Francophone Africa Peer Review Workshop on Sustainable Immunization Financing · 2015. 7. 20. ·...

Francophone Africa Peer Review Workshop on Sustainable

Immunization Financing

Kribi, Cameroon | 4-6 December 2014

By Jonas Mbwangue, Alice Abou Nader, and Andrew Carlson

Table of Contents Introduction ..................................................................................................................................... 2

Proceedings ..................................................................................................................................... 2

Day 1 ........................................................................................................................................... 2

Theme I: Budgeting and Resource Tracking ........................................................................... 3

Theme II: Immunization Legislation ....................................................................................... 8

Day 2 ........................................................................................................................................... 8

Theme III: Advocacy in Practice ........................................................................................... 12

Day 3: Peer Review and Next Steps.......................................................................................... 14

Results ................................................................................................................................... 15

Discussion .............................................................................................................................. 19

Major Challenges that Remain and Next Steps ..................................................................... 20

ANNEXES .................................................................................................................................... 21

Annex A : List of participants ................................................................................................... 21

Annex B: Agenda ...................................................................................................................... 22

Annex C: Small Group Instructions .......................................................................................... 24

Annex D: Small Group Work I Results, Budgeting and Resource Tracking ............................ 28

Annex E: Small Group Work II Results, Immunization Legislation ........................................ 31

Annex F: Peer Review Guide .................................................................................................... 33

Sustainable Immunization Financing (SIF) Program of 37

Introduction Since 2008, the Sabin Sustainable Immunization Financing program has collaborated with 21 low &

middle income countries across Africa, Asia, and Europe. The program focuses on the cultivation of

innovations targeting independently financed public vaccine initiatives. In the Second Sabin Colloquium

on Sustainable Immunization Financing, on 5-6 August 2013 in Dakar, Senegal, seventeen SIF countries

presented their immunization financing innovations in a peer review exercise. Since then, the countries

have sharpened their respective innovations, and on 21-23 July 2014, the six Asian SIF countries

evaluated each other’s progress through the Asia Peer Review Workshop on Sustainable Immunization

Financing in Phnom Penh, Cambodia. On 4-6 December in Kribi, Cameroon, the six Francophone

African countries did the same. This workshop was organized in collaboration with UNICEF and

gathered thirty participants, found in Annex A. This report: (a) conveys the workshop objectives, (b)

unpacks the workshop proceedings, (c) analyses institutionalized, implemented, or aspirational key

innovations, (d) determines the role of technical partners within these processes, and (e) closes with next

steps.

Proceedings The workshop agenda and group work instructions are found in Annex B. There were four cycles of

small group work in which each delegation presented its results in three domains including: (a)

budgeting and budget tracking, (b) legislation, and (c) advocacy strategies. The workshop ended with a

formal peer review, in which each delegate scored the other countries on the relevance and strength of

each one. The delegates engaged intensely in small working groups, plenary discussions, and the formal

peer review. The partner agency representatives, from Sabin, UNICEF and WHO, served as moderators.

Day 1 The day kicked off with a welcome address delivered by two Sabin/SIF Senior Program Officers

(SPOs), followed by an address from the Honorable Minister of Public Health. The entire delegation

observed a moment of silence in memory of former Sabin Executive Vice President Dr. Ciro De

Quadros. The SPOs continued with the three key objectives of the workshop.

