100 000 children 0-14 years

AFP cases with 2 stools within 14 days of onset*

CLASSIFICATION STATUS

2013Analysis based on data received by: 31-Dec

Population Under 15

Cases in Database No. AFP

cases

Annualised Non-polio AFP rate*

Inadequate stools

No Lab Results

>30d after onset

(n) % Confirmed VDPV Compatible Discarded Unclassified Denotified >90 daysCabo Delgado 823555.8 24 24 3.0 20 83% 0 0 0 21 3 0 3 4 0Maputo City 544496.8 11 11 2.1 11 100% 0 0 0 10 1 0 1 0 1Gaza 615532.1 18 18 3.0 15 83% 0 0 0 14 4 0 4 3 1Inhambane 652986.5 16 16 2.5 11 69% 0 0 0 13 3 0 3 5 0Manica 810111.2 21 21 2.6 19 90% 0 0 0 20 1 0 1 2 1Maputo Province 706992.8 12 12 1.7 11 92% 0 0 0 12 0 0 0 1 0Nampula 2145349 53 53 2.5 49 92% 0 0 0 52 1 0 1 4 1Niassa 689381.1 36 34 5.0 31 91% 0 0 0 30 4 2 4 3 4Sofala 877955 49 49 5.7 34 69% 0 0 0 40 9 0 9 15 1Tete 1045032 33 33 3.2 32 97% 0 0 0 33 0 0 0 1 0Zambezia 2053358 62 62 3.1 59 95% 0 0 0 58 4 0 4 3 2Mozambique 10964750 335 333 3.1 292 88% 0 0 0 303 30 2 30 41 11* Indicate global certif ication criteria* Non-polio AFP rate is per 100 000 children 0-14 years

AFP cases with 2 stools within 14 days of onset*

CLASSIFICATION STATUS

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The importance of a solid surveillance system will be addressed through training of surveillance focal persons and health personnel on disease surveillance, which will include case definition and proper case based investigation procedures, reporting, data management, feedback, as well as epidemic preparedness and response. In addition, there will be sensitization of clinicians in the hospitals on disease surveillance with emphasis on case detection and reporting of priority and epidemic prone diseases. This will require strong coordination as well as technical and logistics support to ensure adequate training and supervision of surveillance officers in order to improve the case detection rate and the quality of the stool specimens collected, particularly in weak performing districts.

Furthermore, a plan of action regarding disease prevention and control will be developed and clear surveillance activities will be outlined for disease undergoing eradication, elimination and control, with particular emphasis on AFP and Measles surveillance, and building on the recommendations of the comprehensive surveillance system reviews above referred. Provinces and districts will be closely monitored for implementation of core surveillance activities such as active surveillance, supportive supervision, monitoring, provision of feedback, and action using surveillance data including outbreak investigation and response. This will be done through either monthly or quarterly reports shared at the provincial and national level (as appropriate), and also through the implementation of clear plans of supervision with use of standard checklists and action points.

In order to support the improvement of the national surveillance system, the country has been strengthened through technical and logistical support provided by WHO in addition to a STOP team member who was regularly present in the field between 2012 and 2013.

Finally, risk assessments, which are conducted on quarterly basis, will be used to help identify provinces and districts with significant surveillance gaps for prioritization regarding what concerns strengthening of surveillance in the coming years.

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4.3 Findings from recent programme reviews

1. Effective Vaccine Management Assessment and PIE

EVMA in 2009 and 2012 found that the EPI faces logistic and supply chain management challenges, such as weak forecasting and quantification skills to prevent wastefulness, over-stocking and/or stock outs; limited skills in logistic and supply information system management. For instances, according to the findings of the last effective vaccine management assessment conducted in May 2012, there is vaccine stock out at service delivery level, mainly due to poor vaccine management at provincial and district levels. In the same assessment, the stock management systems and procedures scored 65% for provincial level vaccine store (PVS), 51% for district level vaccine store (DVS) and 38% for health facility level. Vaccine stock outs and / or over-stocks was observed in almost all provincial and district vaccine stores (PVS & DVS) and in 12 of 17 (71%) of health facilities evaluated. At district and health facility, the vaccine management practices need to be improved in terms of temperature recording, calculation of vaccine wastage rate and adequacy of stock records.

Table 17: Effective vaccine management assessment results, May 2012

Mean (%)Item

no.

EVM code

Criteria Central level

Provincial

levelDistrict

levelHealth facility level

1 E1 Vaccine arrival 71  N/A N/A  N/A 2 E2 Temperature 39 62 69 523 E3 Storage Capacity 78 52 49 754 E4 Building, equipment &

transport 84 72 59 715 E5 Maintenance 62 62 48 486 E6 Stock management 59 65 51 387 E7 Distribution 76 41 43 608 E8 Vaccine management 38 46 61 719 E9 MIS, supportive functions 53 62 56 N/A 

Moreover, lack of key logistic amenities like vehicles for distribution and supplies and radio communication equipment for coordination of essential commodity distribution also impair efficient service delivery at all levels. For instance, the low carrying capacity of vaccine from the central to the provincial level, especially to the Central and Northern provinces, where vaccines are transported by airplane (limited cargo space for vaccines in airplanes) is one the constraints affecting vaccine delivery. Distribution of vaccines and other essential MCH supplies from provincial to district levels is also

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highly affected by lack of transport at these levels. As of 2012, only 27% (3/11) of provinces had a reliable transport system for distribution of vaccine and other essential MCH supplies to districts, benefiting 38% of districts countrywide (55 districts in those provinces out of 148 countrywide).

Furthermore, there is also limited computerization of LSCM information system that impairs establishment of reliable LSCM information system and efficient LSCM. Only 22/148 (15%) of districts have computers accessible to EPI and other MCH programs at district level.

In addition, an assessment of the capacity of the cold chain throughout the country indicates insufficient storage capacity at the central level and in 8 of 11 provinces, and in 67 of 148 districts to accommodate the new vaccine (HPV) to be introduced in 2016 (EPI cMYP 2015-2019).

Lastly, to date, there is no cold chain technician at the district level in Mozambique, despite this being indispensably necessary personnel to handle unforeseen problems in the cold chain in the district vaccine stores and health facilities. The whole country depends on the 11 cold chain technicians assigned to provincial vaccine stores (EVAM, May 2012).

Some initiatives are already in place to address some of the barriers identified above. For instance, with support of WHO and UNICEF, MOH has been implementing the recommendations of the various assessments conducted in EPI (EVMA in 2009 and 2012, CC evaluation in 2013 and PIE in 2012 and 2013). Thus, Logistic constraints related to vaccine management are being tackled through the implementation of the vaccine stock management tools (SMT) at national and provincial levels. There has also been training of all national and provincial level EPI managers and logisticians on the use of the district vaccine and data management tool DVDMT. However, few training opportunities targeted district EPI managers (26 out of 148) due to lack of funds, while no follow up visits were conducted to help these districts incorporate DVDMT into their routine practice. WHO guidelines on vaccine management and CC management were adapted and made available to EPI vaccine deposits at all levels. Vaccine temperature monitoring devices, fridge tags were also purchased and distributed.

