Expanded Program on Immunization...Financial Sustainability Plan / Jan 05 /Yemen 2 Financial...

Financial Sustainability Plan / Jan 05 /Yemen

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Republic of Yemen

Ministry of Public Health & Population

Primary Health Care Sector

Expanded Program on Immunization

Financial Sustainability Plan

January 2005


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Financial Sustainability Plan – Yemen

Acronyms Executive Summary

Section 1 Impact of country and health system context on Immunization program costs, financing and financial management

1.1 Country profile 1.2 Macroeconomic performance 1.3 The health sector 1.4 Finance of the health system 1.5 Health planning & budgeting

Section 2 Program Characteristics, Objectives and Strategies

2.1 Introduction 2.2 Program objectives and strategies 2.3 Organization of the EPI 2.4 EPI services and performance 2.5 EPI partners 2.6 Inter-agency Coordination Committee Section 3 Current Program Expenditure and Finance 3.1 Qualitative information – prevaccine fund program 3.2 Sources of immunization funds 3.3 Current EPI funds 3.4 Trends in EPI expenditures 3.5 Basic analysis

Section 4 Future Resources Requirements and Program Financing / Gap Analysis

4.1 Introduction 4.2 Major challenges facing expenditures and costs 4.3 Projection of resource requirements 4.4 Futures financing level projection and patterns 4.5 Gap estimates 4.6 Analysis of the gap

Section 5 Sustainability Financial Strategy, Action and Indicators

5.1 Introduction 5.2 The main drivers of EPI cost


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5.3 Main EPI strengths 5.4 Main EPI weaknesses 5.5 Main opportunities 5.6 Main weaknesses 5.7 Main constraints and risks 5.8 Strategies towards sustainability 5.9 Short term changes 5.10 Medium term changes 5.11 Action plan 5.12 Discussion with EPI partners Section 6 Stakeholders comments Annex 1 Future resource requirements Annex 2 Secure funds Annex 3 Probable funding Annex 4 Secure and Probable funding Annex 5 Members of FSP committee

Annex 7 Agenda of ICC meeting, Attendance, Minutes of the meeting

Annex 8 Acknowledgment


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Acronyms

5YDP Five-year Development Plan

BCG Bacillus Calmett and Guiran

CSO Central Statistical Organization

DHS District Health System

EFARP Economic, Financial and Administrative Reform

EPI Extended Program on Immunization

FSP Financial Sustainability Plan

GAVI The Global Alliance for Vaccines and Immunization

GDP Gross Domestic Product

GNP Gross National Product

GoY Government of Yemen

HBV Hepatitis B Vaccine

HF Health Facility

HSR Health Sector Reform

ICC Inter-agency Coordination Committee

IDA International Development Agency

IMR Infant Mortality Rate

JICA Japanese International Cooperation Agency

MDGs Millennium Development Goals

MoF Ministry of Finance

MoPHP Ministry of Public Health & Population

MoPIC Ministry of Planning and Development

MMR Maternal Mortality Rate

MNT Maternal & Neonatal Tetanus

NGOs Non-governmental Organizations

NHA National Health Accounts

NIDs National Immunization Days

Penta Pentavalent Vaccine

PHC Primary Health Care

PHR+ Partners for Health Reform plus

PRS Poverty Reduction Strategy

OPV Oral Polio Vaccine

SIAs Supplementary Immunization Activities

SNIDs Sub-National Immunization Days

TT Tetanus Toxoid

U5MR Under-Five Mortality Rate

UN United Nations

UNICEF The United Nations children’s Fund

USAID United States of America for International Development

Vit A Vitamin A

VP Vertical Program

WHO World Health Organization


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Executive Summary

Financial sustainability plan is an essential step to sustain and improve EPI program through this multiyear detailed plan, which will enable the program to know when it has adequate and reliable funding, combined with efficient use of resources. The plan will serve also as an advocacy tool for resource mobilization. Yemen faces serious economic and social challenges affecting the public health sector and its efforts to improve the general health situation nationwide. This country with its vast ancient history of civilization is reviving and its modern history has been a story of struggle towards prosperity. Much has been achieved but much more is expected. Human development is the ultimate goal and better health would be the choice. Since the start of its operation in 1978, the Expanded Program on Immunization (EPI) has expanded and currently offers its immunization services towards seven vaccine-preventable diseases. The last antigen to be introduced has been the hepatitis B vaccine since 1998, in addition to tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles which have been used earlier. The country has been polio free since 1998, and measles is still an endemic disease, while high risk approach is being used for achieving the MNT elimination. Major efforts are exerted to achieve the best use of resources. The program offers its services through the public health sector network through fixed, outreach and mobile services. The EPI strategy is to increase the coverage rates, which are currently around 78% for 2004, and ultimately reach the global goal. The pentavalent vaccine would be introduced in 2005 onwards. The program aims besides increasing the level of coverage of the pentavalent and OPV; to achieve a 60% coverage of TT+ for pregnant women by 2007, interruption of the indigenous measles virus and eliminating neonatal tetanus by the year 2006. Other objectives of the program are: sustaining the interruption of the polio virus and ensuring safe vaccination. Yemen is one of the least development countries and confronts a couple of challenges in various areas. In a couple of decades the economy as well as overall development has been growing but with a couple of periods of shortcomings. The major governmental revenue is from oil exports and although half of the population works in the agriculture sector their contribution to the overall economy is low. Most promising sectors in the future are fishery and tourism as well as boosting of the oil industry through exportation of gas reserves. Economic growth has been realized after public reform efforts in the mid nineties, but that had negatively affected the purchasing power of the local currency. A Poverty Reduction Strategy (PRS) was formulated to remedy the reform effects which had resulted in the fact that 42% of the population living under the poverty line. Within the PRS, more resource allocation to social sector has been emphasized on; namely health and education. The level of funding to the health system has not been substantial; the share of the MoPHP from the total government is 4.1 % which is 1.6 of the GDP. The aim is to increase this allocated share to 6% of the government budget and 2% of the GDP by the year 2005. The planning and budgeting process, currently carried in a decentralized manner, is early to evaluate. The major constraint


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in regard is the current line item budgeting which inefficient compared to activity-based budgeting. In mid 2004, the MoPHP has been restructured and a new PHC sector was introduced. The EPI lies within this sector and is receiving heightened attention. Within the overall Health Sector Reform Strategy of 1998, it was anticipated that the provision of accessible, affordable, quality and efficient services would be the ultimate aim. The DHS approach, which was prioritized by the ministry within the overall framework of decentralization, has delegated the planning and implantation role to a lower, more effective level. The districts plan for EPI services are among other services and much attention is to be directed towards raising their awareness and prioritization of immunization services. Nevertheless, the EPI remains as the governing body supervising, monitoring, supplying and ensuring nation-wide immunization goals are realized. The donor agencies namely; WHO and UNICEF have supported the EPI since it had commenced in 1978 and their input and commitment since then has been substantial. Other partner agencies have joined and currently the program receives support from the former two in addition to JICA, WB and USAID. The EPI provides its services through the public health facilities network with minimal involvement of the private sector. The total cost of the immunization program was (in US$ million) 17, 15.5 and 15.4 in 2001, 2002 and 2003 respectively which include also supplementary immunization activities. The decreases in the amount of funding from 2001 to 2003 (Pre-Vaccine and Vaccine Fund Year) is explained by the fact that supplementary immunization activities, which were conducted in 2001 and 2002 constituted the added amounts in the expenditure, rather than the cost of routine recurrent cost. Thus the total expenditure on Routine EPI cost, which was 13.6, 13.4, 14.3 US$ million in 2001, 2002 and 2003 respectively, is considered stable with a reasonable increase from year to year. It is worth to note that the GoY share of the cost of EPI increased from 72% in 2001 to 85% in 2003 while the rest was given by international partner agencies. The routine EPI cost per-child to be vaccinated with 3 doses of DPT3 was around US $ 30 in 2003. The cost includes every thing except the cost of the SIAs, while the average routine recurrent EPI cost per child was about US$ 17 for the period 2001 to 2003. Towards attaining the MDGs, major efforts need to be exerted in the field of maternal and childhood health. Immunization is the corner-stone to achieve reduction in childhood mortalities as well as deaths related to tetanus in the child-bearing age women. In an aim to achieve a universal coverage by immunization services EPI would be gradually increasing its coverage rates matched with increased future resources. On the short and mid term, the EPI will need to increase its staffing, replace its cold chain, train its manpower, enhance its vehicle fleet and strengthen its surveillance system. These objectives need to be carefully planned and complemented by committed financial resources. The support of GAVI began in the year 2002 and an agreement has been reached to stretch the support of introducing pentavalent vaccine to 2014. Nevertheless, predicting the required resources included the period from 2005 until the year 2013 because the first year of projection was considered 2004 in the spreadsheet tool. The year 2004 has been analyzed as current fund. Therefore all the projections is up till 2013 except the cost of pentavalent has been predicted up till 2014 since the


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government would start to pay 10% of the cost in 2006 with 10% increase every year. The total future cost of the program (2005 to 2013) amounted to US $ 327 million. Of this amount a total of US $ 278.2 million is secure and probable through the GoY and EPI international partner agencies. This leaves the program with a funding gap of US $ 48.5 million which constitutes 15 % of the required funding. In depth analysis illustrates the fact that funding gap is most likely to occur towards the end of the planned period; the years 2010 until 2013. The reason behind this gap, is the fact that most of donors commitments are overseen for that forthcoming period. In addition to that the analysis illustrated that peaks of this gap would coincide with supplementary immunization activities such as campaigns in 2005 and 2008 in addition to the huge replacement of cold chain and vehicles in 2005 and 2010. The government share has been increasing annually from US$ 12.1 million in 2001 to US$ 13 million. GoY afford the total cost of vaccines (including HepB) for the last three years . With the introduction of the pentavalent, GAVI would support the cost of the vaccine with a complimentary annual increase of 10% in the GoY share towards the cost. By 2015, the government would be fully paying for the pentavalent vaccine. The governmental share of the cost of the vaccine amounts to around US $ 40 million through the period 2006 – 2014. In addition to the vaccine cost, the government would and has been covering the program cost which includes operating costs and salaries and this situation is most likely to continue over the planned period. Towards sustainability of the process, the GoY contribution would amount to US $ 214 million which constitute 79% of the secure and probable fund and constitute 65% of the total cost for the period 2005 – 2013. In a close overlook to the EPI plan, evidence suggests that the overall situation would be sustainable, given that the share of the gap from the total cost (17%) is due to the lack of knowledge of future resources beyond 2008 for many partners. Nevertheless, a couple of underlying risks may arise which are mostly beyond the control of the health system. Examples of such risks are; epidemics or disasters and most importantly the overall growth of economy and its alignment with the population growth as well as the dependency of the economic growth on oil production. On the other hand, a couple of opportunities are foreseen in the future which would have positive implications on the EPI plan. The heightened attention on MDGs and the fact that immunization activities are major interventions to achieve these goals raises hopes that EPI would receive its required funds. It is likely that several components of the EPI plan would be included in forthcoming donor programmes and projects. The main strategies of financial sustainability would encompass a) mobilizing additional resources (FSP advocacy, stretching the period of GAVI support of Pent up till 2014, increasing the number of ICC members, ensuring and maintaining the current support), b) improving the program efficiency (through reducing vaccine wastage and accomplishing the cold chain and vehicles replacement) and c) Increasing the reliability of the available resources (advocacy and training to local authorities). Therefore the EPI would need to focus on activities that build the local capacity such as training and staffing and capital replacement. This would be complemented by work in the political arena advocating for the financial sustainability plan to close the funding gap.


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Within this plan a couple of changes have been rationally proposed in an effort to establish a sequence and synergism in the approach. On the short term, the plans are to introduce the pentavalent in 2005 onwards as well as completion of major the cold chain and vehicle fleet replacement planned by 2005. Regarding EPI finance, an annual 10 % increase in governments share in the cost of the pentavalent is planned and an annual increase of 5 – 10 % in the EPI year budget is anticipated. The program would also be working on strengthening of its surveillance system and increasing its technical staffing. On the medium term the program would continue to build on the short term achievements such as the annual 10 % increase in government contribution towards the cost of the pentavalent and annual increase in the EPI budget. Subsequent cold chain and vehicle fleet replacement are planned to be ongoing process as required. Indicators of progress have been chosen to monitor implementing the strategies of financial sustainability. They are related to every strategy: 1) Annual increase of 5-10% of the governmental operational EPI cost. 2) Increase the donor support 3) increase number of the ICC members. 4) Wastage rate decrease of Penta to less than 10% by the year 2006. 5) Increase the number of the new cold chain. 6) % of villages with access to vaccination services. 7) More than 90% of the EPI budget used for EPI activities. As a conclusion this Financial Sustainability Plan will serve as an advocacy tool and will be vital in mobilizing resources. With the strong government commitment and the partnership of the international agencies and using this detailed financial plan for mobilizing more resources it’s expected that the financial gap would be closed.


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Section 1

Impact of country and health system context on Immunization program costs, financing and financial management

This section gives a brief background on the performance of the country's economy, improvement efforts and an overview of the current economic performance and its key indicators. Future projections within the overall development framework are illuminated in addition to their impact on the health system as whole and the immunization program in particular. An overview of the health system is also given in this section mentioning the major characteristics of the national system coupled with indicators. It details the current reform efforts and its implications on the immunization program. The section gives a description of the health system finance, flow of funds and future projections given the ongoing reform and restructuring processes. The implications of the existing budgeting and planning system are clarified and their relation to the health system with emphasis on the immunization program. 1.1 Country Profile Yemen is situated in the southwestern corner of the Arabian Peninsula occupying an area of over half a million square kilometers. It is bordered by the Kingdom of Saudi Arabia to the north, the Arabian Sea and Gulf of Aden to the south, Sultanate of Oman to the east, and the Red Sea to the West. The natural topography of the country divides it into four major regions: costal, highlands, Tihama plateau and the eastern plateau in addition to many islands in the Arab and Red seas.

Yemen has a population of 21,069,869 as of the year 2005 (based on estimations from the latest national population census in 1994) and they are spread over 122,000 settlements and villages. The population is predominantly rural where 76 % of the Yemenis live, and the under-15 age group represents 46.3 % of the population with a rapid annual growth of 3.5 %.