1. Document and evaluate implemented or aspirational immunization budget and resource tracking

mechanisms, by country;

2. Revise, improve, or reorient existing or aspirational draft immunization laws or regulations, by

country;

3. Strengthen advocacy practices for sustainable immunization financing.

The SPOs then moved onto the workshop’s first technical theme.

http://www.sabin.org/sites/sabin.org/files/Proceedings%20of%20the%20Second%20Sabin%20Colloquium%20on%20Sustainable%20Immunization%20Financing%20(SIF)%20FV_0.pdf

http://www.sabin.org/sites/sabin.org/files/Proceedings%20of%20the%20Second%20Sabin%20Colloquium%20on%20Sustainable%20Immunization%20Financing%20(SIF)%20FV_0.pdf

http://www.sabin.org/updates/events/asia-peer-review-workshop-sustainable-immunization-financing-practices

http://www.sabin.org/updates/events/asia-peer-review-workshop-sustainable-immunization-financing-practices


Theme I: Budgeting and Resource Tracking

The theme was introduced in plenary. One of the Sabin delegates summarized the concepts and

applications in immunization budgeting and resource tracking. Financial data reporting has generally

improved in Francophone Africa, the presenter deduced. The presenter emphasized that the benefits of

quality reporting include improved financial management and sound advocacy messaging.

The delegates broke into small groups in which they compared experiences in obtaining and analyzing

routine immunization expenditure data from 2009-2014. Budgetary flow analyses and JRF formula

tables were distributed. This analytical exercise allowed the delegates to document good practice in

capturing governmental resource flows and their application. The results found below were presented in

plenary.

Mali

The Malian delegate was the first to enumerate their budget advocacy and tracking approaches. The

presenter ascribed the significant approved budget increase in the finance act to the involvement of the

Ministry of Economy, Finance, & Budget (MOEFB) and parliament throughout the budgetary process

and tracking of immunization expenses. The EPI enjoys excellent budgetary execution: 99.93% in 2011,

89.37% in 2012, and 93.01% 2013, thanks to the MOEFB EPI Focal Point who organizes quarterly

meetings in coordination with the SIF program and the EPI to facilitate the release of approved funds,

according to the presenter.

The Malian government employs the Integrated System for Public Expenditure Management (SIGD),

the Operational Plan (PO), and Activity Reports (RAs) for reporting purposes. Expenditure tracking is

done through a memorandum of understanding signed in 1996 which links the State to UNICEF for the

provision of vaccines, consumables, and relevant equipment, the annual estimation of needs therefor

through an electronic “forecast tool”, the formulation of vaccine orders sent to UNICEF, and payments

made to UNICEF. The Malian delegation recalled that the budgetary process in Mali has an edge: the

budget as dictated by the EPI is adopted at all levels and resources allocated by the government are

handled with utmost care. Still, there exist a few deficiencies including the lack of EPI involvement in

budget advocacy, and the financial reporting apparatus requires certain adjustments.

Congo

Speaking next, the Congolese presenter noted a definite increase in the national immunization budget

from 2011 to 2013, yet is insufficient to cover all immunization needs, namely Gavi co-financing

commitments.


Figure 1. Gap between co-financing and national contributions in Congo

Reporting methods include the cMYP; operational plans; annual work plans; finance acts; monthly,

quarterly, and annual financial reports; health department quarterly and annual financial reports;

budgetary execution reports; and the JRF. To improve the reporting system, the EPI plans to integrate

financial data into monthly activity reports and the National Health Information System (SNIS) report.

Budget preparations and resource tracking are done in the following steps:

1. Submission of draft EPI budgets (functional and investment) to the sectoral budget preparation

office;

2. Integration of EPI budget proposals into the sectoral budget;

3. Presentation of health sector budget in inter-ministerial conferences (devoid of EPI

representation);

4. Tracking of the budgetary process (Counsel of Ministers & Parliament) and subsequently the

adoption of the finance act;

5. Budget execution following orientations; and

6. Capacity building at the intermediate level for local resource mobilization

Despite brandishing a strong disbursement rate (75-100%), the Congolese delegate confessed that the

system still suffers from a few deficiencies, namely the absence of a budget line dedicated to vaccine

purchase, an insufficient EPI budget and the omission of certain operational costs. Considering the rapid

$-

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

$4,500,000

$5,000,000

2011 2012 2013 2014 2015 2016 2017 2018

Co-financement GAVIBudget pays


increase in co-financing/operational costs over the next years, the EPI plans two interventions in the

short term:

1. Creation of a special allocation account for immunization costs and vaccine purchase, targeting

financing gaps and sources.1

2. Formulation of a law which guarantees domestic immunization financing

Senegal

The Senegalese delegation presented their budgeting practices next. The representative expressed that all

data is collected from the State budget, the cMYP, Gavi decision letters, and financial agreement letters

from other partners at the central level. The system doesn’t contain a specific immunization expenditure

tracking mechanism.