In addition a long term cold chain update plan (CCUP) was developed in 2013, which include a depleted cold chain rehabilitation plan, maintenance plan and the plan to expand the cold chain over the years to meet the requirement of the existing and new vaccines to be introduced in the coming years. As already explained above, this plan is under implementation through funds made available by USAID through UNICEF, and part of the HSS funds, for which the country has been approved, have been allocated to cover the funding gap in the mentioned plan.

HSS funds have also been allocated to cover training of EPI staff on vaccine and CC management at district and health facility levels (including the training of CC assistants to handle unforeseen problems in the cold chain vaccine stores and health facilities), and to provide resources for national, provincial and district levels to conduct supportive supervisory visits to lower levels.

2. Data Quality Assessment

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Several studies conducted to assess the quality of data produced by the program, such as the DQA (Data Quality Audit) conducted in 2002, DQS assessment conducted by provinces in several districts between 2010 and 2012, found poor data quality management linked to reliability of data produced, the lack of regular analysis and use of data, issues of data accuracy, completeness, timeliness and consistency between different levels, poor filling out of the vaccination registry book and record keeping, uncertain denominator at the health facility level, amongst others. The verification factor in most of these assessments was situated below the recommended minimum score of 80%. Moreover, there are concerns about large fluctuations in reported coverage from year to another at district level, reflecting low data reliability and poor data management (EPI cMYP 212-2016).

To address poor data management, the MOH with technical and financial support of its EPI partners, mainly WHO, UNICEF and FDC, started the implementation of the recommendations contained in the Data Quality Assessment (DQA). These activities included revision of EPI data collection tools, to capture all relevant immunization information at the service delivery point (health facility and outreach) with regards to children fully immunized by gender, and a separation of doses of vaccine administered by strategy (fixed or mobile); the tally sheets were put together to form a book, one for fixed vaccination post and the other for outreach; the summary sheets were also put in the format of a book, in duplicate, so that the original sheet is sent to district level and the duplicate remains at the health facility book. The same at district and provincial levels; all these measures were to address the issue of losing data and provide better record keeping, for future data verification.

Other measures put in place were the introduction of the EPI vaccination recording books, for defaulter tracing purposes and to help to check if children older than 1 year of age are being included in the numerator; attribution of a unique ID code to each child attending immunization services. This code was also recorded in the child’s health card. This way, it might be easy to identify if the child being immunized belongs or not to a given health catchment area and weather to include or not this child in the numerator, or send the data recorded to the appropriate health catchment area where the child belongs for them to include it in their numerator (note that the child is vaccinated wherever he/she presents for vaccination. It is juts the record that is sent to the appropriate health catchment). These measures will help to minimize the inclusion of out of target group or out of health catchment area children in the numerator, which gives a sensation of good coverage, masking high numbers of un-immunized or under-immunized children.

In addition, training of health staff on the use of data for local decision taking, as contained in the monitoring and evaluation component of the RED strategy, as well as regular feedback to lower levels are also part of the activities under implementation. Further, some training on the use of data quality self-assessment tool (DQS) in order to enable districts to regularly assess and improve the quality of data they produce has also been conducted. However, due to limitation of resources, these trainings have chiefly targeted managers at provincial level, with the expectation that they would cascade down the training if they were able to mobilize resources locally, or use this knowledge to conduct on the job training of district managers during supportive supervisory visits to districts. Again, due to fund constraints, both training

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and supportive supervision at all levels are occasional, and almost with no follow up visits to help staff integrate knowledge and skills acquired during the training into their routine or to make sure they implement the recommendations of the supervisory visits conducted.

The country has planned part of the GAVI-HSS funds to support training of health staff on quality EPI data management, including the use of the DQS tool, with focus at district and health facility levels, while making available resources for national and provincial levels to conduct regular supportive supervisory visits to lower levels.

3. Surveillance Review

Mozambique conducted its last in depth surveillance review in July 2010. The main findings of this exercise were as describe below:

1) There are designated surveillance officers who were trained and periodically refreshed on VPD surveillance, who have the responsibilities for the conduct of VPD at the provincial and district levels.

2) The surveillance network is structured mainly around public health facilities, that is, not involving private facilities.

3) Most Health facility surveillance focal persons and health workers including clinicians have limited knowledge and skills for VPD surveillance due to lack of training and inadequate supportive supervisory visits which do not provide written feedbacks.

4) While IDSR field guides with case definitions and instructions for conducting integrated surveillance for notifiable diseases including VPD were readily available for use at the national, provincial and district levels, they were limitedly available at the health facility level.

5) Monitoring tools for reporting disease trends on weekly and monthly basis exist and are used to keep track of disease trends at the national level from where monthly and quarterly feedback is provided to all levels through bulletins. Availability of means of communication (telephone, internet) facilitates the timely transmission of surveillance data and reports from the lower to the higher level.

6) Active surveillance visits were found to be limited in scope, frequency and quality due to lack of prioritization of health facilities, the non-inclusion of private facilities and limited involvement of community focal persons. Systematic monitoring of active surveillance visits were found to be lacking as no tool was available for such monitoring. Support for VPD surveillance from the national and provincial level is limited by competing priorities at those levels and limited access to means of transportation particularly at the provincial level.

7) The support by health facility labs in the collection, storage and shipment of AFP and measles stool and blood specimens respectively, has been very crucial for VPD surveillance in Mozambique. However, reported delays in shipping AFP stool specimens to the ICL in

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South Africa in the early part of 2010 and the frequent and occasionally prolonged stock out of measles lab reagents and supplies may compromise the quality of lab support for VPD surveillance in Mozambique.

8) The supportive roles of polio committees for polio eradication in Mozambique have helped to maintain key activities including the drafting and submission of annual progress reports by the NCC, the final classification of AFP cases by the NPEC and the lab containment process by the NTF. However, the inability of the NPEC to form quorum for its meetings to classify AFP cases due constant absence of members leads to delays in final classification of AFP cases.

In the light of the above findings, the review recommended among other steps for making the system sensitive, the urgent expansion of the surveillance network to include key private facilities and community focal persons; strengthen the knowledge base and skills of health workers for VPD surveillance; prioritize health facilities for active surveillance visits and supportive supervision and improve access to means of transport by provincial surveillance officers to support active surveillance at the district and health facility levels. The review also recommended that the challenges faced by the lab in support of VPD surveillance should urgently be addressed.