Administratively, the country is divided into 22 governorates which are further divided into 332 districts each of around 45,000 inhabitants. The Yemeni society is labeled as traditional where the agriculture sector absorbs about half of the total work force. 1.2 Macroeconomic Performance 1.2.1 Brief background Unity of both parts of the country in 1990 marked a new era in its history with an ambition that this step would accelerate economic development and growth as well as hopes of prosperity and stability. Nevertheless, burdens inherited from the newly


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established state and the aftermaths of the first Gulf war in the early nineties had its serious implications on the overall economic framework. The mid nineties witnessed economical stagnation, sharp decline in the Gross National Product (GNP) and devaluation of the local currency. In an effort to confront these economic imbalances, the government embarked on an Economic, Financial and Administrative Reform Program (EFARP) which commenced in 1995. These efforts where translated into two ‘Five-year Developmental Plans’ which aimed at attaining economic stability, economic growth, raising incomes and creating new job opportunities. Both plans encompassed into consideration improvement of social services as an approach to achieve human development. Within the framework of the Second Five-Year Development Plan (5YDP) (2001 – 2005) a Poverty Reduction Strategy was adopted to overcome the adverse effects of the reform. The population living in poverty is around 42% and the Poverty Reduction Strategy Paper (PRSP) 2003 – 2005 intended to deal with the different dimensions of poverty. 1.2.2 Current situation The late nineties reform policies and measures have contributed to economic stabilization, liberalization of trade and private sector involvement in economic activity. There has been a 4.4 % increase in the economic growth rate, a drop in the inflation rate and stabilization of the foreign currency exchange rate. Despite the satisfactory performance of the economic reforms, it has resulted in several side effects. The devaluation of the purchasing power of the local currency, removal of subsidies and price hikes of commodities and basic services which were not coupled with a similar increase in the real wages of labor led to a negative affect on the living standards. Currently, Yemen is classified as one of the least developed countries and ranks 148 out of 175 countries on the UNDP Human Development Index (2003) with a per capita GDP of US$ 460. The country faces enormous economic and social challenges; among these are a couple of alarming gaps in a number of development indicators. The following table (1) demonstrates some of the major indicators: Table (1): Country indicators:

Indicator 2003 Fertility rate 6.5% Annual population growth rate 3.5 % GDP per capita 460 US $ Foreign debts as % of GDP 56 % Unemployment 40% People living in poverty 42 % Illiteracy rates between females 73.5% Net enrollment in basic education 59.9 % Health care coverage 50 %

Sources: MoPIC, Millennium Development Goals, 2004 MoPHP, Family Health Survey, 2003.


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Other development indicators: - Limited access to basic service. - Non-renewable water supply is dwindling at an alarming rate. - Half of the children under age of five are malnourished.

1.2.3 Future projections Oil revenues constitute the major contribution to the central state budget and it is the major export. The service sector comes second and fishery and tourism follow, which are two promising sectors although their current contributions to the economy are low. The dependency on the oil exports is a hazardous fact since it is liable to price fluctuations. Currently the Second 5YDP (2001 – 2005) is in action as well as the PRS (2003 – 2005). The developmental plans aim at achieving an annual economic growth of 7 % with emphasis on increasing resource allocation to social services and in particular those directed to the health sector. The next promising step is ongoing process of developing a “Health Investment Plan” to achieve the Millennium Development Goals (MDGs). This process began August 2004, guided by the Millennium Project (UN) and is expected to be finalized by the end of January 2005. This process would facilitate the national efforts of advocating for increased finance for the health system and in particular resources enabling the country to achieve its global commitment within the framework of the MDGs. Another adjuvant process complementing the above mentioned is the formulation of the Third Five-Year Development Plan, MDG based - PRSP oriented (2006 – 2010) which is to take place from January until July of 2005. This plan would envisage the importance of Primary Health Care (PHC) provision as an approach for poverty alleviation. More resource allocation is expected since the forthcoming plan is receiving major consideration on the national level and from development partners. 1.3 Health Sector 1.3.1 General Situation There have been major improvements in the general health situation in the last two decades with a remarkable increase in number of health facilities and health staff providing services as well as a moderate increase in the life expectancy at birth. Nevertheless the health status remains poor and health indictors are one of the least favorable in the Middle-east region. The disease pattern in Yemen describes the epidemiological and demographic changes taking place, with a high incidence and prevalence of communicable diseases such as Malaria, Measles, Tuberculosis and Schistosomiasis. The major causes of childhood mortality are infectious diseases such as diarrhea and acute respiratory illnesses as well as malnutrition. The alarming infant and child mortality rates in addition to maternal mortality are major challenges besides the emergence of non-communicable diseases such as cardiovascular and renal diseases and cancers.


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These health problems are attributable to several factors such as low PHC coverage but other challenges lie beyond the reach of the health system such as; high malnutrition rates, high levels of illiteracy, as well as lack of safe water provision (30 % coverage). In the following table (2) are selective health indicators: Table (2): Selective health indicators

Indicator 2003 Life expectancy at birth 60.4 Infant mortality rate 75 / 1,000 Child mortality rate 102/1000 Maternal mortality rate 366 / 100,000

Source: MoPHP, Family Health Survey 2003 The prevalence of childhood illnesses is one of the highest region-wide where one-third of the under-five deaths are attributable to vaccine preventable diseases. Measles remains a major problem as well as neonatal tetanus. Yemen is in its way to achieve polio eradication and efforts to increase routine immunization have resulted in a modest coverage rate of around 70% for those under the age of one year. The current situation requires increased financial and technical support to improve the extent of routine immunization and enhancement of the surveillance system. 1.3.2 Structure of the Ministry of Public Health & Population Ministry of Public Health & Population (MoPHP) is the major provider of health services thorough its network of health facilities in four levels; health units, health centers and district hospitals, governorate hospitals and specialized hospitals. Along with the public sector there is a widespread unregulated private health sector and health facilities run by NGOs. The Primary Health Care (PHC) has been the approach of the public health system since the early eighties; nevertheless it covers only 45% of the total population. By mid 2004 the MoPHP was restructured aiming at effective management of its various activities and ensuring synergy. A new sector for Primary Health Care translates the focus of the Ministry towards providing a basic package of essential services to the vast population and ensuring integrity of services in the field. The following diagram illustrates the new organigram:


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The 'Expanded Program on Immunization' falls under the PHC sector among other vertical programs such as Malaria, Tuberculosis, Integrated Maternal & Childhood Illnesses, HIV/AIDS, etc. Provision of immunization services on the service level is conducted by the public health facilities free of charge.

1.3.3 Health Sector Reform The public health system by the late nineties experienced several shortcomings on different levels. On the level of service provision, financial and geographical inaccessibility, low quality of services and reduced efficiency has been the experience of the majority of health care clients. On the other hand, on the level of the health system, there has been evidence of low capacity in operational planning in addition to lack of managerial capacity and the absence of managerial tools such as supervision and monitoring systems.

The MoPHP embarked on a reform program in 1998 recognizing the serious shortcomings of the existing health system. The reform comes within an overall context of public sector reform based on decentralization, democratization, civil service modernization, and financial restructuring.

The long-term objectives of the process are to achieve universal access, equity, quality of services in addition to efficiency and financial sustainability. The key element of the reform envisages the establishment of the district health system where other elements such as decentralization, community participation and inter-sectoral cooperation could be realized. Among the elements of reform is the call for redefining

Ministry of Public Health & Population

Planning Sector

Curative care

Sector

Population

Sector

Primary Health Care

Sector

VP EPI VP VP VP

Donor Organizations and

Agencies

WHO UNICEF

GAVI JICA WB

USAID

Governorate Governorate Governorates

District District District

HF HF

Immunization

Activities


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the role of the public sector and encouraging the participation of the private sector as well as donor coordination.

The implementation of the Health Sector Reform (HSR) has been challenging and progress has been achieved in selective elements of the reform namely; the District Health System (DHS) and decentralization. On the other hand, the immunization coverage was estimated to be 28% before the reform and current figures estimate a country-wide coverage of around 70% (latest EPI figures). The MoPHP is expected to conduct a comprehensive review of the health sector which would help in evaluation and development of the new sector vision. This is expected to take place in the period Jan – Jul 2005 coinciding with the development of the Third 5YDP (2006 – 2010). 1.3.4 National Health Priorities The national health priorities are directed towards enhancing the PHC system, which is evident in introducing a sector for PHC in the new structure of the MoPHP and increasing central and governorates budget to PHC related activities. The EPI is one of the major programs in the PHC sector and immunization activities are considered the corner stone within the framework of services provision. During the last eight years there has been strong political support through the participation of the country's leaderships in various nationwide polio eradication campaigns and allocation of required budgets. The MoPHP is in the process of formulating a health investment plan by early 2005, towards achieving the health related MDGs targets. In the process of carrying out the needs assessment and list of interventions, immunization activities stand as the priority intervention to reduce infant and childhood mortalities. A subsequent effort would take place in the first half of 2005, to formulate the Third 5YDP (2006 – 2010) which would be MDGs based PRSP oriented and would encompass the prioritization and significance of immunization activities within an integrated set of cost-effective package of essential services. 1.4 National Health Expenditures 1.4.1 Finance of the health system The national health care system is heavily dependant on household financial contributions and direct provider payments. Based on the National Health Accounts (NHA) study of 1998, households contributed 57.3 % of the total health expenditures whereas the share of the Ministry of Finance (government revenues and tax-based funds) channeled through the MoPHP amounted to 28.5%. The following figure (1) shows the national health expenditures based on the source of funding:


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Figure (1): secure health expenditure

Sources of Health Expenditure

Household57%

Ministry of finance

29%

Donors8%

public Firms

6% Source: National Health Accounts Report, 1998. The per capita spending on health was estimated to be US $ 20 (1998) which is way below the optimum recommended level of funding for a basic package of services, out of this amount the Government share is US$ 7. In spite the fact that cost sharing and nominal fees for services were introduced at all levels of service provision in the recent years, primary health care services remain to be free which include immunization services. 1.4.2. Trends in funds availability Given the fact that there are two major financing sources (the public sector and individual households) and the absence of a health insurance market augments the burden of households seeking health services and dealing with sudden health incidents. It also indicates the importance of attaining increased public funding spending as well as equitable distribution of these funds both in terms of services provided and geographical coverage. The health public spending has been slightly increasing annually but it is way below the optimum levels required to operate public health facilities and there activities as well as the increasing demands of the growing population. The current share of the public health system is 4.1 % of the total government budget which represents 1.6 % of the total GDP. The following table illustrates the changes in public health spending over the period of the last five fiscal years and correspondent changes as of share of the GDP. Table (3): Public health spending (1999 – 2003)

Year 1999 2000 2001 2002 2003 % of MoPHP expenditure

as of the Govt. budget 4.1 4.2 4.6 3.9 4.1

% of MoPHP expenditure as of GDP

1.5 1.4 1.5 1.3 1.6

Source: Preliminary Data; Public Expenditure Review – Health Sector 1999 – 2003


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Latest public expenditure analysis and annual budgetary data show that there has been a slight trend during the past couple of years towards increased expenditures in capital investment and highlighted the fact that a large share of the recurrent budget is consumed by tertiary level care. Other major allocative discrepancies are realized in the low amounts distributed as service operating expenses where evidence suggests that health facilities nation-wide are under funded as well as absorption of a high share of the budget towards salaries and wages for MoPHP staff which suffers from a high load of support staff against the technical health cadre. 1.4.3 Future of health sector funding It has been deemed in the Second 5YDP (2001 – 2005) that there would be an increase in resources allocated to the health sector. The same commitment appeared in the PRSP (2003 – 2005) where by the year 2005 it has been anticipated that the share of health expenditures in the government budget would increase to 6 % which would constitute 2 % of the national GDP. As explained above there has been an increase during the past years and these commitments are likely to be fulfilled. On the other hand, since the fiscal year 2003 there has been a separation of funds for PHC activities from the MoPHP budget and allocated amounts are expected to increase. Another major factor in regard is the recent introduction of the PHC sector which would ultimately facilitate and enhance increased funding. 1.5. Health Planning & Budgeting 1.5.1 Planning and budgeting process Within the overall framework of decentralization, the budgeting, accounting and planning process has been decentralized to the level of governorates and districts which is then bottom-up consolidated to a national ministry budget / plan according to the local authority law no. 4 of 2000. The budgets on the district level are prepared by the district health office and discussed by the support committees formed by the Ministry of Finance (MoF). The plans and budgets are deemed to reflect the local community's needs and aspirations tacking into consideration their technical and absorptive capacity to implement these plans. The experience so far is that the allocated budgets by the MoF are based on historical estimates with slight annual incremental increases. The budgetary allocation does not employ any economic evaluation techniques to asses the financial and social viability of these health allocations neither does it allow the application of measures of horizontal and vertical equity. 1.5.2 Budget Execution and Funds Disbursement The system of budget execution and disbursement of funds is based upon a system of “local accounting units”, affiliated to the Ministry of Finance, each serving a governorate or a district. These accounting units act as sub-treasury in their area of


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operation and their role is to receive revenues and disburse funds according to the requests from the ministry's branch's which are governorate or district health offices. The budget categorization and itemization (salaries, goods & services, maintenance, capital investment, etc) does not facilitate efficient use of allocated resources neither does it respond to technical aspects of public health activities. Another shortcoming in the financial system is the usual delays in disbursement which hinders timely conduction of activities. In any given district, the district health office would apply for their recurrent and operating costs to conduct planned activities through requests conveyed to the accounting unit. It is upon the district health office to prioritize or include any PHC or immunization activities within its annual plan. Another financial asset to the district health system is the retention of revenues generated through user fees and the revolving drug fund which are mainly used to enhance quality of services and pay incentives. On the other hand, the central offices of the MoPHP retain direct control over capital investment funds which is disbursed according to annual nation-wide investment plans. 1.5.3 EPI Planning & Budgeting The process of planning and budgeting for the EPI is similar to the health sector process. It is worth to note that there are two procedures for disbursement of funds to cover immunization activities:

a. The district health office, within its annual plan, requests the conduction of immunization activities from the accounting unit. Funds are disbursed and accounts are cleared on that level. Local authorities and district health offices decide upon the immunization activities and allocated resources.

b. Most of the vertical programs (e.g. EPI) disburse their funds

centrally to the assigned district health office according to nation-wide plans. These health offices conduct the activities and clear vouchers with the related program according to a unified accounting system. The EPI program among others follows this method of disbursement of funds and the accounting system underlying in this case is activity-based disbursement which is deemed to be more efficient.


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Section 2 Program Characteristics, Objectives and Strategies

This section briefly presents information on the EPI program, its aims and objectives as well as its ongoing strategies. An overview of the program achievements over the past recent years and future approaches is highlighted in addition to the related role of development partners. 2.1 Introduction The national Expanded Program on Immunization began its operation in 1979 as a vertical program within the structure of the MoPHP supported by WHO and UNICEF and others, and it continued as such until 1987 when it was integrated with PHC. Since its creation, six diseases have been targeted through vaccines namely; tuberculosis, poliomyelitis, diphtheria, pertussis, neonatal tetanus and measles. In the year 1998, hepatitis B vaccine was introduced partially in some governorates as a pilot project and it was generalized to nationwide in the year 2002. 2.2 Program objectives and strategies 2.2.1 Program Objectives The overall aim of the EPI is to reduce the morbidity and mortality of vaccine- preventable diseases. To achieve this aim, the program objectives towards:

- Increasing the scope of immunization coverage through several approaches. - Introduction of the pentavalent vaccine covering a wider scope of vaccine-

preventable diseases.