To address this drawback, Senegal proposes to implement a tracking tool from the Directorate of

Prevention down to medical regions and districts and to organize annual and quarterly statement

tracking meetings.

DRC

According to Table 1 below, the strong involvement of the Parliamentary Support Network on

Immunization (REPACAV) and the Ministry of Finance & Budget (MOFB) in the entire budget process

since 2011 has truly improved the country’s immunization budget credibility, according to the presenter.

Since 2012, a significant effort has been exerted to address the approved resource mobilization plan

within the finance act. The capacity to mobilize approved EPI resources has multiplied by five, going

from around $1 million in 2011 to over $5 million since 2012.

Table 1. Trend in EPI budget execution in DRC from 2010-2014

Year 2010 2011 2012 2013 2014

Budget

Approuvé (CFA)

6,900,388 4,925,617 5,836,637 10,610,555 13,379,110

Budget Mobilisé

(CFA)

839,595 1,138,646 5,262,437 6,504,662 6,504,662

The EPI and its partners structure the cMYP for a period of five years in coordination with REPACAV

members. This five-year plan breaks into an Annual Operational Plan (PAO)2 in which budgetary

projections are stipulated. Every August, the EPI with the assistance of REPACAV maps out program

needs and dictates the budgetary projections for the next year. These projections are deposited,

discussed, and transmitted to the Directorate of Studies and Planning (DEP) and defended before the

1 This intervention was conceived during a Gavi assessment in October 2014, in which MOH counterparts agreed that the account would be capitalized by airline taxes. 2 The reader should note that the cMYP and the 2015 POA were finalized in January 2015 and approved by the ICC the next month.


Minister of Public Health, who relays them to the Minister of Budget. The Budget Minister coalesces

projections from all Ministers into a document called the “Draft Finance Act” adopted during the

congress of the Council of Ministers, which is sent to and defended in parliament. During its reading,

REPACAV verifies that the immunization credit lines are consistent with the EPI projections. Once

examined by the National Assembly and Senate, REPACAV may either approve the current budget or

negotiate for an increase in accordance to program needs, after which a vote is held in the National

Assembly and the Finance Act is sent from the Senate to the Presidency official approval. Next, the EPI

credit lines are known and secured. The budgetary process then follows in three steps:

1. Commitment form: The MOH Credit Manager signs a document called a “commitment form”

and conveys it to the Minister of Budget (MOB).

2. Liquidation: Once the MOB receives the commitment form, it advises the MOF to liquidate the

budget.

3. Order to pay: Once notified by the MOB to liquidate the budget, the MOF remits payment. Each

line is disbursed except for “vaccine purchase” and “co-financing payment”, the latter of which

are sent to the UNICEF account.

The EPI organizes mid-year and annual reviews on immunization activities in coordination with partners

and REPACAV, and formulates the annual immunization activity report (JRF, RSA, etc.). At the end of

each trimester, MOF inspectors visit the expenditure controllers in an accountability reporting mission,

the result from which is sent to the Court of Audit, which follows up on this mission at the end of the

year and sends its report thereon to parliament. At the provincial level, tracking is done through an

expenditure tracking form, “Form 6”, which local EPI structures send to the central Directorate at the

end of every month.

Cameroon

The Cameroonian delegation then delivered their presentation on budget preparations and relevant

approaches. The progressive increase in government financial contributions to EPI from 2011-2013 is

the function of advocacy led by EPI leaders and parliamentary pressure on decision-makers on the

importance of immunization in the process. (Table 2).