4. KAP study on routine immunization and new vaccine introduction

In late 2012, the Ministry of Health with the support of UNICEF Mozambique, carried out a qualitative formative research study in the four provinces of Zambézia, Tete, Cabo Delgado and Inhambane to evaluate the knowledge, attitude and practices on routine immunization and introduction of the new vaccine PCV-10 with the purpose of understanding barriers and beliefs of the families toward immunization. The findings included:

1) Women feel that vaccination is positive because it improves children’s health and prevents illness in general.

2) The immune-preventable diseases that women participants know best are polio, measles and tetanus;

3) Tuberculosis is sometimes confused with the acronym for the vaccine (BCG).

4) When women talk about diseases, they do not describe the symptoms, an indication that they do not know the diseases being prevented by the specific vaccines.

5) Community opinion leaders’ knowledge about vaccinations does not differ much from that of the women but when requested they are willing to mobilize the community to participate in any specific health outreach activity.

6) Activists are trained in a vertical manner, and often know very little about vaccination, while community health workers (APEs) have received integrated training, know about immune-preventable diseases and have a formal role in the community, representing the health system in remote areas.

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7) The health workers interviewed found difficult to talk about vaccination due to linguistic and conceptual problems, and at the moment of the study they had no visual communication aids. Health workers currently tend to take their own initiatives, whether in organizing the vaccination queue or taking measures on non-adherence. They talk about vaccines immediately before vaccination activities begin, and then reduce to a minimum the interpersonal communication with the people who bring children to be vaccinated. Finally, they tend to be rude to caregivers when they ask for information, as if the fact of being questioned means doubting their capacity and authority.

8) Gender issues and the limited involvement of men in vaccination have negative effects on adherence, aggravating existing structural problems such as distance from home to the health unit or outreach team gathering point.

Selected recommendations emerged from the study including the following:

From the service provision side:

1) Diversify communication on vaccination opportunities, by increasing and improving the quality of interpersonal communication, especially by health workers.

2) Reinforce the capacity building plan for CHW (APEs) and health promotion activists on immunization on top of other health areas.

3) Conceive visual IEC communication materials that associate each disease with each vaccination to ensure standardization of messages from health workers.

4) Conceive simple audio-visual on vaccination in local languages to be used in the health centres during the health promotion sessions and by the Institute of Social Communication multimedia units to be used in community video debated sessions in rural areas.

5) Develop a monitoring and evaluation plan for communication on health that includes indicators on interpersonal communication, to assess the interpersonal capacities and techniques of health workers.

6) Ensure that in the communication interventions implemented for the National Health Week, there should be always a clear remainder to the routine immunization schedule

From the community engagement side:

1) Involve men in vaccination through dedicated health education sessions for them, focusing on topics such as men’s responsibility for children and the economic advantages of vaccination, as men are considered heads of family and breadwinners.

2) Disseminate best practices of men’s collaboration with women, to show that it can be a reality (positive deviance) and to create motivation in the community.

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3) Involve more community leaders in vaccination promotion, to enable the participation of other opinion leaders like teachers, religious leaders and traditional healers who currently feel that they do not have the necessary authorization to do so.

4) Work with traditional healers, so that they assist in the production of communication material, helping to identify correspondence between traditional and biomedical diseases and, should this exist, helping to find a definition for any “new disease” that uses terminology that can be easily understood.

4.4 Stock management

Logistical constraints identified in EVM and other reviews are being tackled through the implementation of vaccine stock management tools at different levels (district - DVDMT, province and national - SMT) and training of the staff on the utilization of these tools. In addition, a long term cold chain refurbishment plan will be developed which should include a depleted cold chain rehabilitation plan, maintenance plan and a plan to expand the cold chain over the next years to meet the requirements of the existing and new vaccines to be introduced including IPV. Training of health workers on vaccine and cold chain management as well as provision of adequate guidelines will complement these activities.

5. Monitoring and evaluation

5.1.1 Updating of monitoring tools

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All vaccination guidelines and reporting tools will be updated to include IPV, rotavirus and measles second dose according to the updated cMYP. A tally sheet to monitor vaccination demand and usage will be updated, printed, introduced to vaccination supervisors and disseminated. New registration books with additional columns for the new vaccines will be produced to be administered at vaccination site.Vaccination cards will also be updated, reprinted and distributed at all vaccination sites. These will be introduced in the training for health care workers to make sure that staff is familiar with the new changes. If a child presents with an older vaccination card without space for recording IPV, all information from the old card should be transferred to a new vaccination card and IPV should be recorded.

National (SISMA/MB2) and international (WHO-UNICEF Joint Reporting Forum) health information systems will be updated to ensure accurate reporting on coverage, drop-outs and left outs of the new vaccines. Updating the health information system requires timely communication with the national authority to ensure sufficient time to change the system. The first steps have already been taken to update the health information system by informing the HIS department, Directorate of DPC in the Ministry of Health about the planned vaccine introductions.

The joint introduction ensures that all of these updates can happen simultaneously, which greatly optimises use of human and financial resources particularly for updating the health information system, printing of tally and vaccination cards, training for health workers and others.

Mozambique is currently analysing equity by looking at vaccination coverage at district level to understand which districts are underperforming and enabling targeted and intensified services in those districts. Mozambique is currently not collecting data disaggregated by gender, however, during the next revisions to the immunization reporting forms and the revision of the cMYP, this will be taken into consideration.

5.1.2 Adverse Event Following Immunisation (AEFI) monitoring and reporting

Even though serious adverse events following immunization (AEFI) caused by IPV are extremely rare as, IPV consists of inactivated wild-type poliovirus strains, which does not carry any risk of vaccine-associated polio paralysis, the training of health workers in relation to vaccine introduction will include a component on AEFI to ensure that involved staff is prepared to respond to any potential event including risk communication. The Social mobilization and communication sub-committee will be responsible for managing the AEFI communication. Focal points will be identified and trained on how to communicate in case of possible rumours and AEFI. Furthermore, the social mobilisation and communication plan includes ways to avoid misperceptions about vaccine-safety and adverse events. In case of a detected adverse event, the Pharmaceutical Department in the Ministry of Health will immediately take action. 2 Sistema Informático de Saúde para Monitoria e Avaliação/Módulo Básico (Health informatic system for monitoring and evaluation / Basic Module)

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To strengthen surveillance of AEFI, the EPI programme will institutionalize AEFI surveillance by integrating it into the already existing pharmaco-vigillance system, which has already trained focal persons at provincial, district and selected health facility around the country. Vaccinators and clinicians will be sensitized such that they are made aware of the possibility of AEFI and know to inform the focal person in case of any suspicion; the focal person will in turn report via the appropriate existent reporting channels

6. Advocacy, communication, and social mobilisation

For advocacy, orientations will be provided to key policy makers and government agencies on IPV, its rationale and benefits. Similarly advocacy meetings will be held at provincial,

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district and community level for the creation of enabling environment to support the IPV introduction.