On the other hand, the program is governed by its five-year action plan (2001 – 2005). The specific objectives of the program are:

a) Introducing the Pentavalent vaccine in 2005 and achieving at least 80% coverage of Penta3/OPV3 by the year 2007 for children less than one year.

b) Achieving 60% coverage for pregnant women with TT2+. c) Sustaining the interruption of polio virus. d) Interruption of the indigenous measles virus by the year 2006. e) Ensuring safe vaccination. f) Achieving the maternal neonatal tetanus elimination by the year 2007.

2.2.2 Program Strategies Within the local context and resource limitations, the EPI faces a couple of challenges confronting its effort to achieve the above-mentioned objectives. Nevertheless, the


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program has formulated its own strategies which enable it of providing its crucial services and fulfilling the needs of the growing population. Several approaches and have been in place in addition to many other forthcoming ideas and strategies would enable the program of realizing its aim and objectives. 2.2.2.1 Immunization activities To ensure global coverage target by immunization activities, each health facility defines its target population within its catchment’s area. The health facility plans and conducts its vaccination activities through three strategies: fixed, outreach and mobile services. Currently, there are 2347 governmental health facilities which provide permanent (fixed) vaccination services. The private health sector does not provide any routine vaccination services but they do take part during Polio campaigns. There is a hope that the increasingly growing sector will gradually be integrated into provision of PHC services. Every effort is exerted to ensure all public health facilities provide vaccination services. Social mobilization has effectively contributed to EPI activities and raised public awareness in services provided. The participation of the country’s leadership and seniors in EPI campaigns had a positive influence. Several aspects need to be strengthened to assist the EPI of achieving its aim through the activities performed nation-wide. The program requires more financial resources to increase the scope and scale of services provided. On the other hand, staffing of additional number of qualified technical personal is crucial to ensure the effectiveness of services. 2.2.2.2 Immunization, Decentralization and Integration Within the framework of the decentralization policy, the responsibility of planning, implementing and monitoring immunization activities is performed at the level of governorates and districts under the supervision of the national immunization program. Bottom-up micro-planning process is under implementation in an effort to attain effectiveness and sustainability of the process. Decentralization within the District Health System approach has been in favor of the health system and has assisted in integration of PHC (of which EPI are the corner stone) at the service level. Supervision and support from the governorate health offices plays a major role in ensuring the appropriateness and effectiveness of conduction of these activities. It is early to evaluate the impact of decentralization process on immunization but it is evident that lower levels need to be strengthened in aspects such as training on planning, management, maintenance, etc. 2.2.2.3 Safety injection The governemnt has committed to WHO /UNICEF joint statment of 1999 on safety of injection. A proposal for safety injection has been attached to the strategic plan of action 2001-2005 which was presented with the application to GAVI.


20

2.2.2.4 EPI target diseases surveillance EPI target diseases surveillance system has improved in the last few years. AFP surveillance meets the certification standard but it‘s worth to note that it is positioned under the Epidemiology Department in MoPHP. Measles surveillance has been improving and there is a good coordination between EPI and the Surveillance Department aiming at revealing the actual measles situation in Yemen. Improving the other EPI target diseases surveillance remains a priority. 2.2.2.5 Immunization Schedule The EPI currently targets seven vaccine-preventable diseases and the target groups are children under one year and women in the childbearing age. With the introduction of the pentavalent in 2005, an additional antigen would be introduced (Hib B) and accordingly the immunization schedule for children would change. Routine vaccination of children: The objective of the EPI is to complete vaccination of children before their first birth day according to the following table:

Table (4): Children vaccine schedule:

Vaccine Age of vaccination

BCG, zero dose of OPV Within the 1st week of age DPT1/OPV1/HBV1* At 6 weeks of age DPT2/OPV2/HBV2 At 10 weeks of age DPT3/OPV3 At 14 weeks of age 1st dose Measles/HBV3 & Vit A At nine months of age 2nd dose Measles** At 18 months of age

* HBV has been introduced in 1998. ** 2nd dose of measles was adopted in 2002.

Starting from early 2005, pentavalent will be introduced through the support of GAVI (introducing new vaccine) and the schedule will be as follows:

Table (5): Children vaccine schedule (effective 2005):

Vaccine Age

BCG, zero dose of OPV Within the 1st week of age Penta1/OPV1 At 6 weeks of age Penta2/OPV2 At 10 weeks of age Penta3/OPV3 At 14 weeks of age 1st dose Measles & Vit A At nine months of age 2nd dose Measles & Vit A At 18 months of age


21

Tetanus vaccination for childbearing age women (15-45): The policy is to give all childbearing age women (age 15 to 45), tetanus vaccination with special attention on pregnant women. In addition to the routine vaccination conducted in the health facilities, Maternal & Neonatal Tetanus (MNT) campaigns are conducted in high risk districts. Table (6): Tetanus vaccination schedule – childbearing age women

Dose Schedule TT1 At the first contact TT2 After one month TT3 After six month TT4 After one year TT5 After one year

2.3 Organization of EPI 2.3.1 National level The national EPI Director is responsible for design of immunization policies, coordinating immunization efforts, mobilizing government, international and public support and assisting in controlling of EPI-target diseases. Under the national EPI Director the program has a branch located in Aden Governorate and supervises and supports the southern and eastern governorates. The national EPI program is divided into two main sections: the technical section and finance/ administration section. Technical section: headed by the national EPI technical officer comprises the following units: 1- Operational unit: It consists of eight national operation officers, who are considered the continuous link between the EPI director and the governorates. They provide training and technical assistance to the governorates, in addition to supervision and monitoring the program progress. 2- Data management unit: A computerized information management unit, which collects and analyzes coverage data. Its tasks include monitoring the completeness and timeliness of activities as well as monthly feedback to concerned authorities at different levels.

3 Vaccines management unit: Responsible of receiving and storing all the vaccines and equipments of EPI. Its task includes supply and distribution of all vaccines and equipments to the governorates.

4- Cold chain repair and maintenance unit: Its responsibility is the repair and maintenance of all cold chain equipments as well as of training and follow up of the maintenance sub-workshops in the governorates.


22

Finance and administration section: headed by the finance officer, who handles personnel, finance, budgeting, customs, transport (transport repair and maintenance) and clerical activities and is responsible of establishing appropriate office procedures for the EPI directorate 2.3.2 Governorate level The Director General of Health Office at governorate level has the full responsibility and authority to plan, implement, monitor and supervise EPI activities in his governorate. The director of PHC, and EPI governorate supervisor, together with district supervisors, assist in carrying out these activities. The EPI related governorate health office staff is as follows:

- PHC director - EPI governorate supervisor - EPI district supervisors - Health education officer - Statistical officer - Cold chain stores clerk - Cold chain repair, maintenance technician

2.4 EPI services and performance 2.4.1 Routine immunization EPI activities, as measured by reported coverage, underwent gradual development until 1987. Reported coverage in 1990 for DPT 3/ polio 3 and measles immunization reached 84% and 74% respectively due to the conduction of national campaign supported by WHO and UNICEF. Due to discontinuity of support during the period 1991– 1997 the reported DPT 3/ Polio 3 coverage deteriorated to figures around 40%. In the year 1998, the coverage rate increased to 68% and continued to be in the range of the seventies until the year 2001. Additional resources and revitalization of the program contributed to this substantial increase during this period. Unfortunately the coverage declined in the years 2002 and 2003 to 68% and 65% respectively due to a management gap caused by the delay in government budget disbursement, especially after the government took over the responsibility of purchasing vaccines in 2002. Those management gaps have been overcome to a far extent, which has been reflected in an increase in the coverage rates to 78% for DPT3/OPV3 in 2004


23

Figure (2) % coverage of DPT3/OPV3 1998-2004

Source: National EPI Since the program commenced in 1979, UNICEF used to provide all the vaccines. The situation changed from 2002 onwards, when the government has undertaken the responsibility of vaccines budgeting and procuring through UNICEF. However, the government has been procuring the hepatitis B vaccine since its introduction in 1998. 2.4.2 Polio Eradication Due to the success of the National Immunization Days (NIDs) conducted since 1996 through 2001; the country has become free of wild poliovirus since 1998. SNIDs have been conducted in the last few years and will be conducted according to the epidemiological data. Accordingly, Yemen presents its certification document to the regional certification committee every year. Plans has been prepared to conduct NIDs in 2005 to minimize or eliminate the risk of any importation. 2.4.3 Measles elimination Measles is endemic disease in Yemen and many outbreaks do occur every year. 3046, 1298, 928, 8536 measles cases have been registered in 2000, 2001, 2002 and 2003 respectively. The reason behind the 2003 increase in registered cases is improvement in the surveillance system. Mass campaigns have been conducted in 2001 for children from 9 months to 5 years and have resulted in 94% coverage. A second dose of measles vaccine was adopted in 2003; nevertheless coverage rates are still low. In the year 2005, a catch up campaign are planned in September to interrupt the circulation of indigenous virus. A funding proposal for the campaign has been presented to donors. Mass campaigns for children from 9 months to 5 years are to be conducted every 2-3 years according to epidemiological data. Measles surveillance system is improving but there still room for better achievement. Laboratory diagnoses started in 2003 and more samples have been tested ever since. WHO has supported in provision of laboratory materials especially the reagents.

% coverage of DPT3/OPV3 1990-2004 - Yemen84

47 50 50 5444 47 51

68 72.3 75.9 75.669 66

78

0102030405060708090

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

j


24

2.4.4 Neonatal tetanus elimination Yemen has considered the high-risk approach since 2000 to eliminate neonatal tetanus. 173, 133, 122, 84 neonatal tetanus cases were registered in 2000, 2001, 2002 and 2003 respectively. Several MNT campaigns have been conducted through support of WHO, UNICEF and JICA. An alternative approach besides campaigns is girl vaccination in schools. Another approach besides those mentioned is promoting hygienic delivery carried out in coordination with the reproductive health program. 2.5 EPI Partners The program is in partnership and receives support from the following international and multi/bi lateral organizations and agencies:

- WHO: Supports the program through provision of technical support, training, health education, cold chain supply and transport costs. WHO supports the EPI according to a biennium plan agreed upon with the government of Yemen, which takes into consideration the regional and global objectives. In addition to its regular support the WHO secures extra budget according to the plans and needs of the government.

- UNICEF: Their support is directed towards: o Provision of vaccines which continued until the year 2001. o Health education activities in facilities. o Training on vaccination and cold chain supply.

- GAVI: Their support to the EPI commenced in 2002 towards: o Provision of new vaccines (pentavalent vaccine to be introduced in 2005) o Strengthening of immunization services. o Support to Safety of injections.

- Other Partners: JICA, World Bank (IDA), USAID. Their contributions are very

crucial and will be showed in this plan. 2.6 The Inter-agency Co-ordination Committee (ICC): The Inter-agency Co-ordination Committee (ICC) has been established in 1996 and it is currentlly fully operational. HE the Minister of Public Health & Population is the chair of the commiitee and the heads of the country offices of WHO and UNICEF are among the members of the committee. The membership includes; representatives of the Government of Japan and the World Bank as welll as the Deputy Minister for Primary Health Care and the EPI national manager as a secretary. A core group exists acting as a technical body for the ICC. Its members are the EPI national manager, National EPI advisor, UNICEF health officer and WHO EPI consultant. This group meets regularly and follows up on related issues. Terms of Reference of the ICC:

1. To coordinate support from government, partner agencies and others to strengthen EPI


25

2. To assess the EPI program activities 3. To develop and monitor EPI communication and social mobilization plan 4. To create a fund raising mechanism both externally and locally (government

and private sectors) 5. To ensure co-ordination among key partners and government in planning and

implementation of EPI 6. To provide MoPHP with EPI related technical advices


26

Section 3

Current Program Expenditures and Financing This section gives an overview on the total cost of the EPI and a breakdown by cost category and financial source. The information is presented in the form of a comparison between a Pre-Vaccine Fund and Vaccine Fund Year. 3.1 Quantitative information - pre-vaccine fund program 3.1.1 National Immunization Program cost The total annual cost of the national immunization program in 2001, 2002 and 2003 is estimated to be US$ millions 17, 15.5 and 15 which includes the cost of Supplementary Immunization Activities (SIAs); National and Subnational Immunization Days of polio (NIDs, SNIDs), Measles mass campaign and Maternal and Neonatal Tetanus Campaigns (MNT). Figures show that there has been an increase in the total expenditure on routine immunization activities excluding SIAs, where the budget raised as follows: US$ millions 13.6, 13.4 and 13.3 for the years 2001, 2002 and 2003 respectively. The recurrent and capital expenditure format for the overall national immunization program expenditure is derived from FSP Tool 2004. It clearly appears that the greatest absolute increase in government expenditure has been associated with the procurement of the routine vaccines including Hep B vaccine. The greatest relative increase in expenditure will be with the introduction of the pentavalent vaccine 2006 and onward, when the Government of Yemen (GoY) starts to take over the cost of the new vaccine. 3.1.2 National Immunization Days (NIDs) of cost: During NIDs, oral polio vaccine and Vitamin A are distributed to children under the age of five. The average cost per annum for NIDs has increased since the late 1990s until now. The composition of expenditures for the NIDs differs from those for the routine program. Vaccine is the largest category of expenditures which constitutes around 50 percent of the total budget. In the year 2001, around US$ 1,189,287 was spent on polio vaccines and this amount subsequently decreased to US$ 215,578 in 2003 with the improvements achieved in polio eradication and conducting SNIDs instead of NIDs. The following table (7) illustrates the cost of the NIDs and SNIDs