Table 2. Government contribution to the EPI 2011-2013.

Year MOH Budget

(CFA)

EPI Budget

(CFA) Percentage

2011 151,810,000,000 1,482,541,985 0.9

2012 151 420 000 000 1,691,859,893 1.1

2013 162 448 000 000 2,190,960,477 1.3


Resource tracking is done through the cMYP, the work plan/annual budget, the integration of the MOPH

budget and the finance act and a system informed by financial management, the Cameroonian presenter

explained.

Madagascar

After having endured difficulties from 2010-2012 in mobilizing the approved budget, the Malgache

representative indicated that the Sabin/SIF Program, in collaboration with WHO, UNICEF, and Gavi,

multiplied its advocacy missions to the MOF and parliament to compel the release of funds allocated to

the EPI. These efforts found convincing results in 2013 & 2014, according to the Malgaches. As

illustrated in Figure 2 below, the disbursed budget exceeded the approved budget during these two

years. Not only did the EPI receive the entire approved budget, but also mobilized resources outside of

the approved budget.

Figure 2. Evolution of proposed and approved EPI budgets in Madagascar 2010-2014.

The government employs Monthly Activity Reports (RMAs) to track financial data at the district level,

which are consequently consolidated at regional and national levels. Furthermore, the government

periodically implements technical and financial evaluations at regional and districts levels. The EPI

prepares, submits, and tracks its budget through the following means:

1. The EPI formulates its budget according to the cMYP 2012-2017.


2. The MOPH and MOFB examine the EPI budget compared to those from each ministry.

3. A preparatory budgetary conference takes place so that stakeholders may analyze the budget and

send it to the Council of Ministers for their approval.

4. The Parliamentary Health and Finance Committees then examine the budget; the budget

therefore transforms from proposed to approved.

5. The MOPH and MOFB adjust the credit lines in proportion to the approved budget.

6. Budget execution at regional and district levels.

7. The Directorate of Studies & Planning and the Administrative & Financial Directorate in

collaboration with the Secretary General and the MOHP consolidate budget execution reports

from each MOPH program.

8. MOFB Technical Officers analyze the budget execution.

Theme I: Group Work

Delegates then broke into three small groups in order to identify the strengths, weaknesses, innovations,

and proposed solutions to improve the countries’ resource tracking systems as elucidated in each

presentation. The results of the small group evaluations are found in Annex D.

Theme II: Immunization Legislation

Following the group work, a Sabin representative presented the legislative process of all SIF countries.

The presentation illustrated each country’s progress to date in the elaboration of their immunization-

related legislation. The delegate reiterated that this section of the workshop would be conducted in two

phases: presentations in plenary and small group evaluations. The group work results are as follows:

Day 2 Work began at 8:40 with the read-aloud of the Day 1 report, to which four key amendments were made.

Each delegation then presented their legislative projects.

Cameroun The Cameroonian delegation was the first to recount their legislative process to date. The project began

in 2011, when the SIF Program formed a legislative working group in the country. After its inception,

the group conducted a diagnostic review on all immunization-related legislative texts, the result from

which was presented to stakeholders. The Prime Minister instituted an Inter-Ministerial Committee in

June 2012 to guide the process. The Committee is presided over by the Minister of Public Health and is

staffed by administrative, technical, and financial representatives. Within the Committee is a Technical

Working Group, which includes individuals from parliament, MOF, and civil society. A draft

immunization law was elaborated and shared with stakeholders. The major obstacles encountered by


Cameroon have been the difficulty in obtaining a consensus over the immunization fund and law’s ambit

(Health Fund/Immunization/HIV Support Fund).

Senegal

Senegal’s legislative process kicked off in January 2012. It rests at Phase 3, whereby the country is

composing its draft immunization law. National institutions involved include the MOH and parliament.