Further, the Minister of Health will conduct high level advocacy with major representatives of the National Government in order to identify a national champion of the joint introduction of IPV. The recent example of mobilizing the First Lady to support the communication campaign for the HPV vaccine introduction is a concrete example of government readiness to ensure high level political commitment. At provincial level, Governors or Governor’s spouses will be mobilized as provincial immunization champions.

In add to this, religious and traditional leaders will be mobilized through advocacy meetings to ensure that the population will be fully mobilized to participate in the vaccination campaign and to reduce the risk of encounter any resistance or rejection at community level.

The ministry of health is currently undertaking training on interpersonal communication skills in selected provinces. The introduction of some of these activities or recommendations in the IPV introduction campaign will be key to ensure a full mobilization for the introduction itself and to improve the adherence to routine immunization. In particular, involving key influencers and mobilizing men to support women adherence to the campaign are key strategies to be considered. Scaling up to all provinces the trainings in interpersonal skills for health providers will also be very important to ensure that caregivers can improve their knowledge on the different vaccines provided during the interactions with health providers, be aware of the full vaccination schedule and of the advantages of the introduction of the two new vaccines.

Finally, specifically for the introduction, a mass media campaign will be designed by the MoH with its partners. The main expected products are:

Two TV and a Radio spots, with the radio spot produced in the main national languages beyond Portuguese. The first one will be mainly informational appealing to adherence from caregivers, while the second will highlight a success story of a full engaged man supporting his wife in bringing his child to the health unit

The development of a thematic SMS to be sent to all MCEL, VODACOM and MOVITEL users. The SMS will also be sent to all community radio coordinators to ensure that they are engaged in the campaign

Carry on campaign telephone based evaluation survey to monitor the broadcasting of the spots and assess the level of reach, recall and impact of the campaign

The IEC package for the IPV introduction will include several components to target key audiences:

For Caregivers:

TV and Radio Spots SMS

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For local administrators:

Advocacy leaflet visually highlighting the performing and non-performing districts in terms of vaccination calendar completion, flagging the “red” and “green” districts with the aim of stimulating the completion

For religious and traditional healers:

Update and reproduction of booklet for religious leaders developed by MoH and the Council of Religions in Mozambique, with UNICEF support in 2014, updating the vaccination calendar information

Call for action leaflet with the detailed information of the introduction campaign

For health providers and community health workers:

Reproduction of IPC training modules for each health units. Visual Aids correlating each vaccine with each disease, type (oral or injection)

and the location of the vaccine (right arm, left leg, etc.) to be used with caregivers

The Ministry of Health will organize a launch ceremony at national, provincial and district level with the high level presence of major representatives from the Government and with civil society influencers.

Interpersonal communication training for health workers will be a key activity. Past experiences show that health workers are the most trusted sources of information and at the same time many studies also reveal that health workers do not explain to care givers about the number of times they need to have their children vaccinated, reassure them for any concerns they may have and explain any possible side effects and what action to take in case of these side effects. Social mobilizers will also be trained on IPC. Simple easy to understand messages will be designed for care-givers and families.

Building on the findings of the studies above and those of MICS and DHS as already in 4.2 above, access problems due to lack of adequate information will be addressed through development of a specific communication strategy that target low school education communities, in order to empower these communities to participate in the promotion of healthy behaviours, including using available preventive health services, such as compliance with immunization schedule, exclusive breastfeeding in the first 6 months of life, ante-natal care, family planning, and others.

For behaviour change communication, tailored messages will be developed to reach families and caregivers with information on IPV. Communication material will be produced, pre-tested and finalized. Globally available generic material will be used to

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develop FAQs, fact sheets and training material. Radio and TV will be used to disseminate key messages to encourage care-givers to take their children for IPV vaccination. Special efforts will be made to reach hard to reach children.

Moreover, efforts will continue to increase the involvement of community leaders and local organizations in surveillance activities. Volunteers from local NGOs and other influent people in the communities will be oriented and integrated as part of community surveillance network, to continue surveillance activities in the communities for early detection of suspected AFP cases and measles, as well as of other epidemic prone diseases.

In addition to this, the MoH has just approved and launched in August 2013 the community involvement strategy, which amongst others, includes the training and deployment of community health workers (APE’s) as a means to extend the health services to remote communities. These structures will be used to establish a permanent linkage between health sector and communities. The EPI will seize this opportunity to strengthen EPI communication and utilization.

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7. List of Annexes

7.1 Annex C – IPV Introduction Timeline of Activities

MozambiqueActivity May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr MayDraft implementation plan for introducing IPV with OPV3 at DTP3/Penta 3 health contactBrief key stakeholdersFunding secured from GAVI and other partnersEstablish procedures for implementationSubmitt Proposal Application to GAVIAdapt Information, Education and Communication (IEC) materials & develop communication plan for educating communitiesPrint & disseminate IEC materialsReview and revise immunization formsPrint revised immunization formsDistribute revised immunization forms to prov & districtsConfirm space at regional and district cold storesClear vaccine supply from customsFinalise budgetFinancial resources received at central levelPre-arranged budget is transferred from central to region Pre-arranged budget is transferred from region to district Develop training plan for introducing IPV with OPV3 at DTP3/Penta 3 health contactMicroplanning at district levelsImplement training plan - TOT central & provincial levelsImplement training plan - district levelImplement training plan - health facility levelImplement communication strategyTransport vaccine to districts

Transport vaccine to health facilitiesDelivery of IPV to target populationInstitute monitoring of adverse events following immunisation (AEFIs) for IPVSupportive supervision visits central to districtSupportive supervision visits district to health facilityMonthly reporting of IPV doses deliveredAnalyze reported IPV dataSubmit financial report to GAVISubmit progress report to GAVI

2014 2015 2016Annex C. IPV Introduction Timeline of Activities

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7.2 Annexes D1 – D2

Annex D1

Component /activityTotal Resource Requirements in

MZM

Total Resource Requirements in

USDGovernment Common

Fund

GAVI New Vaccine

Grant - IPV

GAVI New Vaccine Grant

- RotavirusWHO USAID-

UNICEF HSS Funded Funding Gap

MZM US$ US$ US$ US$ US$ US$ US$ US$ US$Training 13,968,225 476,731 12,184 0 464,547 0 0 0 0 476,731 0