Table 7: NID and SNIDs cost 2001-2003 Year 2001 2002 2003 Polio Campaigns (total) $2,028,287 $1,725,671 $553,787 Vaccines $1,189,287 $ 543,609 $215,578 Other operational costs $ 839,000 $1,182,062 $338,209

source: FSP Yemen Jan 05


27

The governments share in immunization days has mainly been directed towards the provision of operational costs, which constituted 25%, 30% and 50% of the total cost of the campaigns during the three years. International agencies; WHO, UNICEF and JICA supported those NIDs and SNIDs through the provision of financial support, training, planning, cold chain and health education. All the financial support from the GoY and the donor partners was easily handled and utilized. Another added category in expenditure during the NIDs was the Vitamin A (Vit A) capsules given as a grant from UNICEF. The government paid for the additional operational cost incurred from Vit A provision which was US$ 15,000, 9,000 and 19,000 for the years 2001, 2002 and 2003 respectively. 3.1.3 Measles campaign cost A mass measles campaign had been conducted in 2001 for children aged 9 months to 5 years. A coverage of 94% had been achieved which resulted in a decline in measles cases in the subsequent two years. The campaign cost was around US$ 1 million; vaccines and injection supplies constituted around the half of this cost. The government, WHO and UNICEF shared the full contribution in funding the campaign. 3.1.4 MNT campaign cost: The “high risk approach” had been adopted in Yemen, which implies the conduction of local MNT campaign in high risk districts. The cost of these campaigns was US$ 286,374, 407,338 and 180,546 in 2001, 2002 and 2003 respectively. The GoY and UNICEF were the main financers for these campaigns. 3.2 Sources of Immunization Funds The major source of immunization of funds in Yemen is governmental resources channeled through the MoPHP. Their contribution represents 72 and 85% in 2001 and 2003 of the total funds. The rest of the required resources are secured through international agencies and NGOs. The government pays for salaries, wages, office equipments, maintenance, transportation and operational cost. The government used to partially support the cost of routine vaccines until the year 2001; currently it pays for the full cost of vaccines since 2002. The private sector input to support vaccination delivery is minimal, with hopes that they would take part in EPI operations in the near future. In the year 2001, a total of YR 280 million was paid to the EPI bank account. The fund was divided as follows: expenditures for vaccine make up 35.7% (YR 100 million), wages and overtime accounting for 1.1% (YR 3 million), operating expenses accounting for 7.3% (YR 20.4 million), transportation accounting for 32.8% (YR 91.8 million), rental of cars and equipment accounting for 4.9% (YR 13.8 million) and finally fuel and maintenance expenditures of cold chain, vehicles and office equipment amounted to almost 18.2% (YR 51 million). In the year 2002, a total of YR 285 million was paid to the EPI bank account. The break down of this funs was as follows: expenditures for vaccine make up 37% (YR


28

105 million), wages and overtime accounting for 1.4% (YR 4 million), operating expenses accounting for 3.5% (YR 10 million), transportation accounting for 34% (YR 96 million), rental of cars and equipment accounting for 4% (YR 11.5 million) and finally fuel and maintenance expenditures of cold chain, vehicles and office equipment was almost 20.1% amounted to (YR 57.5 million). In the year 2003, there was an increase in the total expenditure amounting to YR 350 million. The break down of expenditures was as follows: vaccine make up 46.2% (YR 161.8 million), while those for wages and overtime accounting for 1.2% (YR4 million), operating expenses accounting for 4.8% (YR 16.7 million), Transportation accounting for 27.4% (YR 96 million), rental of cars and equipment accounting for 4% (YR14 million), while fuel and maintenance expenditures of cold chain, vehicles and office equipment was 16.4% (YR 57.5 million). The following table illustrates the expenditures for the three years 2001 – 2003 and the change in the amounts per item: Table (8): Governmental payment to EPI bank account (2001 – 2003)

Item 2001 in Million YR

2002 in Million YR

2003 in Million YR

Vaccine 100 35.7% 105 36.8% 161.8 46.2% Wages and overtime 3 1.1% 4 1.4% 4 1.1% Operating expenses 20.4 7.3% 11 3.9% 16.7 4.8% Transportation 91.8 32.8% 96 33.7% 96 27.4% Rental cars and equipments 13.8 4.9% 11.5 4% 14 4%

Fuel and maintenance of cold chain and vehicles 51 18.2% 57.5 20.2% 57.5 16.4%

Total 280 100% 285 100% 350 100% source: FSP Yemen Jan 05 Yemen began receiving GAVI Fund support in June 2002. For the purposes of this document, annual yearly expenditure during 2001-03 has been taken as “pre vaccine expenditure on EPI’. As expenditure on EPI varies from year to year, an average based on the 5-year expenditure will give more realistic figure for the purpose of future financial planning. As shown in Figure 3, 4 and 5, the GoY contribution represented 72 to 85% of the immunization funds while the remaining sources of funds where contributed through the international development partners.


29

Figure 3 Sources of EPI funds 2001

Source of Immunization Funds 2001

National Government

72%

JICA8%

WHO5%

UNICEF9%

World Bank.IDA

6%


Figure4: Sources of EPI funds 2002


National Government

79%

UNICEF5%

JICA2%

World Bank.IDA5%

WHO4%

GAVI - Vaccine Fund5%


Figure 5: Sources of EPI funds 2003


National Government

85%

JICA0.0%UNICEF

3%GAVI - Vaccine

Fund3%

WHO2%

World Bank.IDA7%


30

The above figures illustrate the fact the share of the GoY contribution has increased, which also points out to the fact that EPI activities are receiving considerable attention and prioritization. This fact that there has been a trend of increased finances and that the GoY is the major financer is also significant since it allows future predictions that the government will remain to play the same role. Introducing of the GAVI vaccine funds will be an asset to face any difficulties in the future. It is worth to note that, as with all new initiatives aiming at establishing baseline information on a national scale, there are inherent limitations in the completeness and validity of data.

3.3 Current EPI Funds In the year 2004, the total expenditure on EPI was US$ 15 million. The vaccine and injection supplies expenditures which include supplemental immunization activities account to 15.4% (US$ 2.5 million), while those for wages and overtime account for 24.7% (US$ 4 million). On the other hand, operating expenses account for 6.8% (US$ 1.1 million), capital costs including cost of new cold chain account for 6.8% (US$ 1.1 million), shared cost which include building and fixed assets account for 32.7% (US$ 5.3 million) and finally maintenance and overhead expenditures of cold chain, vehicles and office equipment amount to 13.6% (US$ 2.2 million). The following table illustrates the current expenditures for the year 2004. Table (9): Total current EPI Expenditures 2004:

Item Total expenditure in US $ million Percentage

Vaccines & injection supply 2.2 15% Wages and overtime 4.1 27% Operating expenses 1.2 8% Shared cost (including building and fixed asset) 5.3 35%

Maintenance and overhead expenditure 2.2 15% Total 15 100% source: FSP Yemen Jan 05 In the year 2004, the government fully contributed to the total cost of routine and underused vaccines which constituted US$ 1,094,092. Its contribution towards the total cost was the main share of EPI cost which constituted 87% of the total expenditure. The following figure (6) illustrates the source of funds for the year 2004.


31

Figure 6. Source of EPI funds

source of EPI funds 2004

87%

5%

2%2%1%

3%

Government

UNICEF

WB/IDA

WHO

GAVI

JICA


3.4 Trend in EPI Expenditure By comparing the total expenditure on EPI from 2001 to 2003 (Pre-Vaccine and Vaccine Fund Year), data shows that the amount of funding decreases. The reduction in expenditure is explained by the fact that supplementary immunization activities, which were conducted in 2001 and 2002 constituted the added amounts in the expenditure, rather than the cost of routine recurrent cost. Thus the total expenditure on routine recurrent EPI is considered stable with a reasonable increase from year to year. Figure 7: EPI expenditure 2001-2004

EPI Expenditure 2001-2004In US$ million

$-

$4

$8

$12

$16

$20

Total EPI Exp. $17 $15.5 $15.4 15

Routine Recurrent Exp. $6.8 $7.7 $8.0 9

2001 2002 2003 2004

source: FSP Yemen Jan 05 It is worth to mention here, that the GoY pays to the EPI bank account the program operational cost on the level of the headquarter, governorates and districts level. It also transfers an additional amount of funds to UNICEF to procure the vaccine. This


32

annual payment (including operational cost of NIDs) rose from YR 280.3 million (US$ 1.6 million) in 2001 to about YR 350 million (US$ 2.1 million) in 2003. The GoY expenditure for routine EPI vaccines during 2001 was YR 37 million and YR 63 million for the cost of Hepatitis B vaccine. This amounts to YR 100 million (US$ 605,000), which represents 35.7% of the total amount paid from the government. The expenditure on routine EPI vaccines by the government during the year 2004 is YR 300 million (US$ 1.6 million) which represents the total cost of procuring vaccines. The contribution of the government to operational costs for 2004 has not yet been finalized. The average annual expenditure which has been paid directly to the EPI bank account over the period 2001-03 was YR 305 million (US $ 1.6 million). The following figure illustrates the trend of gradual increase of governmental inputs to the EPI and in particular towards the cost of the vaccine. . Figure 8.Government Payment to EPI Bank Account 2001-2004

Government payment to EPI bank account (YR Million)

0

50

100

150

200

250

300

350

Vaccine 100 105 161.8 300

Wages and Overtime 3 4 4 4

Operating Expenses 20.4 10 16.7 91.5

Transportation 91.8 96 96 108

Rental of cars and equipment 13.8 11.5 14 11.5

maintenance (cold chain, vehicles andoff ice equipment)

51 57.5 57.5 65

2001 2002 2003 2004

Source: FSP Yemen - Jan 2005

There has been a considerable increase in the total government expenditure on EPI from 2001 to 2003 which is mainly attritubale to the fact of vaccine procurement. The reason of the slight decrease in 2004 is due to the absence of supplementary campaigns. The following figure (9) illustrates the total government expenditure on EPI (2001 to 2004):


33

Figure 9 Governmental expenditure on EPI 2001-2004

Total Governmental Expenditure on EPI 2001-2004 (US$)

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

Gov 12,173,714 12,203,227 13,006,018 12,959,906

2001 2002 2003 2004

source: FSP Yemen Jan 05 The international partners’ contribution varies from year to another and the pattern follows their agreed upon financing plans and action plans. WHO and UNICEF have fixed allocated amounts through their regular budget but their secure extra-budgets varys according to planned supplementary immunization activities. JICA and the World Bank have multi-year plans with governemnt, therfore their spending varies from a year to another. The following figure (10) clarifies the international partners expenditure on EPI 2001-2004 : Figure 10: International partners expenditure on EPI 2001-2004

International Partners Expenditure on EPI 2001-2004 (US$)

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2001 0 1669117 1321287 843765 1059488

2002 736078 762446 340000 656177 751864

2003 519200 461629 16000 357472 1020500

2004 232000 755000 222150 270390 487500

GAVI - Vaccine Fund UNICEF JICA WHO World Bank.IDA



34

3.5 Basic data analysis

The total expenditure on EPI from all resources has increased from 2001 to 2003. Although the absolute figures reflect a slight decrease in 2003, the reason is the suspension of NIDs and measles campaign according to the technical plans. The routine expenditure (excluding the SIA) has increased annually as shown in the following figure (11):

Figure 11 Total EPI expenditure Versus routine expenditure:

Total Exp. Vs Routin Exp. on EPI

$-$2$4$6$8

$10$12$14$16$18

Total EPI Exp. $17 $15.5 $15.4 15

Rouitne cost $13.6 $13.40 $14.30 14.2

2001 2002 2003 2004


It is clear that the government had the major share in funding the national

immunization program. It also evident that the payment of the government is increasing on routine EPI and especially on the cost of the routine vaccine. The reason is the take over of the cost of the vaccines since 2002.

The program cost as a share of the government health spending plus total

donor support is hard to estimate due to unavailability of data. The MoPHP is in its way of completion a comprehensive analysis of health expenditures from all sources and presenting a NHA report covering the period 1999 – 2003. This report would present relevant data on program share of total health spending from different sources.

Routine vaccine including the traditional and the underused vaccine (Hep B)

represented 7%, 8% and 8% of the total cost of EPI in 2001, 2002 and 2003 respectively. The increase in the amount of resources devoted to EPI is due to the fact of gradual introduction of Hep B vaccine, Figure (8) and table (10)


35

Table (10). Governemnt Annual payment to EPI bank account:

Vaccine 100 35.7% 105 37.0% 161.8 46.2% 300 51.7%Wages and Overtime 3 1.1% 4 1.4% 4 1.1% 4 0.7%Operating Expenses 20.4 7.3% 10 3.5% 16.7 4.8% 91.5 15.8%Transportation 91.8 32.8% 96 33.8% 96 27.4% 108 18.6%Rental of cars and equipment 13.8 4.9% 11.5 4.0% 14 4.0% 11.5 2.0%maintenance (cold chain, vehicles and office equipment) 51 18.2% 57.5 20.2% 57.5 16.4% 65 11.2%

TOTAL 280 100% 284 100% 350 100% 580 100%

2003in million YR

2004in million YRin million YR

2001in million YR

2002

Source: FSP Yemen – Jan 2005

The cost per fully-immunized child as of the year 2003 (considered here as a

child whom has received three doses of DPT and OPV) is US$ 30.68. This figure has increased from US $ 25.71, 30.23, 30.68 in 2001, 2002 and 203 respectively. The increase of the cost per fully immunized child is attributable to the low coverage rates in 2002 and 2003 and the high wastage rate of vaccine. The cost includes every thing except the cost of the SIAs, while the average routine recurrent EPI cost per child was about US$ 17 for the period 2001 to 2003. Lessons are to be learnt in such a case where targets could have been achieved especially with the availability of infrastructure and resources.

Of total routine EPI annual expenditures for 2003, GoY is providing US$ 13

million, whereas external donors/EPI partners are providing US$ 2.3 million, while the same figure for 2001 was US$ 12.2 million for the government and the external donors was US$ 4.8 million Table (11).

Table (11). Funding trends for Routine EPI

EPI expenditure 2001 2002 2003 2004 US$ US$ US$ US$

National Government $12,173,714 $12,203,227 $13,006,018 $12,959,906 GAVI – Vaccine Fund $ - $ 736,078 $ 519,200 $ 232,000 UNICEF $ 1,669,117 $ 762,446 $ 461,629 $ 755,000 JICA $ 1,321,287 $ 340,000 $ 16,000 $ 222,150 WHO $ 843,765 $ 656,177 $ 357,472 $ 270,390 World Bank.IDA $ 1,059,488 $ 751,864 $ 1,020,500 $ 487,500 USAID-ADRA $ - $ - $ - $ 20,000

Total $17,067,370 $15,449,792 $15,380,818 $14,946,946 Source: FSP Yemen – Jan 2005

By comparing the government contribution on EPI to international partners, its

share is major and has increased substantially over the past years. The GoY share was 72%, 79%, and 85% in the years 2001, 2002 and 2003 respectively, and it was increased to 87% in 2004 as shown in the following figure:


36

Figure 12 Government Vs international expenditure on EPI (%)

Government Vs international expenditure on EPI (%)

7279

8587

2821

1513

2001

2002

2003

2004

Gov Exp. Intl Exp.