These institutions organize law drafting workshops, stimulate information sharing, and advocate to key

officials. The country plans to hold a large legal consultation with stakeholders including civil society in

March 2015 and in July 2015, to submit the draft law for adoption by the National Assembly. The

delegation acknowledged the country’s institutional instability as well as the lack of a formal inclusive

framework to advance the work. This has greatly hampered the legislative process. Senegal plans to

implement such a framework, reinforced by an inclusive advocacy coalition staffed by MPs, former

MPs, civil society, PTF, and relevant ministers.3 Further, the peers have also appointed a focal point in

parliament to act as a steward throughout the remainder of the legislative process.

Mali

A presenter from the Malian delegation then took the floor. The process began in 2011 with a review of

all existing legislation, led by the government. Using the results from this study, a draft law was

elaborated by sectoral ministers, parliament, civil society, and the private sector. In fact, the presenter

cited the team’s coordination with the private sector in assessing the parafiscal implications of the draft

law as a necessary benefit. The major difficulty has resided in the MOH Legal Unit charged with

examining the draft law’s quality and to send it to the Council of Ministers for their approval on behalf

of the government. The key innovations have been the involvement of civil society organizations

(CSOs), MPs, and the private sector in the development of the draft law, as well as the establishment of

a MP Network on Immunization, the planned National Immunization Fund, and the establishment of a

monitoring group spearheaded by the Pilot Committee.

DRC

In DRC, the EPI and its partners initiated the process with the formation of a group of MPs sensitized on

immunization issues. The MPs extended their knowledge to their honorable colleagues and garnered a

large following of MPs to their cause and pledged their support to the elaboration of a law to address

these gaps in the EPI. Since its establishment, several initiatives have been undertaken, including:

1. Employment of a multidimensional team composed of government (MOH), EPI experts and

officials, the National Assembly, and partners to rigorously scrutinize all aspects of the proposed

law.

2. Organization of knowledge exchanges with health professionals to enrich the law.

3 As of January 2015, thirty MPs joined this coalition, and since then, patterned on REPACAV, the MPs sent an affirmation letter to the National Assembly President for official approval. In May 2015, the coalition held its first official meeting. For more information, see Immunization Financing News 6 (4), page 7 first column.

http://www.sabin.org/sites/sabin.org/files/sif_newsletter_vol_6_no_4_final_24-2-2014.pdf


3. Education of a critical mass of MPs from both chambers on the importance of the law.

4. Organization of a meeting to establish the mid-year statement on the status of immunization in

DRC.

5. Elaboration of a law proposal enumerating the fundamental principles of immunization in DRC,

endorsed by an MP from the majority party and one from the opposition.

Deposited at the Office of the National Assembly, the law proposal was then sent through the National

Assembly President to the Office of Studies for consultation, consistent with Article 167, Lower

Chamber Internal Regulation. In reference to Line 2 Article 47 of the Constitution which stipulates, “the

law dictates the fundamental principles and rules of the organization of public health and food

security…”, the Office of Studies advised the authors of the law proposal in June 2014 that it would be

necessary for the immunization law to address all law proposals already submitted in relation to public

health (reproductive health, anti-tobacco) in addition to immunization, so that the one law contains all

fundamental principles and rules necessary for public health.

Congo

Congo-Brazzaville presented their legislative process next. The draft law was conceptualized in April

2012 during an advocacy briefing (SAV) followed by a peer exchange workshop between Madagascar

and DRC in November 2012. Following these meetings, working sessions then took place among

stakeholders and resulted in the elaboration of an immunization draft law. The draft law required a

revision so that it could be aligned with the Health Minister’s vision, to produce a general law on health.

The Congolese EPI was also recommended to involve other stakeholders, namely the MOF and civil

society, to accelerate the law’s adoption.