Adapt Trainig Materials 64,000 2,184$ 2,184$ 2,184$ -$

Print Training materials 293,000 10,000$ 10,000$ 10,000$ -$

Central Level 1,010,100 34,474$ 34,474$ 34,474$ -$

Provincial level 3,771,125 128,707$ 128,707$ 128,707$ -$

District Level 8,830,000 301,365$ 301,365$ 301,365$ -$

Communicaction & Social Mobilization 9,014,000 307,645 0 0 130,853 76,792 0 100,000 0 307,645 0

Central Level 1,536,000 52,423$ 52,423$ 52,423$ -$ Provincial level 2,298,000 78,430$ 78,430$ 78,430$ -$

District Level 5,180,000 176,792$ 76,792$ 100,000$ 176,792$ -$

Vaccine Delivery 4,319,750 147,432 31,254 0 8,857 107,321 0 0 0 147,432 0

Central Level 407,000 13,891$ 13,891$ 13,891$ -$

Provincial level 508,750 17,363$ 17,363$ 17,363$ -$

District Level 3,404,000 116,177$ 8,857$ 107,321$ 116,177$ -$

Monitoring & Evaluation 7,720,778 263,508 9,133 0 73,230 121,145 60,000 0 0 263,508 0

Rev ise M&E tools 60,000 2,048$ 2,048$ 2,048$ -$

Print M&E tools 1,318,500 45,000$ 7,085$ 37,915$ 45,000$ -$

Integrated Disease Surveillance 5,014,549 171,145$ 121,145$ 50,000$ 171,145$ -$

Post Evaluation Introduction (PIE) 1,034,730 35,315$ 35,315$ 35,315$ -$

Technical Assistance 293,000 10,000$ 10,000$ 10,000$ -$

Supportive Superv ision 6,776,145 231,268 0 0 0 231,268 0 0 0 231,268 0

Central level Supervision (Central to Prov incial / District levels) 687,763 23,473$ 23,473$ 23,473$ -$

Provincial level Superv ision (Prov inces to District / H Facility levels) 2,719,163 92,804$ 92,804$ 92,804$ -$

District level Superv ision (Districts to H Facility level) 3,369,220 114,990$ 114,990$ 114,990$ -$

Waste Management 2,730,300 93,184 18,184 0 75,000 0 0 0 0 93,184 0

Build Incinerators 2,197,500 75,000$ 75,000$ 75,000$ -$

Fuel for Incinerators & Open Burning Waste 532,800 18,184$ 18,184$ 18,184$ -$

Program Management 2,110,000 72,014 0 0 72,014 0 0 0 0 72,014 0

Overheads 2,110,000 72,014$ 72,014$ 72,014$ -$

TOTAL 46,639,198 1,591,782$ 70,756$ -$ 824,500$ 536,525$ 60,000$ 100,000$ -$ 1,591,782$ -$

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Annex D2

Nr of Particip.

Allowance / unit cost

Nr of days Total in MZN Total in USD

Facilitators Central Level 6 - - - -

Participants Central Level 8 - - - -

Perdiem for Provincial Staff ( 11 Prov*3/Prov*1500/Person*6 Days) 33 1,500.00 6 297,000.00 10,136.52

Air Transport Participants (3 Northern Prov*3/Prov*28000 Mts/person) 9 28,000.00 1 252,000.00 8,600.68

Air Transport Participants (4 Central Prov*3/Prov* 24000 Mts/person) 12 24,000.00 1 288,000.00 9,829.35

Fuel Transp Participants - 2 Southern Prov *1000 Km*0.20 L/Km*40 Mts/L 2000 40.00 0.2 16,000.00 546.08

Fuel Transp Participants - 2 Southern Prov *1000 Km*0.20 L/Km*40 Mts/L 400 40.00 0.2 3,200.00 109.22

Perdiem for Driver (4 Souhtern Prov*1 Driver/Prov*6 Days/) 4 937.50 6 22,500.00 767.92

Overheads ( 6 Central Facil + 8 Central Part + 33 Prov Partcip) 47 200.00 1 9,400.00 320.82

Coffe/Tea ( 47 + 4 Fdrivers) 51 500.00 4 102,000.00 3,481.23

Room renting 1 5,000.00 4 20,000.00 682.59

SUB TOTAL 1,010,100.00 34,474.40 Grande Total 1,010,100 34,474

Central Level Training

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Annex D3

Nr of Particip.

Allowance / unit cost

Nr of days Total in MZN Total in USD

Perdiem for District Staff (16 Dist & 2 persons/Dist)1 30 1,125.00 6 202,500.00 6,911.26

Transport for Participants (250/person/return trip)2 30 250.00 1 7,500.00 255.97

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Air ticket for Central Facilitaor - MoH 2 28,000.00 1 56,000.00 1,911.26

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Overheads (30 distr + 5 in host dist + 3 prov partictp) 40 200.00 1 8,000.00 273.04

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 41 300.00 4 49,200.00 1,679.18

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 399,325.00 13,628.84

Perdiem for District Staff (17 Dist & 2 persons/Dist)1 32 1,125.00 6 216,000.00 7,372.01

Transport for Participants (250/person/return trip)2 32 250.00 1 8,000.00 273.04

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Air ticket for Central Facilitaor - MoH 2 28,000.00 1 56,000.00 1,911.26

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Overheads (32 distr + 3 in host dist + 3 prov partictp) 42 200.00 1 8,400.00 286.69

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 43 300.00 4 51,600.00 1,761.09

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 416,125.00 14,202.22

Perdiem for District Staff (21 Dist & 2 persons/Dist)1 40 1,125.00 6 270,000.00 9,215.02

Transport for Participants (250/person/return trip)2 40 250.00 1 10,000.00 341.30

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Air ticket for Central Facilitaor - MoH 2 28,000.00 1 56,000.00 1,911.26

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Overheads (32 distr + 3 in host dist + 3 prov partictp) 50 200.00 1 10,000.00 341.30

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 51 300.00 4 61,200.00 2,088.74

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 483,325.00 16,495.73

Perdiem for District Staff (17 Dist & 2 persons/Dist)1 32 1,125.00 6 216,000.00 7,372.01

Transport for Participants (250/person/return trip)2 32 250.00 1 8,000.00 273.04

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Air ticket for Central Facilitaor - MoH 2 25,000.00 1 50,000.00 1,706.48

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Overheads (32 distr + 3 in host dist + 3 prov partictp) 42 200.00 1 8,400.00 286.69

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 43 300.00 4 51,600.00 1,761.09

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 410,125.00 13,997.44

TRAINING - PROVINCIAL LEVEL BUDGET - 1

Niassa Province

Cabo Delgado Province

Nampula Province

Zambezia Province

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Annex D4

Nr of Particip.