37

Section 4

Future Resources Requirements and Program Financing / GAP Analysis

This section estimates and analyzes the gap between future resource requirement and available financing to achieve the programs targets and strategies explained in section 2 over the current commitment year and for few years after. 4.1 Introduction To estimate and analyze the gap between future resource requirement and available financing the starting point is set as the multiyear financial plan. The method of estimation is:

• Measurement of the current available resources of NIP by types of inputs (vaccines, personnel, etc) the activity or approach used (routine or supplemental) and who is expected to contribute (Government and donors)

• Determination of the additional resources required over several years • Identification of the funding available to match these additional requirements • Estimation and clarification of the cause of the funding gaps.

To estimate the gap, a background summary of resources over the current commitment year has been developed in section 2 and 3. 4.2 Major Challenges facing Program Expenditures and Costs: Although major advances have been acheived over the last two decades in terms of strengthening and the public heatlh system, quality of service, coverage and accessibility still represent major challenges. Relisation of the reform efforts emabrked on by the MoPHP in 1998 have not yet been realised. The reform focuses on mangement improvement, decentrilsation and adoption of the Districh Health System (DHS). These elements among others would ultimately have a positive implication on the services provided. Nevertheless, the provision of basic health services has resulted in a drop in the IMR from 80 in 1996 to 75 in the last five years as well as a decline in U5MR from 112 in 1996 to 102 in the same period.

There are two principal financial sources for immunization activities in Yemen; the government funds and the international development partners. International agencies have exerted a major effort to meet the shortfall in required budgets through fund raising mechanism. When the GoY faced difficulties in meeting immunization cost needs and commitments in 2001, the international agencies backed their effort and assessed in meeting these needs.


38

It is evident that the greatest absolute increase in expenditure has been associated with the procurement of the routine vaccines. The GoY used to contribute partially to the cost of vaccine which was provided by UNICEF until 2001, and then in 2002 the government took over the cost of the vaccine for routine immunization which was a major challenge. The MoPHP has proposed to expand GAVI support for introducing the new vaccine (Pentavalent) from 5 years to 10 years. This would help the GoY to take over gradually the cost of the new vaccine. This effort is in close consultation and support of the Ministry of Finance. 4.3 Projection of Resource requirements (Refer to Annex 1 to 4) As the year 2004 has been passed and it was analyzed in the section three under the recurrent cost, the projections have been made for the period from 2005 to 2013 except for the pentavalent cost the projection was for 2005 to 2014 because there was an agreement with GAVI that the government will start to take over the cost starting from 2006 - 2014 and GAVI support will finish in 2014 as it will be explained in the next paragraph. As the figure (13) below demonstrates that the main cost would be allocated to Personnel and secondly the cost of the new vaccine. Fortunately both items ahs a top priority from GoY and GAVI and their fund is considered secure. Figure (13): Projection of Future Resources Needs.

Projection of Future Resource Needs (US$ Millions)

$-

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

$35.0

$40.0

$45.0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Other optional information

Other SIAs

Measles Campaigns

Polio Campaigns

Other capital costs

Cold chain equipment

Vehicles

Other routine recurrent costs

Transportation

Personnel

Injection supplies

New and underused vaccines

Traditional Vaccines

FSP tool Yemen Jan 05 4.3.1 Routine Recurrent Cost 4.3.1.1 Vaccines The basic EPI program involves the usage of BCG, DPT, OPV, Measles and TT vaccines. So far, these vaccines including Hep B vaccine have been totally supplied by the GoY since 2002 and the amount paid reached to YR 105 million (US$


39

630,000). The total vaccine procured by the government was YR 161.8 million (US$ 893,000) in 2003 and reached to YR 300 million (US$1,6262,000) in 2004 (Table 10). Starting from the year 2005, the pentavalent vaccine (DPT_HepB_HIB) will be introduced to the EPI schedule and the cost of this vaccine will be supported by GAVI. Their commitment is estimated to be US$ 52,900,500 over the period of 10 years including the freight. The government will gradually contribute to the cost from the beginning where it would pay 10% of the cost in 2006. Its share would increase subsequently by 10% annually until it is totally funded by internal resources in the year 2015. (see the below table) Table (12): Governemnt and GAVI support for the Vaccine Cost (In US$)

Government Contribution Year Vaccine cost

% #

GAVI Contribution

2005 8,069,620 0 - 8,069,620 2006 6,323,864 10% 632,386 5,691,478 2007 6,974,800 20% 1,394,960 5,579,840 2008 7,211,943 30% 2,163,583 5,048,360 2009 7,923,221 40% 3,169,289 4,753,932 2010 8,192,611 50% 4,096,305 4,096,306 2011 8,969,463 60% 5,381,677 3,587,786 2012 9,274,425 70% 6,492,098 2,782,327 2013 9,589,755 80% 7,671,805 1,917,950 2014 9,915,807 90% 8,924,226 991,581 2015 10,252,944 100% 10,252,944 0

Source: FSP Yemen – Jan 2005 The government will continue to pay for the traditional vaccines which will cost US$ 10,209,156 over the period 2005 – 2013, Table (13). The total vaccine cost would represent an annual average of 28% of the total cost of the EPI as the following tables: Table (13): Government support for the traditional vaccine (in US$) Year 2005 2006 2007 2008 2009 2010 2011 2012 2013 2005-2013

Traditional Vaccine

cost 867,812 925,610

1,007,865

1,078,280

1,152,319

1,230,146

1,271,971

1,315,218

1,359,935

10,062,383

source: FSP Yemen Jan 05 Table (14): % cost of all vaccine out of the total EPI cost

Year 2005 2006 2007 2008 2009 2010 2011 1012 2013

% vaccine cost 22% 22% 25% 25% 28% 24% 26% 28% 29%

source: FSP Yemen Jan 05 4.3.1.2 Injection Supplies Disposable syringes have been used for routine immunizations for a couple of years. GAVI and IDA assisted in procuring Auto-disposable (AD) syringes for three years


40

and the GoY utilized this support for an additional year covering the period 2001-2004. From the year 2005 onwards, AD syringes for routine EPI and measles and MNT campaigns will be procured by GOY at an estimated cost of US$ 615,542 in 2005 and amounting to US $ 1.1 million in 2013 (Table 3). The total injection supplies required for the period 2005-2013 is estimated at US$ 8.6 million Table (15): Injection supplies 2005- 2013

Year Injection Supplies (in US$)

2005 575,018 2006 651,702 2007 804,352 2008 877,995 2009 967,259 2010 1,049,642 2011 1,097,672 2012 1,134,993 2013 1,173,583

Total Injection supplies 8,332,216

Source: FSP Yemen - Jan 2005 4.3.1.3 Staff One of the major factors resulting in low coverage rates and inadequate performance is the issue of poor management and supervision on certain levels in the EPI program. Therefore an increase in staff has been the choice which is to take place starting 2005 at all levels. Medical and technical staff will be employed at the central level as well as strengthening of the mid level (governorate and district level) would be crucial. The bulk increase in the staff would be at the service level where there is a need to have two vaccinators at every post. Cost assumptions related to current and additional staffing is part of the national and governorates budget. Current full and part-time committed staff costs in the EPI program were estimated within the government expenditure. Annual pay per full time NIP health workers, allowances and per-diems for outreach vaccinators/mobile teams were estimated and the percentage of time devoted to EPI calculated to derive annual EPI- related staff costs. A total of US $ 8 million is estimated for 2005 and US $ 12.4 million in 2013. The total staff cost for the period 2005-2013 is estimated at US $ 94 million.


41

Table (16): Personnel Cost 2005- 2013

Year EPI Workers

Per-diems for outreach vaccinators/

Mobile team (in USD)

Total Personnel (in USD)

2005 7,025,821 1,154,345 8,180,166 2006 7,917,482 1,329,787 9,247,269 2007 8,243,392 1,386,544 9,629,938 2008 8,587,121 1,446,470 10,033,591 2009 8,949,410 1,509,697 10,459,107 2010 9,333,783 1,576,861 10,910,644 2011 9,739,794 1,647,878 11,387,672 2012 10,169,784 1,723,171 11,892,955 2013 10,624,780 1,802,922 12,427,702 Total 80,591,367 13,577,675 94,169,044


4.3.1.4 Transportation This item covers the petrol and maintenance of the vehicles for both the fixed sites and vaccine delivery and outreach activities. In developing a future forecast a 2% increase in the price of petrol was incorporated as well as estimation of maintenance cost of 15% of the fuel cost was used. A total of US$ 10,697 is estimated for 2005 and US $ 341,883 in 2013. The total cost for the period 2005-2013 is estimated at US$ 2.4 million. The cost of this item will most likely be covered through the government budget. 4.3.1.5 Maintenance and Overhead This item covers both maintenance and overhead mainly for building, Cold Chain equipments, ice for campaigns and the other recurrent cost like computers. In the calculations an average useful life year of 5 years cold chain was used, as well as a 2% increase in the price of the cold chain equipment. Maintenance cost was estimated as 5% of the capital value. A total of US$ 2.1 million is estimated for 2005 and US$ 3.3 million in 2013. The total maintenance and overhead cost for the period 2005-2013 is estimated at US$ 26.5 million. These costs will be incurred by government. 4.3.1.6 Short Term Training A key strategy to improve program performance is the focus on regular basic and refreshment training. Training is recommended to cover the EPI modules of training mid level managers. The training will include new technical issues such as management and administration of new vaccine and computing use for EPI. An amount of US$ 116,236 will be spent on this account in 2005 and total funds for the period 2005-2013 would accumulate to US$ 1.133 million. (Annex 1). Support to training is most likely to be covered by international partners namely; WHO and UNICEF.


42

4.3.1.7 IEC / Social Mobilization Social mobilization has played a major role in the success of NIDs. Several approaches would be employed namely; advocacy meetings, training, inter-personal communication, local means, mass media and distribution of leaflets to parents and announcing for outreach and mobile vaccination sessions. The future costs of social mobilization would amount to US$ 670,184 for 2005-2013 (an annual average of US$ 75,000). Government as well as international partners such as GAVI, WHO, UNICEF, and other partners are most likely to cover the expenses of such activities.. 4.3.1.8 Supervision, Monitoring and Disease Surveillance A total of US$ 596,882 is estimated for 2005 and US$ 1 million in 2013. The total cost for the period 2005-2013 is estimated at US$ 8.1 million. The government and the international partners will make joint contribution to this item. 4.3.2 Routine Capital Cost 4.3.2.1 Vehicles Transport capacity needs to be expanded in order to extend routine immunization and ensure effective supervision and mobile sessions. An average useful life year of vehicles of five years was used in calculations. The major increase in the fleet of vehicles is planned to take place in 2005 with a minimum increase in the following years in addition to replacement of the existing vehicles. This will require approximately US$ 8.2 million as capital cost. There has been an allocated amount earmarked by EPI GAVI and the remaining amount is likely to be provided by the Government and donors/EPI partners. 4.3.2.2 Cold Chain Development Much of the current cold chain infrastructure was supplied in the last 10 years and is now reaching the end of its useful economic life, therefore the existing cold chain needs replacement. Upgrading the cold chain is needed to increase the capacity especially with the introduction of pentavalent vaccine and to meet the network of new sites offering immunization. Cold chain replacement and expansion plan for the period of 2005-2013 (Annex 1) requires US$ 17.6 million. This amount is likely to be provided by GAVI, GoY and other EPI partners. 4.3.2.3 Other capital cost This item includes computers, photocopiers and fax machines, incinerators, operators, servers and laptops. Estimated requirements for the year 2005 amounted to US$ 132,339 and a total of USD 1 million for the period of 2005-2013. It is most likely that the international partners will support this item. 4.3.3. Routine versus supplemental immunization Providing immunization services through fixed sites will constitute the major portion of required funding which in other words is a sustainable approach. Outreach services


43

would increasingly receive increased resource portions from year to year. This reflects the fact that activities directed towards strengthening the reach hard to reach children is emphasized on. Campaigns will constitute a major portion in some years especially in 2005 when a mass catch campaign of measles is planned for children from 9 months to 15 years. Another increase in the campaign budgets is planned in the years 2008 and 2009 when a mass follow up measles campaign is planned. On the other hand, Polio NIDs is planned in 2005 and 2006 and SNIDs and MNT campaign will continue until 2007. Local campaigns in high risk areas will be conducted annually according to the epidemiological situation. Td vaccination for students’ of school will substitute the MNT campaign. The following figure (14) explains the resource allocated to every approach. Figure 14: Immunization cost by strategy:

Immunization Costs by Strategy (US$ Millions)

$0.0

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

$35.0

$40.0

$45.0

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Campaigns

Outreach

Fixed Site Delivery


As explained above in 4.3.1 and 4.3.2 the cost of routine immunization activities were highlighted according to the cost category. The cost of supplementary immunization activities from 2005-2013 will represent about 5.7% of the total cost of EPI. 4.4 Future Financing level Projections and Patterns GoY will allocate an amount equivalent to US$ 214 million as secure and probable fund for EPI during the period 2005-2013 as illustrated in tables 17, 18 and 19. This fact is based on the experience of the past few years and governments commitment towards EPI. The EPI multi-year plan has been approved by the government and accordingly its contribution is classified as secured. On the other hand, GAVI support of around US$ 43 million for pentavalent vaccine (freight wages will also be paid by GAVI) in addition to some other US$ 3 million in 2005 and 2006 for other activities are classified as secured and would substantially complement the GoY and other partner’s contribution.