Allowance / unit cost

Nr of days Total in MZN Total in USD

Perdiem for District Staff (13 Dist & 2 persons/Dist)1 24 1,125.00 6 162,000.00 5,529.01

Transport for Participants (250/person/return trip)2 24 250.00 1 6,000.00 204.78

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Air ticket for Central Facilitaor - MoH 2 25,000.00 1 50,000.00 1,706.48

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Overheads (32 distr + 3 in host dist + 3 prov partictp) 34 200.00 1 6,800.00 232.08

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 35 300.00 4 42,000.00 1,433.45

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 342,925.00 11,703.92

Perdiem for District Staff (10 Dist & 2 persons/Dist)1 18 1,125.00 6 121,500.00 4,146.76

Transport for Participants (250/person/return trip)2 18 250.00 1 4,500.00 153.58

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Air ticket for Central Facilitaor - MoH 2 25,000.00 1 50,000.00 1,706.48

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Overheads (32 distr + 3 in host dist + 3 prov partictp) 28 200.00 1 5,600.00 191.13

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 29 300.00 4 34,800.00 1,187.71

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 292,525.00 9,983.79

Perdiem for District Staff (13 Dist & 2 persons/Dist)1 24 1,125.00 6 162,000.00 5,529.01

Transport for Participants (250/person/return trip)2 24 250.00 1 6,000.00 204.78

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Air ticket for Central Facilitaor - MoH 2 25,000.00 1 50,000.00 1,706.48

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Overheads (32 distr + 3 in host dist + 3 prov partictp) 34 200.00 1 6,800.00 232.08

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 35 300.00 4 42,000.00 1,433.45

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 342,925.00 11,703.92

Perdiem for District Staff (14 Dist & 2 persons/Dist)1 26 1,125.00 6 175,500.00 5,989.76

Transport for Participants (250/person/return trip)2 26 250.00 1 6,500.00 221.84

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Perdiem for Central Driver (Travel of Central Facilitators) 1 1,125.00 8 9,000.00 307.17

Fuel for Transport Central - Provincial Level (1200 Km*0.2L/Km*40Mts/L) 1200 40.00 0.2 9,600.00 327.65

Overheads (26 distr + 5 in host dist + 3 prov + 2 Central + 2 Drivers) 36 200.00 1 7,200.00 245.73

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 38 300.00 4 45,600.00 1,556.31

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 329,525.00 11,246.59

TRAINING - PROVINCIAL LEVEL BUDGET - 2

Tete Province

Manica Province

Sofala Province

Inhambane Province

65

Annex D5

Nr of Particip.

Allowance / unit cost

Nr of days Total in MZN Total in USD

Perdiem for District Staff (12 Dist & 2 persons/Dist)1 24 1,125.00 6 162,000.00 5,529.01

Transport for Participants (250/person/return trip)2 24 250.00 1 6,000.00 204.78

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Perdiem for Central Driver (Travel of Central Facilitators) 1 1,125.00 8 9,000.00 307.17

Fuel for Transport Central - Provincial Level (500 Km*0.2L/Km*40Mts/L) 500 40.00 0.2 4,000.00 136.52

Overheads (26 distr + 5 in host dist + 3 prov + 2 Central + 2 Drivers) 34 200.00 1 6,800.00 232.08

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 36 300.00 4 43,200.00 1,474.40

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 307,125.00 10,482.08

Perdiem for District Staff (8 Dist & 2 persons/Dist)1 16 1,125.00 6 108,000.00 3,686.01

Transport for Participants (250/person/return trip)2 16 250.00 1 4,000.00 136.52

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Perdiem for Central Facilitator - MoH 3 2 2,000.00 8 32,000.00 1,092.15

Perdiem for Central Driver (Travel of Central Facilitators) 1 1,125.00 8 9,000.00 307.17

Fuel for Transport Central - Provincial Level (200 Km*0.2L/Km*40Mts/L) 200 40.00 0.2 1,600.00 54.61

Overheads (26 distr + 5 in host dist + 3 prov + 2 Central + 2 Drivers) 26 200.00 1 5,200.00 177.47

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 28 300.00 4 33,600.00 1,146.76

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 237,525.00 8,106.66

Perdiem for District Staff (7 Dist & 2 persons/Dist)1 14 1,125.00 6 94,500.00 3,225.26

Transport for Participants (250/person/return trip)2 14 250.00 1 3,500.00 119.45

Perdiem for Provincial Staff (3/ prov) 3 1,250.00 6 22,500.00 767.92

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov 1 937.50 6 5,625.00 191.98

Fuel for Transport for Prov Particip & Central Facilitators 4 500 40.00 0.2 4,000.00 136.52

Perdiem for Central Facilitator - MoH 3 2 2,000.00 6 24,000.00 819.11

Perdiem for Central Driver (Travel of Central Facilitators) 1 1,125.00 6 6,750.00 230.38

Fuel for Transport Central - Provincial Level (100 Km*0.2L/Km*40Mts/L) 100 40.00 0.2 800.00 27.30

Overheads (26 distr + 5 in host dist + 3 prov + 2 Central + 2 Drivers) 24 200.00 1 4,800.00 163.82

Coffe / Tea (32 dist + 3 host distr + (3 +1) prov & central facilit + 1 driver ) 26 300.00 4 31,200.00 1,064.85

Room renting 1 3,000.00 4 12,000.00 409.56

SUB TOTAL 209,675.00 7,156.14 Grande Total 3,771,125 128,707

1. Perdi ems are paid as per National Regulati on (Arrival & Departure days are a lso paid for those participants coming from outs i de the host Ci ty/Vi l lage. The ones l ivi ng in host City/Vi l la ge do not receive any perdiem, but wi l l have the meals as a l l other pa rticip during the tra ini ng days . Therefore, perdiem has been cal culated based on the Nr of dis tricts - 1. Ex , in Niassa: 16 di stricts - 1 = 15 x 2 pa rtc/di s trict x dai l y a l lowance x nr of days , incl udi ng arri val and return.

4. Tra ining wi l l take part in one of the di stricts . Therefore, the team of faci l i tators wi l l ha ve to travel l to the venue tra ining. Fuel i s ca l cul ated on the bas is of 20L/100 Km * Cost/L. It ha s been used the a verage of 500 km for a return trip, except for a l l 4 provinces of south zone for which i t was consi dered 100 km a return trip. Where neccessary, adjustemnts wi l l be ma dse on a case to case bas is .

3. Central level Fa ci l i tator wi l l need 2 a dditi ona l days . One day to join the provi ncia l team & one da y travel back after the tra i ning.

2. Pa rtcipa nts from host dis tri ct do not need transport

TRAINING - PROVINCIAL LEVEL BUDGET - 3

Gaza Province

Maputo Province

Maputo Cidade

66

Annex D6

Nr of Particip.

Allowance / unit cost

Nr of days Total in MZN Total in USD

Nr of Districts 148 Nr of Facilitators (2 per District - the ones trained at provincial level) 296 Nr of Health facilities with Fixed Vaccination Post 1,224 Perdiem for HF Staff (1224 HF * 1 Persons / HF * 4 days)1 1,224 1,125 4 5,508,000 187,986

Transport for Participants (250/person/return trip)2 1,224 250 1 306,000 10,444

Perdiem for District Facilitators (training will be conducted at District Head Quarters) 296 - 0 - -

Overheads (1,224 HF + 296 District Facilitators ) 1,520 200 1 304,000 10,375

Coffe / Tea (1,224 HF + 296 District Facilitators ) 1,520 300 4 1,824,000 62,253

Room renting (148 districts * 2 days meeting * 3,000 MZN/day) 148 3,000 2 888,000 30,307

SUB TOTAL 8,830,000 301,365 Grande Total 8,830,000 301,365

TRAINING - BUDGET DISTRICT LEVEL

Health Level Facility Training

67

Annex D7

Nr of Particip.

Allowance / unit cost

Nr of days Total in MZN Total in USD

Develop Communication Strategy for Multiple Vaccine Introduction - Consultant 1 90,000.00 1 90,000.00 3,071.67 Develop / Adapt Communication Material (Same consultant) 6 - - - Test Communication Material (EPI and DePROS) 1 50,000.00 1 50,000.00 1,706.48 Print Communication Material 1 900,000.00 1 900,000.00 30,716.72 Distribute Communiucation Materials to Provinces 11 10,000.00 1 110,000.00 3,754.27 Orientation of Media 1 10,000.00 1 10,000.00 341.30 Air Spots on the Media (100,000 / Month * 2 + 150,000 Last Month) 3.5 100,000.00 1 350,000.00 11,945.39 Press Conference 1 6,000.00 1 6,000.00 204.78 Launching Cerimony 1 20,000.00 1 20,000.00 682.59

SUB TOTAL 1,536,000.00 52,423.21

Adapt Communication Material in Main Local Languages (EPI & Commun. Team) 11 10,000.00 1 110,000.00 3,754.27 Distribute Communiucation Materials to Districts 11 10,000.00 1 110,000.00 3,754.27 Orientation of Media 1 10,000.00 1 10,000.00 341.30 Air Spots on the Media (50,000 / Month * 2 + 75,000 Last Month) * 11 Prov 38.5 50,000.00 1 1,925,000.00 65,699.66 Press Conference (11 Prov * 3,000 Mts) 11 3,000.00 1 33,000.00 1,126.28 Launching Cerimony (10,000 * 11 Prov) 11 10,000.00 1 110,000.00 3,754.27

SUB TOTAL 2,298,000.00 78,430.03

Distribute Communiucation Materials to Health Facilities (5,000 * 148 Dist) 148 5,000.00 1 740,000.00 25,255.97 Orientation Meetings with of Local Leadership (10,000 * 148 Dist) 148 10,000.00 1 1,480,000.00 50,511.95 Theatre Groups (15,000 * 148 dist) 148 15,000.00 1 2,220,000.00 75,767.92 Air Spots on the Community Radio (5000 * 3 Months * 148 Dsit) 148 5,000.00 1 740,000.00 25,255.97

SUB TOTAL 35,000.00 5,180,000.00 176,791.81 Grande Total 9,014,000 307,645

Social Mobilization Central Level

Social Mobilization Provincial Level

Social Mobilization District Level

68

Annex D8

Vaccine Delivery central store to Provinces

Central Store to Northern Provinces - Air 3 60,000.0

0 1 180,000 6,14

3

Central Store to Central Provinces - Air 4 50,000.0

0 1 200,000 6,82

6

Central Store to 4 Southern Provinces - Truck (2000 Km*0.2L/Km*40 Mts/L) 2000 40.0

0 0.2 16,000

546

Perdiem for Logistician (4 Southern Prov.*1 Logistician*4 Days/) 1 1,500.0

0 4 6,000 20

5

Perdiem for Driver (4 Southern Prov.*1 Driver*4 Days/) 1 1,250.0

0 4 5,000 17

1

SUB TOTAL       407,000 13,89

1 Vaccine Delivery Provincial Stores to DistrictsNr of Regional / Provincial Stores 11 -   - -

Provincial Store to Districts ( 2500 Km/Prov.*11 Prov.*0.2L/Km*40 Mts/L) 27500 40.0

0 0.2 220,000

7,509

Perdiem for Logisticians (11 Prov.*1 Logistician/Prov.*10 Days/) 11 1,500.0

0 10 165,000 5,63

1

Perdiem for Driver (11 Prov.*1 Driver/Prov.*10 Days/) 11 1,125.0

0 10 123,750 4,22

4

SUB TOTAL       508,750 17,36

3 Vaccine Delivery District Stores to Health FacilitiesNr of District Stores 148 -   - -

Provincial Store to Districts ( 1000 Km/District*148 District*0.2L/Km*40 Mts/L)14800

0 40.0

0 0.2 1,184,000

40,410

Perdiem for Logisticians (148 District*1 Logistician/District*5 Days/) 148 1,125.0

0 5 832,500 28,41

3

Perdiem for Driver (148 District*1 Driver/District*5 Days/) 148 937.5

0 10 1,387,500 47,35

5

SUB TOTAL       3,404,000.00 116,17

7

69

Grande Total       4,319,7

50 147,4

32

70

Annex D9

Nr of Particip.

Allowance / unit cost

Nr of days Total in MZN Total in USD

Central Level Supervisors (2 / Prov) 22 - - - -

Perdiem for Superv (3 Northern Prov*2 Superv/Prov*2000 Mts*7Days) 6 2,000.00 7 84,000.00 2,866.89

Air Transport Supervisors (3 Northern Prov*2/Suprv*28000 Mts/person) 6 28,000.00 1 168,000.00 5,733.79

Air Transport Participants (4 Central Prov*2/Superv* 24000 Mts/person) 8 24,000.00 1 192,000.00 6,552.90

Fuel Transp Participants - 2 Southern Prov *1000 Km*0.20 L/Km*40 Mts/L 2000 40.00 0.2 16,000.00 546.08

Fuel Transp Participants - 2 Southern Prov *1000 Km*0.20 L/Km*40 Mts/L 400 40.00 0.2 3,200.00 109.22

Perdiem for Driver (4 Souhtern Prov*1 Driver/Prov*7 Days/) 4 1,250.00 7 35,000.00 1,194.54

Fuel Visit to Districts (11 Prov*1000 Km*0.20 L/Km*40 Mts/L+ 11000 40.00 0.2 88,000.00 3,003.41

Perdiem Prov Driver (7 Prov Traveled to by Air * 937.5*5 Days) 7 937.50 5 32,812.50 1,119.88

Perdiem Prov EPI Manager (11 Prov * 1500 * 5 Days) 11 1,250.00 5 68,750.00 2,346.42

SUB TOTAL 687,762.50 23,473.12 Grande Total 687,763 23,473

SUPPORTIVE SUPERVISION - BUDGET CENTRAL LEVEL

Supervision Central Level

71

Annex D10

Nr of Particip.