44

JICA is committed to support an amount of US$ 480,000 as secured fund. Future support is expected from JICA which is to be discussed further; therefore around US$ 6.1 million is their probable fund for the period 2005 to 2008. The World Bank (International Development Agency) will initially support to an amount of around US$ 2.5 million for the years 2005 and 2006 as a probable fund. Another amount of about US$ 800,000 for 2005 would be available as a probable fund through their package service PIMAC. WHO will secure an amount of US$ 300,000 per year. Another US$ 1,000,000 will be contributed to the NIDs in 2005 and 2006. UNICEF will contribute an amount of US$ 300,000 yearly. Potential contributions are expected form USAID through several operating agencies (ADRA) and future support within expected World Bank projects and programmes. The fact that international agencies do not have medium term plans and projections it is difficult to project their contributions for the whole period covering 2005 – 2013. The following table highlights the secure funds covering the period of FSP. Other international partners have expressed their interest and willingness to contribute to future EPI requirements. Table 17: Secure Funding EPI Cost 2005- 2013 Secure Funding 2005 2006 2007 2008 2009 2010 2011 2012 2013 2005-2013

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$National Government 17,550,057$ 18,962,992$ 19,354,585$ 20,776,187$ 22,362,604$ 24,028,344$ 25,953,420$ 27,739,405$ 29,529,884$ 206,257,477$ GAVI - Vaccine Fund 9,092,669$ 6,871,265$ 5,779,840$ 5,048,360$ 4,753,933$ 4,096,305$ 3,587,785$ 2,782,327$ 1,917,951$ 43,930,435$ UNICEF 300,000$ 300,000$ -$ -$ -$ -$ -$ -$ -$ 600,000$ JICA 480,000$ -$ -$ -$ -$ -$ -$ -$ -$ 480,000$ WHO 800,000$ 300,000$ -$ -$ -$ -$ -$ -$ -$ 1,100,000$ World Bank.IDA -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ USAID-ADRA -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ PHR+ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ PIMAC 704,071$ -$ -$ -$ -$ -$ -$ -$ -$ 704,071$

Total Secure Funding 28,926,797$ 26,434,257$ 25,134,425$ 25,824,547$ 27,116,537$ 28,124,649$ 29,541,205$ 30,521,732$ 31,447,835$ 253,071,983$ Total Cost / Resource Req 40,545,301$ 33,418,206$ 32,563,259$ 32,733,171$ 32,612,527$ 38,622,416$ 40,025,535$ 38,384,671$ 37,913,201$ 326,818,287$ Funding Gap 11,618,504$ 6,983,949$ 7,428,834$ 6,908,624$ 5,495,990$ 10,497,767$ 10,484,330$ 7,862,939$ 6,465,366$ 73,746,304$

Figure 15. Secure Funding towards EPI Cost by Partners 2005- 2013 Secure fund of EPI 2005-2013

GAVI - Vaccine Fund17.4%

UNICEF0.2%

JICA0.2%

WHO0.4%

PIMAC0.3%

National Government

81.5%


45

Projections for probable funds are based on historical trends and/or other information and which is likely that funds will be made available. The anticipated probable funds required are illustrated in the Table (18) for the period 2005 – 2013. These allocated resources have been negotiated and there has been initial consent to allocate these resources. Table 18: Probable Funding of the EPI Cost 2005- 2013 Probable Funding 2005 2006 2007 2008 2009 2010 2011 2012 2013 2005-2013

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$National Government 650,400$ -$ 829,247$ 888,415$ 957,780$ 1,024,000$ 1,070,573$ 1,111,789$ 1,154,880$ 7,687,083$ GAVI - Vaccine Fund -$ -$ 321,741$ 351,198$ 386,904$ 419,857$ 439,069$ 453,997$ 469,433$ 2,842,198$ UNICEF -$ -$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 2,100,000$ JAICA 1,840,559$ 1,566,559$ 1,368,559$ 1,368,559$ -$ -$ -$ -$ -$ 6,144,236$ WHO -$ 500,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 2,600,000$ World Bank.IDA 2,086,202$ 454,828$ -$ -$ -$ -$ -$ -$ -$ 2,541,031$ USAID-ADRA -$ -$ 138,654$ -$ -$ -$ -$ -$ -$ 138,654$ Partenars For Health Refo -$ -$ 346,636$ -$ -$ -$ -$ -$ -$ 346,636$ PIMAC -$ 800,000$ -$ -$ -$ -$ -$ -$ -$ 800,000$

Total Probable Funding 4,577,161$ 3,321,387$ 3,604,837$ 3,208,172$ 1,944,683$ 2,043,857$ 2,109,642$ 2,165,786$ 2,224,314$ 25,199,839$ Total Resource Requireme 40,545,301$ 33,418,206$ 32,563,259$ 32,733,171$ 32,612,527$ 38,622,416$ 40,025,535$ 38,384,671$ 37,913,201$ 326,818,287$ Funding Gap 35,968,140$ 30,096,819$ 28,958,422$ 29,525,000$ 30,667,844$ 36,578,559$ 37,915,894$ 36,218,885$ 35,688,888$ 301,618,448$ source: FSP tool Yemen Jan 05

As a conclusion, the total available funds for EPI during 2005-2013 are therefore US$ 278,271,822 as secure and probable fund and US$ 48,516,465 is the remaining gap. The below table (19) and figure illustrates the share of each partner towards the total cost of EPI during the period 2003 – 2015. Table 19. Secure and probable fund 2005-2013 Secure + Probable Funding 2005 2006 2007 2008 2009 2010 2011 2012 2013 2005-2013

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$National Government 18,200,457$ 18,962,992$ 20,183,832$ 21,664,602$ 23,320,384$ 25,052,344$ 27,023,993$ 28,851,194$ 30,684,764$ 213,944,561$ GAVI - Vaccine Fund 9,092,669$ 6,871,265$ 6,101,581$ 5,399,558$ 5,140,837$ 4,516,162$ 4,026,854$ 3,236,324$ 2,387,384$ 46,772,633$ UNICEF 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 2,700,000$ JICA 2,320,559$ 1,566,559$ 1,368,559$ 1,368,559$ -$ -$ -$ -$ -$ 6,624,236$ WHO 800,000$ 800,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 3,700,000$ World Bank.IDA 2,086,202$ 454,828$ -$ -$ -$ -$ -$ -$ -$ 2,541,031$ USAID-ADRA -$ -$ 138,654$ -$ -$ -$ -$ -$ -$ 138,654$ PHR+ -$ -$ 346,636$ -$ -$ -$ -$ -$ -$ 346,636$ PIMAC 704,071$ 800,000$ -$ -$ -$ -$ -$ -$ -$ 1,504,071$

Total Secure + Probable Fu 33,503,958$ 29,755,644$ 28,739,262$ 29,032,719$ 29,061,220$ 30,168,506$ 31,650,847$ 32,687,518$ 33,672,149$ 278,271,822$ Total Resource Requireme 40,545,301$ 33,418,206$ 32,563,259$ 32,733,171$ 32,612,527$ 38,622,416$ 40,025,535$ 38,384,671$ 37,913,201$ 326,818,287$ Funding Gap 7,041,343$ 3,662,562$ 3,823,997$ 3,700,453$ 3,551,307$ 8,453,910$ 8,374,689$ 5,697,153$ 4,241,053$ 48,546,465$ source: FSP tool Yemen Jan 05


46

Figure 16. Secure & Probable Funding by Partners 2005- 2013

Secure & Probable Funds 2005-2013

National Government77%

World Bank.IDA1%

GAVI - Vaccine Fund17%

UNICEF1.0%JICA

2%

WHO1.3%

PIMAC0.5%

USAID-ADRA0.00%

PHR+0.01%


4.5 Gap Estimates (Resource Requirements – Secure & Probable Funding). As mentioned above, the required resources for EPI in Yemen for 2005-2013 is estimated to be US$ 327 million Table (19). Most of this cost is likely to be borne by GoY and GAVI. It is estimated that the other EPI Partners will provide US$ 17.5 million for the period 2005 - 2013. This is over and above the current contribution which amounts to US$ 3 million already provided from, UNICEF, JICA and WHO in 2004. Keeping in view the trend of support for EPI by Partners during 2001 - 2004, the average yearly total EPI cost was US$ 16 million where on average support of US$ 3 million was provided in 2004 by those donors. GAVI and the GoY provided the difference in resource required. GAVI will be playing a greater role in assisting the government in introduction of the pentavalent vaccine by providing the total cost in 2005 and 90% in the next year. The GoY would contribute to the remaining cost of the pentavalent vaccine and increasing gradually until 2015 when its contribution would be the total cost. The two following figures (17 & 18) on secure and probable funds and the funding gaps illustrate the fact that the gap is increasing when we go far in projection. That is because it is difficult for some partners to commit themselves further than two to four years. GAVI support have agreed upon with the GoY to be extended until the year 2014. There seems to be a peak in the funding gap in 2005 which is due to the fact that required funds for the measles mass campaigns have not been secured. Another peak is in 2010 and 2011 because of the major replacement of cold chain and vehicle in addition to the planned mass measles campaign.


47

Figure 17: Future Secure financing and Gaps: Future Secure Financing and Gaps (US$ Millions)

$-

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

$35.0

$40.0

$45.0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Funding Gap

0

0

PIMAC

PHR+

USAID-ADRA

World Bank.IDA

WHO

JICA

UNICEF

GAVI - Vaccine Fund

Sub-national Gov.

National Government

source: FSP tool Yemen Jan 05

Figure 18: Secure and Probable financing and Gaps: Secure and Probable Funding and Gaps (US$ Millions)

$-

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

$35.0

$40.0

$45.0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Funding Gap

0

0

PIMAC

PHR+

USAID-ADRA

World Bank.IDA

WHO

JICA

UNICEF

GAVI - Vaccine Fund

Sub-national Gov.

National Government

source: FSP tool Yemen Jan 05 4.6 Analysis of the Gap in Addition to wht

The total funding gap from 2005 to 2013 is estimated at US$ 48,546,465. Around 55% of this gap stands in the period from 2010 to 2013.

Fortunately the total cost of vaccine US$ 82,445,509 will not be affected

by the funding gap since the vaccine will be fully supported from the GoY and GAVI.


48

Section 5

Sustainable Financing Strategy, Action and Indicators This section deals with the strategies and steps to be taken towards financial sustainability. This is based on prior analysis and the feasibility of embarking on these options. It also includes a set of targets and selected evaluation indicators to be employed to achieve these targets. 5.1 Introduction In an effort to set a list of strategies which would enable the EPI to sustain its finance, an in depth exploration of the whole situation has been presented. Through the prior two sections (section 3 and 4) an analysis of all aspects of EPI finance have been considered and the outcomes are to be used to develop appropriate strategies and approaches. The forthcoming sections analyze the main drivers of EPI cost and the main drivers of funding. This analysis allows for better understanding on the future of the EPI. The result of this analysis is summarized in the section discussing the Main FSP Findings. 5.2 The main drivers of EPI cost The total cost of EPI in 2005 is taken as an example for the main drivers of EPI. The below table and figure show that the main driver of EPI cost is the basic program cost which constitutes 39.7% financed by the government. The second major driver is the cost of pentavalent vaccine 19.9% which will be financed together by the government and GAVI until 2014. Capital costs which constitute US$ 4.5 million 11.2% is the third major driver. This includes mainly the cold chain and the transportation means and it most likely that this would be an area where partners are requested to contribute. In addition to that there are some other important drivers and areas that the partners would be requested to contribute like: training, enhancing supervision, EPI target diseases surveillance and the SIA. Table 20: Main Drivers of EPI cost in 2005

co st d river ab so lu te co st %

T rad itional V accines 867 ,812 2 .1

N ew and underused vaccines 8 ,069 ,620 19 .9

In jection supp lies 575 ,018 1 .4

B asic p rogram 16 ,113 ,720 39 .7

T rain ing 781 ,822 1 .9

C apital C osts 4 ,531 ,150 11 .2

S IA s 9 ,606 ,159 23 .7

T o ta l 40 ,545 ,301 100 .0

M ain d rive rs o f E P I co s t in 200 5


49

Figure 19: Main drivers of EPI in 2005

Main drivers of EPI cost in 2005

Traditional Vacc2%

Penta21%

Capital 12%

SIAs18%

AD1.5%

Basic program46%

5.3 The main drivers of EPI funding: As it was clear some partners couldn’t make any financial commitments beyond 2008. Therefore it was preferred to explore the finances during the period 2005 – 2008. According to the below table and figure the main financing of EPI is the government 70% and in the second place GAVI 18.4%. In the third and fourth place are JICA 6.2% and the World Bank 2.3% among the other EPI financers. Others contributions are on a smaller scale but it is still required and appreciated. Only GAVI as an external donor is committed to continue its support till 2013. On the other hand, the GoY contributions to EPI are expected to remain major and increase over the forthcoming years. The government increases the budget of the MoPHP by 5 – 10% annually with focus on PHC activities and EPI. It is envisaged that there would be an increase in the remuneration scale if civil servants in the overall effort of increasing the productivity of the governmental sector. Implications of such an increase would substantially increase the share of the government funding of EPI.

Table 21: Main Drivers of EPI cost in 2005

Financing drivers 2,005 2 ,006 2 ,007 2 ,008 US$ US$ US$ US$

G overnm ent 18,200,457 18,962,992 20,183,832 21,664,602

G AVI 9,092,669 6 ,871,265 6 ,101,581 5,399,558

UN ICEF 300,000 300,000 300,000 300,000

JICA 2,320,559 1 ,566,559 1 ,368,559 1,368,559

W HO 800,000 800,000 300,000 300,000

W B 2,086,202 454,828 - -

USAID-ADRA - - 138,654 -

PHR+ - - 346,636 -

P IMAC 704,071 800,000 - -

Toata l 33,503,958 29,755,644 28,739,262 29,032,719

M ain drivers of EP I financing 2005-2008


50

Figure 20: Main financing drivers of EPI 2005-2008

Main driver of financing of EPI 2005-2008

Government70.3%

GAVI -18.4%

UNICEF0.7%

JICA6.2%

WHO0.5%

PIMAC1.1% PHR+

0.3%

W B2.3%

USAID-ADRA0.1%

5.4 Main EPI strengths The main strengths of the EPI program are as follows:

The government share in the cost of the program is substantial and increasing.

There is a line item in the MoPHP for procuring vaccines and there is a commitment to gradual increase the GoY share in the cost of introduction of the pentavalent in addition to the traditional vaccines.

Major achievements have been realized such as an increase in coverage rates

of DPT3/OPV3 (78% in 2004) and success in various immunization campaigns.

5.5 Main EPI weaknesses The main weaknesses of the EPI program are:

Some partners couldn’t make substantial commitments beyond the year 2008.

The vaccine wastage is around 20 % for DPT which is high above the optimal average.

With the current low coverage of the public health system network, substantial

efforts are to be carried out to reach the global target of EPI coverage.

The immaturity of the disease surveillance system


51

5.6 Main Opportunities The program within the framework of this plan would be taking the advantage of upcoming opportunities to achieve its goals and objectives and efficiently use any allocated resources. The main opportunities are:

Additional resources could be mobilized towards EPI from current supporting partners. The FSP would encourage more resource allocation and commitment towards achieving these mutual goals. The FSP could be the start point towards future planning and financing as well as planning for multi-year commitments by partners.

Within the heightened attention towards achieving the MDGs, there would be

an opportunity to advocate for the FSP since immunizations activities are corner stone interventions towards achieving these goals.

An opportunity of attaining more resource allocation from forthcoming donor

partners projects and programs supporting the health sector.

Another opportunity lies in the increasing focus by the GoY towards PHC services and EPI in particular which has been evident in increase support and resource allocation.

5.7 Main Constraints and Risks There are several constraints and risks towards achieving the goals of the FSP. Most of these risks lie beyond the reach of the EPI and MoPHP. The underlying risks and constraints are:

Since the economy is dependent on oil production, the availability of resources may be affected by oil exports and price fluctuations.