Allowance / unit cost

Nr of days

Total nr Districts Total in MZN Total in USD

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 8 140,000.00 4,778.16

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 8 52,500.00 1,791.81

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 4 8 36,000.00 1,228.67

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 8 32,000.00 1,092.15

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 8 32,000.00 1,092.15

SUB TOTAL 292,500.00 9,982.94

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 9 157,500.00 5,375.43

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 9 59,062.50 2,015.78

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 4 9 40,500.00 1,382.25

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 9 36,000.00 1,228.67

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 9 36,000.00 1,228.67

SUB TOTAL 329,062.50 11,230.80

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 11 192,500.00 6,569.97

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 11 72,187.50 2,463.74

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 3 11 37,125.00 1,267.06

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 11 44,000.00 1,501.71

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 11 44,000.00 1,501.71

SUB TOTAL 389,812.50 13,304.18

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 9 157,500.00 5,375.43

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 9 59,062.50 2,015.78

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 4 9 40,500.00 1,382.25

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 9 36,000.00 1,228.67

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 9 36,000.00 1,228.67

SUB TOTAL 329,062.50 11,230.80

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 7 122,500.00 4,180.89

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 7 45,937.50 1,567.83

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 4 7 31,500.00 1,075.09

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 7 28,000.00 955.63

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 7 28,000.00 955.63

SUB TOTAL 255,937.50 8,735.07

SUPPRTIVE SUPERVISION - BUDGET PROVINCIAL LEVEL

Niassa Province

Cabo Delgado Province

Nampula Province

Zambezia Province

Tete Province

72

Annex D11

Nr of Particip.

Allowance / unit cost

Nr of days

Total nr Districts Total in MZN Total in USD

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 5 87,500.00 2,986.35

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 5 32,812.50 1,119.88

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 4 5 22,500.00 767.92

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 5 20,000.00 682.59

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 5 20,000.00 682.59

SUB TOTAL 182,812.50 6,239.33

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 7 122,500.00 4,180.89

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 7 45,937.50 1,567.83

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 4 7 31,500.00 1,075.09

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 7 28,000.00 955.63

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 7 28,000.00 955.63

SUB TOTAL 255,937.50 8,735.07

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 7 122,500.00 4,180.89

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 7 45,937.50 1,567.83

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 4 7 31,500.00 1,075.09

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 7 28,000.00 955.63

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 7 28,000.00 955.63

SUB TOTAL 255,937.50 8,735.07

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 6 105,000.00 3,583.62

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 6 39,375.00 1,343.86

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 4 6 27,000.00 921.50

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 6 24,000.00 819.11

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 6 24,000.00 819.11

SUB TOTAL 219,375.00 7,487.20

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 1,250.00 7 4 70,000.00 2,389.08

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 937.50 7 4 26,250.00 895.90

Perdiem for District Offiecer to Acompany prov team to the field 1 1,125.00 4 4 18,000.00 614.33

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 4 16,000.00 546.08

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 4 16,000.00 546.08

SUB TOTAL 146,250.00 4,991.47

Perdiem for Povincial Supervisors (2 persons/Prv)1 (each 7 days for 2 districts) 2 600.00 7 3 25,200.00 860.07

Perdiem for Driver (Prov Particip & Facilitators) - 1/prov (each 7 days for 2 districts) 1 375.00 7 3 7,875.00 268.77

Perdiem for District Offiecer to Acompany prov team to the field 1 450.00 4 3 5,400.00 184.30

Fuel for Transport of prov supervisors to districts (return trip for a single 2 districts visit) 500 40.00 0.2 3 12,000.00 409.56

Fuel for supervisory field work in the district (average 250 Kms/District) 500 40.00 0.2 3 12,000.00 409.56

SUB TOTAL 62,475.00 2,132.25 Grande Total 2,719,163 92,804

Maputo Cidade

SUPPRTIVE SUPERVISION - BUDGET PROVINCIAL LEVEL - 2

Manica Province

Sofala Province

Inhambane Province

Gaza Province

Maputo Province

73

Annex D12

Nr of Particip.

Allowance / unit cost

Nr of days

Total nr Districts Total in MZN Total in USD

Pediem for District Supervisors (2 per district) - 5 days overnighting only1 2 1,125.00 5 148 1,665,000 56,826

Perdiem for District Offiecer to Acompany prov team to the field 1 703.00 5 148 520,220 17,755

Fuel for supervisory field work in the district 1000 40.00 0.2 148 1,184,000 40,410

SUB TOTAL 3,369,220 114,990 Grande Total 3,369,220 114,990

1 On average, 5 days overnight per district. The rest of the days, they will return home at the same day at the end of normal working hours.

SUPPRTIVE SUPERVISION - BUDGET DISTRICT LEVEL

Supervision to Health Facilities

74

75

8. List of acronyms

AD – Auto-disableAEFI - Adverse Event Following ImmunizationBMW – Bio-medical wastageCC – cold chainCCUP – Cold Chain Upgrade PlanCMAM – Central de Medicamentos e Artigos Médicos (Centre for Pharmaceutical and Medical SuppliescMYP – comprehensive Multi-year planDQS – Data Quality Survey EPI – Expanded Program on ImmunizationEPI – Expanded Program on ImmunizationEVMA – Effective Vaccine Management AssessmentGAVI – Global Alliance for Vaccines and ImmunizationHib – Haemophilus influenza type bHIS – Health Information SystemICC – Inter-country Committee IEC – Information, education, communicationIPV – inactivated polio vaccineIPV – Inactivated Poliomyelitis VaccineJRF – Joint Reporting ForumMDG – millennium development goalsMLM – Mid-Level ManagementMSD – measles second doseNHIS – National Health Information SystemNIP – National Immunization ProgrammeNITAG - National Immunization Technical Advisory GroupNVS – National Vaccine StorePESS - Plano Estratégico do Sector da Saúde (Health Sector Strategic Plan)PIE – Post-introduction evaluationREC – Reaching Every CommunityRED – Reach Every DistrictRED – Reaching Every DistrictSAGE – Strategic Advisory Group of ExpertsVIG - Vaccine Introduction GrantsWPV2 – wild poliovirus type 2

76

9. References

77

i Instituto Nacional de Estatistica, INE (National Institute for Statistics)ii Health Sector Review 2012iii UNDP Human Development Index Report 2013