The fertility rate, which is one of the highest world wide, is a major risk since

the current rates may not be in line with the annual growth in economy Emerging risks such as; Rift valley fevers, polio importation, disasters,

measles outbreaks and other health hazards

With the ongoing process of decentralization, the fear that local authorities may not be aware of the priority and prioritization of immunization activities. Efforts to advocate for use of local revenues in EPI are required.

5.8 Strategies towards Sustainability In an effort to achieve the best results based on the program strengths and underlying opportunities as well as over coming any forthcoming risks, this plan includes a set of future strategies based on the local context and program vision. A full description of the strategies is provided in 5.11 Action Plan. The program strategies would be articulate upon the following:


52

o Mobilizing Additional Resources o Improve Program Efficiency o Increase the Reliability of Resource Availability

5.8.1 Efforts to Mobilize Additional Resources The strategy in this regard would focus on:

Extension the period of GAVI support for introducing pentavalent vaccine up till 2014 and the government will take over of the vaccine cost by annual increasing 10% of its share.

Advocating for the FSP to encourage more donor support (World Bank,

EC, USAID, etc) and ensure the current EPI partners commitments

Increasing the number of the ICC members from 8 to 14 members to ensure better commitment and support.

Ensure and maintain the governments support and plans to increase

staffing and program operating costs 5.8.2 Improving Program Efficiency

Reducing the vaccine wastage rate of pentavalent to less than 10% by 2006.

To carry out major cold chain replacement by the end of 2005 and plans to

carry out regular replacement.

To complete the programs efforts of establishing a complete fleet of support vehicles used in transportation and out reach and mobile services.

5.8.3 Increase the Reliability of Resource Availability

To advocate and sensitize local authorities on prioritization of EPI activities and use of local revenues in such efforts

5.9 Short term Changes The following changes are anticipated in the short term period:

Introduction of the pentavalent in 2005 onwards

An annual 10 % increase in governments share in the cost of the pentavalent

A 5 – 10 % annual increase in the EPI operational governmental cost.


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The Injection Safety – IDA support until 2006, government commitment to share 60 % of the cost 2007 onwards

Major cold chain replacement in 2005 and then to be an ongoing process.

Vehicle fleet replacement planned for 2005

Strengthening of the surveillance system

Strengthening the programme with new technical staffing

Construction of the new programme premises to be completed in 2007

5.10 Medium term Changes

The continuation of the annual 10 % increase in governments share in the cost of the pentavalent

The continuation of the 5 – 10 % annual increase in the EPI operational

governmental cost.

A subsequent cold chain replacement planned in 2010.

A subsequent vehicle fleet replacement in 2010.


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5.11 Action Plan

Dimension of Financial

Sustainability Main Strategies Progress

Indicators Actions, When, Implementation Responsibility

Extension the period of GAVI support for introducing pentavalent vaccine up till 2014

Increase the share of the government 10% yearly

- approval for the government commitment has been obtained

MOPHP / MoF

Advocating for the FSP to encourage more donor support (World Bank, EC, USAID, etc) and ensure the current EPI partners commitments

Increase of the donor support

Ongoing MOPHP, ICC

Increasing the number of the ICC members

Increase the member from 8 to 14

1st half of 2005 MOPHP

Efforts to mobilize

Additional Resources

Ensure and maintain the government support and plans to increase program operating costs

Increase the annual operational budget by 5-10% yearly

- follow up the finance department to allocate the required budget.

- last quarter of every year

MOPHP: EPI / Finance

Reducing the vaccine wastage rate of pentavalent to less than 10 % by 2006

Wastage rate decrease to less than 10% by 2006

- Training of EPI health workers in 2005.

- Monitoring and evaluating of the wastage rate at different levels in 2005-2006.

MOPHP / EPI

To carryout major cold chain replacement by the end of 2005 and plans to carry out regular replacement

Increase the number of the new cold chain facilities

- Request of the required new cold chain each year.

- Installation of the new cold chain.

MOPHP / EPI Improving

Program Efficiency

To complete the programs efforts of establishing a complete fleet of support vehicles used in transportation out reach and mobile services

% villages with access to vaccination services.

- Requesting the required transport means.

- Monitoring the vaccinators of outreach and mobile teams.

- ongoing process

MOPHP / EPI

Increase the Reliability of

Resource Availability

To advocate and sensitize local authorities on prioritization of EPI activities and use of local revenues in such efforts

More than 90% of EPI budget used for EPI activities

- Sensitization session for local authorities.

- Formulation of the EPI committee at governorate level and include the local authorities and community leaders.

- 1st half of 2005

MOPHP/ EPI/ Governorates


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5.12 Discussion with EPI partners concerning (Future “Probable” Financing) As a conclusion, based on the commitment of GoY and pattern of support for EPI by the partners particularly GAVI, the EPI during 2005-2013 despite its considerable expansion, both in terms of volume and range of services, is going to face a minimal lack of funds. All partners expressed their views that the FSP and the EPI is a commendable effort by the government. Immunization remains a top priority area within the government development strategy. The following includes a discussion of the possible risks associated with each source of funds and relationship with key financing partners Based on the last three years actual spending, it is likely that funds (other than the Peant vaccine cost ) on EPI of US$ 20.5 million from all donors will be available for the period 2005-2013. Their financing is mentioned in Table 19 (section 4) and the Figure 20 below in this section and it is distributed as follows: On the other hand, GAVI support of around US$ 43 million for pentavalent vaccine (freight wages will also be paid by GAVI) in addition to some other US$ 3 million in 2005 and 2006 for other activities are classified as secured and would substantially complement the GoY and other partner’s contribution.

• WHO will secure an amount of US$ 300,000 per year. Another US$ 1,000,000 will be contributed to the NIDs in 2005 and 2006.

• UNICEF will contribute an amount of US$ 300,000 per year .

• JICA is committed to support an amount of US$ 480,000 as secured fund.

Future support is expected from JICA which is to be discussed further; therefore around US$ 6.1 million is their probable fund for the period 2005 to 2008.

• The World Bank (International Development Agency) will initially support to

an amount of around US$ 2.5 million for the years 2005 and 2006 as a probable fund. Another amount of about US$ 1.5 million for 2005 would be available as a probable fund through their package service PIMAC.

• Other international partners have expressed their interest and willingness to

contribute to future EPI requirements.

• Potential contributions are expected form USAID through several operating agencies (ADRA and PHR+) and future support within expected World Bank projects and programmes. Their contribution will be amounted to US$ 0.5 million in 2005. it was too difficult to them to made further commitment but they are in the process of preparations to contribute more in the next few year.

• A possibility of including EPI within the future framework of upcoming donor

support and heightened attention towards achieving the MDGs. Potentially; World Bank projects, EC support and others.

• The following figure (21) highlights the secure funds covering the period of

FSP.


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Figure 21: Secure and Probable Funding of EPI Cost by Partners 2005- 2013

Secure and Probable Funds 05-13

$-

$5

$10

$15

$20

$25

$30

$35

2004 2005 2006 2007 2008 2009 2010 2011 2012

Mill

ions

GAVI - VaccineFund

PHR+

USAID-ADRA

World Bank.IDA

WHO

JICA

NationalGovernment


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Section 6 Stakeholder Comments

Comments of WR, Yemen The draft Plan was discussed at the WHO office, the 14th of December with Dr Hashim El Zein and all the comments were taken into consideration. WHO provides EPI yearly an amount of US$ 200,000 through the regular budget which approved with Yemen government every two years. Most of the assistance of WHO is going to technical issues like training, supervision and surveillance of the EPI target disease. In addition to that WHO provides with some supplies (like cold chain equipment, polio vaccine…etc), which necessarily required and had a substantial impact on the program. WHO will continue to support with an amount of US$ 300,000 per year for the future in addition to US$ 1,000,000 as a support for operational cost of the NIDs in 2005 and 2006 and will exert efforts to advocate for securing the polio vaccine of NIDs. WHO will try to increase their fund to meet the ambitious plan of the government. Moreover, WHO provides also some extra budget every year especially for supplementary immunization activities like NIDs, MNT, and measles campaigns to assist in achieving the regional and global objectives. The extra budgetary fund can’t be made as a commitment from WHO because it needs long time to present any proposal to donors and to get the fund after months to one year. To avoid the prolonged time of getting the extra budget, the government is to present the proposals of unfunded activities along with the regular budget. 14 December 2004 Comments of UNICEF, Yemen UNICEF as another partner assisted the efforts of the Government of Yemen to develop a Financial Sustainability Plan (FSP) for its immunization program. The draft Plan was discussed at the UNICEF office, the 14th of December with Dr Majdi Bayoumi, Health Nutrition Programme Officer and Dr Solofo Ramaroson Senior Programme Officer and most of the comments were reflected in the final version. Given the low coverage of immunization in Yemen, ensuring adequate and reliable funding for expanding and sustaining coverage is critical. The FSP must be read in conjunction with the Government’s strategy to improve immunization services and the National Health Policy. UNICEF Representatives mentioned that the FSP documents reconfirm the Government’s commitment to maintain and increase its budgetary allocation to immunization services. UNICEF commitment is based on a 5 year plan of operation signed with the GoY. The current plan covers the period 2002 - 2006. As demonstrated by its contribution from 2001 to 2004 UNICEF fund raising efforts will mobilize


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more resources than the amounts pledged in this plan. In summary, UNICEF Yemen is satisfied with the process and content of the FSP and hopes that the Plan would remain a living document that would accommodate further improvements in the future. 14 December 2004


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ANNEX 1. FUTURE RESOURCE REQUIREMENTS FOR YEMEN (in USD) Cost Category 2005 2006 2007 2008 2009 2010 2011 2012 2013Routine Recurrent Cost US$ US$ US$ US$ US$ US$ US$ US$ US$

Vaccines (routine vaccines only) 8,937,432$ 7,249,474$ 7,982,665$ 8,290,223$ 9,075,540$ 9,422,757$ 10,241,434$ 10,589,643$ 10,949,690$ Traditional Vaccines 867,812$ 925,610$ 1,007,865$ 1,078,280$ 1,152,319$ 1,230,146$ 1,271,971$ 1,315,218$ 1,359,935$ New and underused vaccines 8,069,620$ 6,323,864$ 6,974,800$ 7,211,943$ 7,923,221$ 8,192,611$ 8,969,463$ 9,274,425$ 9,589,755$

Injection supplies 575,018$ 651,702$ 804,352$ 877,995$ 967,259$ 1,049,642$ 1,097,672$ 1,134,993$ 1,173,583$ Personnel 8,180,166$ 9,247,269$ 9,629,936$ 10,033,591$ 10,459,107$ 10,910,644$ 11,387,672$ 11,892,955$ 12,427,702$

Salaries of full-time NIP health workers (immuni 7,025,821$ 7,917,482$ 8,243,392$ 8,587,121$ 8,949,410$ 9,333,783$ 9,739,794$ 10,169,784$ 10,624,780$ Per-diems for outreach vaccinators/mobile team 1,154,345$ 1,329,787$ 1,386,544$ 1,446,470$ 1,509,697$ 1,576,861$ 1,647,878$ 1,723,171$ 1,802,922$

Transportation 92,340$ 177,085$ 259,405$ 282,599$ 291,854$ 306,627$ 312,660$ 325,080$ 341,883$ Fixed site and vaccine delivery 79,640$ 152,730$ 223,729$ 243,733$ 251,715$ 264,456$ 269,659$ 280,371$ 294,863$ Outreach activities 12,700$ 24,355$ 35,676$ 38,866$ 40,139$ 42,171$ 43,001$ 44,709$ 47,020$

Maintenance and overhead 2,429,602$ 2,607,983$ 2,818,722$ 2,921,758$ 2,942,031$ 3,086,625$ 3,152,963$ 3,220,984$ 3,289,976$ Short-term training 116,236$ 118,560$ 120,931$ 123,350$ 125,817$ 128,333$ 130,900$ 133,518$ 136,188$ IEC/social mobilization 68,704$ 70,078$ 71,480$ 72,909$ 74,368$ 75,855$ 77,372$ 78,920$ 80,498$ Supervision, Monitoring and Disease Surveillance 596,882$ 875,388$ 892,896$ 910,754$ 928,969$ 947,549$ 966,500$ 985,830$ 1,005,546$ Other Outreach costs (excluding per-diems, transpo -$ -$ -$ -$ -$ -$ -$ -$ -$ Other routine recurrent costs -$ -$ -$ -$ -$ -$ -$ -$ -$

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

Subtotal Recurrent Costs 20,996,380$ 20,997,539$ 22,580,387$ 23,513,179$ 24,864,945$ 25,928,032$ 27,367,173$ 28,361,923$ 29,405,066$ Routine Capital Cost -$ -$ -$ -$ -$ -$ -$ -$ -$

Vehicles 1,256,387$ 1,249,679$ 960,983$ 211,763$ 125,905$ 1,456,074$ 1,379,746$ 1,108,807$ 418,846$ Cold chain equipment 3,142,424$ 1,861,258$ 1,729,083$ 710,233$ 897,867$ 4,378,422$ 2,085,944$ 1,940,631$ 816,370$ Other capital costs 132,339$ 106,333$ 70,466$ 32,681$ 165,771$ 145,424$ 99,708$ 61,906$ 201,622$

Subtotal Capital Costs 4,531,150$ 3,217,270$ 2,760,532$ 954,677$ 1,189,543$ 5,979,920$ 3,565,398$ 3,111,344$ 1,436,838$ Supplemental Immunization Activities -$ -$ -$ -$ -$ -$ -$ -$ -$

Polio Campaigns 3,173,157$ 3,231,942$ 682,283$ -$ -$ -$ -$ -$ -$ Vaccines 1,075,595$ 1,081,227$ 225,256$ -$ -$ -$ -$ -$ -$ Other operational costs 2,097,562$ 2,150,715$ 457,027$ -$ -$ -$ -$ -$ -$

Measles Campaigns 5,536,804$ 105,749$ 106,869$ 1,969,096$ 109,177$ 110,366$ 2,337,247$ -$ -$ Vaccines 1,664,238$ 31,456$ 31,456$ 573,449$ 31,456$ 31,456$ 658,906$ -$ -$ Injection supplies 967,410$ 18,285$ 18,285$ 333,342$ 18,285$ 18,285$ 383,017$ -$ -$ Other operational costs 2,905,156$ 56,008$ 57,128$ 1,062,305$ 59,436$ 60,625$ 1,295,324$ -$ -$

Yellow Fever Campaigns -$ -$ -$ -$ -$ -$ -$ -$ -$ Vaccines -$ -$ -$ -$ -$ -$ -$ -$ -$ Injection supplies -$ -$ -$ -$ -$ -$ -$ -$ -$ Other operational costs -$ -$ -$ -$ -$ -$ -$ -$ -$

MNT Campaigns (CBAW) 896,198$ 345,862$ 288,218$ -$ -$ -$ -$ -$ -$ Vaccines 115,912$ 45,360$ 37,800$ -$ -$ -$ -$ -$ -$ Injection supplies 148,596$ 58,150$ 48,458$ -$ -$ -$ -$ -$ -$ Other operational costs 631,690$ 242,352$ 201,960$ -$ -$ -$ -$ -$ -$

Td -$ -$ 514,729$ 553,373$ 591,160$ 629,241$ 661,363$ 695,163$ 730,731$ Vaccines -$ -$ -$ -$ -$ -$ -$ -$ -$ Injection supplies -$ -$ 94,919$ 100,408$ 105,536$ 110,519$ 114,277$ 118,162$ 122,180$ Other operational costs -$ -$ 419,810$ 452,965$ 485,624$ 518,722$ 547,086$ 577,001$ 608,551$

Enter other Campaigns -$ -$ -$ -$ -$ -$ -$ -$ -$ Vaccines -$ -$ -$ -$ -$ -$ -$ -$ -$ Injection supplies -$ -$ -$ -$ -$ -$ -$ -$ -$ Other operational costs -$ -$ -$ -$ -$ -$ -$ -$ -$

Subtotal Supplemental 9,606,159$ 3,683,553$ 1,592,099$ 2,522,469$ 700,337$ 739,607$ 2,998,610$ 695,163$ 730,731$ Shared cost and other optional information -$ -$ -$ -$ -$ -$ -$ -$ -$

Shared Personnel Costs 84,547$ 86,238$ 87,963$ 89,722$ 91,516$ 93,347$ 95,214$ 97,118$ 99,060$ Shared Transportation Costs -$ -$ -$ -$ -$ -$ -$ -$ -$ Building 5,327,065$ 5,433,606$ 5,542,278$ 5,653,124$ 5,766,186$ 5,881,510$ 5,999,140$ 6,119,123$ 6,241,506$ Other optional information -$ -$ -$ -$ -$ -$ -$ -$ -$

Other (please specify) -$ -$ -$ -$ -$ -$ -$ -$ -$ Other (please specify) -$ -$ -$ -$ -$ -$ -$ -$ -$ Other (please specify) -$ -$ -$ -$ -$ -$ -$ -$ -$ Other (please specify) -$ -$ -$ -$ -$ -$ -$ -$ -$ Other (please specify) -$ -$ -$ -$ -$ -$ -$ -$ -$

Subtotal Optional 5,411,612$ 5,519,844$ 5,630,241$ 5,742,846$ 5,857,702$ 5,974,857$ 6,094,354$ 6,216,241$ 6,340,566$ GRAND TOTAL 40,545,301$ 33,418,206$ 32,563,259$ 32,733,171$ 32,612,527$ 38,622,416$ 40,025,535$ 38,384,671$ 37,913,201$

Routine (Fixed Delivery) 29,770,710$ 28,379,096$ 29,547,497$ 28,723,894$ 30,360,852$ 36,262,245$ 35,334,484$ 35,920,035$ 35,330,903$ Routine (Outreach Activities) 1,168,432$ 1,355,557$ 1,423,663$ 1,486,808$ 1,551,338$ 1,620,564$ 1,692,441$ 1,769,473$ 1,851,567$ Supplemental Immunization Activities 9,606,159$ 3,683,553$ 1,592,099$ 2,522,469$ 700,337$ 739,607$ 2,998,610$ 695,163$ 730,731$


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ANNEX 2. SECURE FUNDING FOR YEMEN (in USD) Secure Funding 2005 2006 2007 2008 2009 2010 2011 2012 2013 2005-2013

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$National Government 17,550,057$ 18,962,992$ 19,354,585$ 20,776,187$ 22,362,604$ 24,028,344$ 25,953,420$ 27,739,405$ 29,529,884$ 206,257,477$ GAVI - Vaccine Fund 9,092,669$ 6,871,265$ 5,779,840$ 5,048,360$ 4,753,933$ 4,096,305$ 3,587,785$ 2,782,327$ 1,917,951$ 43,930,435$ UNICEF 300,000$ 300,000$ -$ -$ -$ -$ -$ -$ -$ 600,000$ JICA 480,000$ -$ -$ -$ -$ -$ -$ -$ -$ 480,000$ WHO 800,000$ 300,000$ -$ -$ -$ -$ -$ -$ -$ 1,100,000$ World Bank.IDA -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ USAID-ADRA -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ PHR+ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ PIMAC 704,071$ -$ -$ -$ -$ -$ -$ -$ -$ 704,071$

Total Secure Funding 28,926,797$ 26,434,257$ 25,134,425$ 25,824,547$ 27,116,537$ 28,124,649$ 29,541,205$ 30,521,732$ 31,447,835$ 253,071,983$ Total Cost / Resource Req 40,545,301$ 33,418,206$ 32,563,259$ 32,733,171$ 32,612,527$ 38,622,416$ 40,025,535$ 38,384,671$ 37,913,201$ 326,818,287$ Funding Gap 11,618,504$ 6,983,949$ 7,428,834$ 6,908,624$ 5,495,990$ 10,497,767$ 10,484,330$ 7,862,939$ 6,465,366$ 73,746,304$ ANNEX 3. PROBABLE FUNDING FOR YEMEN (in USD) Probable Funding 2005 2006 2007 2008 2009 2010 2011 2012 2013 2005-2013

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$National Government 650,400$ -$ 829,247$ 888,415$ 957,780$ 1,024,000$ 1,070,573$ 1,111,789$ 1,154,880$ 7,687,083$ GAVI - Vaccine Fund -$ -$ 321,741$ 351,198$ 386,904$ 419,857$ 439,069$ 453,997$ 469,433$ 2,842,198$ UNICEF -$ -$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 2,100,000$ JAICA 1,840,559$ 1,566,559$ 1,368,559$ 1,368,559$ -$ -$ -$ -$ -$ 6,144,236$ WHO -$ 500,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 2,600,000$ World Bank.IDA 2,086,202$ 454,828$ -$ -$ -$ -$ -$ -$ -$ 2,541,031$ USAID-ADRA -$ -$ 138,654$ -$ -$ -$ -$ -$ -$ 138,654$ Partenars For Health Refo -$ -$ 346,636$ -$ -$ -$ -$ -$ -$ 346,636$ PIMAC -$ 800,000$ -$ -$ -$ -$ -$ -$ -$ 800,000$

Total Probable Funding 4,577,161$ 3,321,387$ 3,604,837$ 3,208,172$ 1,944,683$ 2,043,857$ 2,109,642$ 2,165,786$ 2,224,314$ 25,199,839$ Total Resource Requireme 40,545,301$ 33,418,206$ 32,563,259$ 32,733,171$ 32,612,527$ 38,622,416$ 40,025,535$ 38,384,671$ 37,913,201$ 326,818,287$ Funding Gap 35,968,140$ 30,096,819$ 28,958,422$ 29,525,000$ 30,667,844$ 36,578,559$ 37,915,894$ 36,218,885$ 35,688,888$ 301,618,448$ ANNEX 4. SECURE & PROBABLE FUNDING FOR YEMEN (in USD) Secure + Probable Funding 2005 2006 2007 2008 2009 2010 2011 2012 2013 2005-2013

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$National Government 18,200,457$ 18,962,992$ 20,183,832$ 21,664,602$ 23,320,384$ 25,052,344$ 27,023,993$ 28,851,194$ 30,684,764$ 213,944,561$ GAVI - Vaccine Fund 9,092,669$ 6,871,265$ 6,101,581$ 5,399,558$ 5,140,837$ 4,516,162$ 4,026,854$ 3,236,324$ 2,387,384$ 46,772,633$ UNICEF 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 2,700,000$ JICA 2,320,559$ 1,566,559$ 1,368,559$ 1,368,559$ -$ -$ -$ -$ -$ 6,624,236$ WHO 800,000$ 800,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 300,000$ 3,700,000$ World Bank.IDA 2,086,202$ 454,828$ -$ -$ -$ -$ -$ -$ -$ 2,541,031$ USAID-ADRA -$ -$ 138,654$ -$ -$ -$ -$ -$ -$ 138,654$ PHR+ -$ -$ 346,636$ -$ -$ -$ -$ -$ -$ 346,636$ PIMAC 704,071$ 800,000$ -$ -$ -$ -$ -$ -$ -$ 1,504,071$

Total Secure + Probable Fu 33,503,958$ 29,755,644$ 28,739,262$ 29,032,719$ 29,061,220$ 30,168,506$ 31,650,847$ 32,687,518$ 33,672,149$ 278,271,822$ Total Resource Requireme 40,545,301$ 33,418,206$ 32,563,259$ 32,733,171$ 32,612,527$ 38,622,416$ 40,025,535$ 38,384,671$ 37,913,201$ 326,818,287$ Funding Gap 7,041,343$ 3,662,562$ 3,823,997$ 3,700,453$ 3,551,307$ 8,453,910$ 8,374,689$ 5,697,153$ 4,241,053$ 48,546,465$


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ANNEX 5. MEMBERS OF FSP COMMITTEE:

- Deputy Minister of PH & P for PHC, Dr. Majed AL Jonaid - Dr. Ali AL Mudhwahi, Family Health Director - Dr. Jamal Abdul Habib, National EPI Manager - Dr. Jamal Nasher, Health Policy and Planning Unit - Mr. Mohammed AL Abbasi, Finance affairs Director - Dr Hashim Ali El Zein,WHO Representative - Dr Mohamed Osama Mere, WHO/Yemen/EPI consultant - Dr. Osmat Azzam, WB consultant - Dr Mahmmed Hajar, National EPI advisor


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Annex 6: Minutes of the interagency Coordinating Committee (ICC) Meeting

Minutes of the interagency Coordinating Committee (ICC) Meeting Date: 26th January 2005 Venue: H.E the Minister’s Office (Meeting Room) Agenda: attached Attendants: attached Chair Person: H.E the Minister of Public Health & Population The minister started the meeting by welcoming the attendants and gave his congratulation for Eid-Al ADHA, thin he highlighted the importance of this meeting in order to reach for approval of the FSP before sending it to GAVI secretariat and EMRO Office. He said that the FSP reflects the commitment from the government toward EPI in general and to take over gradually the cost of the Pentavalen vaccine for the coming years. H.E the Minister added that the ministry is giving EPI this year the first priority in order to reach every child especially for those who are difficult to reach. Also the ministry has already taken over the cost of the routine vaccine since 2002 and as regards Hepatitis B it was introduced with a total cost from the government since 1999. Then he gave the floor to the EPI Director to present the briefing on the FSP. The presentation mentioned the process of formulation the FSP and the steps which started from the attendance the workshop held in Cairo in May 2004 till end of the FSP formulation and also mentioned the national team and technical assistance received from WHO and World Bank consultants. The EPI manager also presented the strategies, goals and the main findings of the FSP as the following:

- The total cost of fully immunized child as 30$, the government cost increases every years in 2003 it was 85% of the total cost. In 2005 the main cost drivers of the programme would be the cost of the basic program and vaccines (Introduction of Pentavalent).

- The cost of the programme 2005-2013 is expected to be 327 million USD of which US$ 278 million is secure and probable fund and the gap is US$ 48 million USD requited funding.

- The main challenges are the high fertility rates emerging risks.

- Strategies :

Expansion of ICC members to assist in mobilizing resources. Extension of GAVI support up until 2013. An annual 10 % increase in government share in the cost of the pentavalent. A 5 – 10 % annual increase in the governmental EPI operational budget.


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The Injection Safety – IDA support until 2006, government commitment to share 60 % of the cost 2007 onwards.

After that - by the agenda of the meeting on the other topics- the EPI manager presented the main progress in implementing GAVI related activities in 2004 which mentioned:

- The preparation of introduction the new vaccine. - Districts micro planning and red approach. - Enhancing supervision. - Total expenditure 641,112 $ (46%) until January 2005.

And then presented the future plan for 2005 which around (1,376,776 USD) as a share of the government and GAVI fund to implement this activities as followed:

- Capacity building at all levels (central , gov. , dist): - Monitoring & Supervision at all levels. - Planning. - Outreach activities. - Cold chain & Vaccine supply. - Information system. - Health education.

Other items: Dr Jamal introduced the plan for 2005 including the introduction of pentavalent vaccine Discussion: H.E the minister and all the members thanked the team for their work and for the distribution of the FSP document to the members before this meeting. The World Bank ember refereed to budget effected to be probable. UNICEF : has requested to amend the budget according to what will be provided by them. WHO Representative highlighted the importance of the routine immunization and following the strategies for each vaccination site to work as fixed- outreach, mobile and to assure continues effective supervision and to be sure for strict preparation to conduct the second DQA during 2005. Outcome: After the discussion the members approved the plan for 2005 and the FSP taking into consideration the remarks mentioned. Closure of the Meeting: H.E the minister closed the meeting with his thanks to all.


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AGEND FOR THE I.C.C MEETING – 26TH JANUARY 2005

- Opening speech by H.E Prof. Mobammed Yehya Al-Noami, Chairperson of I.C.C.

- Presentation of the Financial Sustainability Plan (FSP) by

Dr Gamal Abdul Habib .

- Discussion on the presentation of FSP.

- Any other topic.

- Closing. Attendants: HE. Dr Mohamed Yehia Al Noami, Minister of public Health and population DR Majed Al Jonaid, Deputy Minister of PH&P. Dr Hashim Al I El Zein, WHO Representative/ Yemen Dr Solofo Ramaroson, Senior Program Officer/ UNICEF Dr Ali Al Mudhwahi, Family Health Director Dr Jamal Abdel Habib Abdel Sattar, National EPI manger Dr Mohamed Osama Mere, WHO/ EPI – Consultant Dr Mohamed Hajar, National EPI Advisor Dr Afrah Al Ahmadi, Operation Officer World Bank Mr Takuji Date, Medical Project Coordinator, JICA


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Acknowledgement: We would like to express our thanks to every one that has any input or effort in this FSP and we know without this assistant the mission would have not accomplished. special thanks is extended to the staff of EPI who assisted in collecting and processing the data: Dr Mohamed Ibrahim, MNT officer, Dr Ghada Al HAbob, Measles officer, Mr Ibrahim Al Ansi and Moaz Mohamed Al Hakimi, data management, Mr. Shaef Al Jehefi, finance officer, and Mr Tawfiq Kaid cold chain officer, Adel Thabet, Finance department.

Expanded Program on Immunization...Financial Sustainability Plan / Jan 05 /Yemen 2 Financial...

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