Madagascar

Beginning in 2011, a series of information sessions were organized, targeting a variety of institutions –

the MOFB, parliament, and technical & financial partners. These efforts resulted in the finalization of an

advocacy document and a draft immunization law in February 2012. Since 2013, the EPI has

endeavored to finalize the law and share it among the Ministries and the newly elected National

Assembly members. The delegation recognized the commitment from the Health Minister, who was

simultaneously the Prime Minister, as a great advantage. Areas for improvement include the turnover

rate of ministerial officers, indecision between a law on health or immunization financing, and the

organization and function of the National Immunization Fund (FNV) that is stipulated in the draft law.

For next steps, Madagascar intends to create a law drafting committee, submit the draft law to the

Government Council and Council of Ministers for them to relay it to the National Assembly for

adoption. The country will further endeavor to finalize the Decree of Application before 2016.


Legislative Status by Country

According to the previous presentations, the pairs determined that Senegal, Mali, and Congo are

between Phases 3 and 4, as illustrated in the table below. In Mali, consultations have been sidelined due

to the resumption of the war in November 2014. In contrast, DRC, Cameroon, and Madagascar are in

the consultation phase.

Table 1a.

Legislative Process in Francophone SIF Countries

SIF Program

Country

Phase I Phase II Phase III Phase IV Phase V Phase VI Background

Legislative

Research

Legislative

Strategy

Selected

Drafting of

Bill/Amendments

Stakeholder

Consultation

Bill Submitted

to Parliament

Passage of

Bill/Amendments

Cameroon Phase IV

Madagascar Phase IV

DRC Phase IV

Congo Phase III/IV

Mali Phase III/IV

Senegal Phase III/IV

Table 1b.

Legislative Process in non-Francophone SIF Countries

SIF Program

Country

Phase I Phase II Phase III Phase IV Phase V Phase VI

Background

Legislative

Research

Legislative

Strategy

Selected

Drafting of

Bill/Amendments

Stakeholder

Consultation

Bill Submitted

to Parliament

Passage of

Bill/Amendments

Georgia Phase VI

Indonesia Phase VI

Moldova Phase VI

Mongolia Phase VI

Nigeria Phase VI

Uzbekistan Phase VI

Vietnam Phase VI

Liberia Phase V

Nepal Phase V

Cambodia Phase III

Kenya Phase III

Uganda Phase III

Sri Lanka Phase II

Armenia Phase I

Ethiopia Phase I

Sierra Leone Phase I


Finishing off the legislative portion of the workshop, the peers evaluated each other’s status in the

legislative process in small groups. Their results are found in Annex D.

Theme III: Advocacy in Practice

A Sabin representative introduced the third and final technical theme, and each delegation shared their

advances towards domestic advocacy practices for sustainable immunization financing at the national

and subnational level.

DRC

The DRC delegation informed their fellow participants on their advocacy coalition. The coalition is

branded as a multidisciplinary team transformed into an exclusively parliamentary mission. The

immunization advocacy network of parliamentarians was established in 2012. The network constitutes a

dialogic platform extended to the provincial level and includes sectoral officers, professional health

organizations, civil society, and beneficiary communities. The presenter indicated that Sabin/SIF in

conjunction with WHO, UNICEF, and Gavi has organized sensitization and training activities targeting

national institutions (in government and parliament) on sustainable immunization financing. Such

activities are conducted at the provincial levels as well, to sensitize provincial parliamentarians,

financial officers, and other relevant authorities to persuade them to secure an immunization budget line

for their province, and to encourage the governors to interface with the Provincial Coordination

Committee Presidents in order to make this happen. During the REPACAV (Parliamentary Support

Network on Immunization) MPs’ dialogues with prospective members, they employ a three-dimensional

communication strategy in order to recruit them or to pledge to act in favor of the coalition’s interests:

1. Political Dimension: Immunization is a rallying subject, safe from political aims and divisions.

REPACAV wields a strong membership from both majority and minority parties of parliament.4

2. Economic Dimension: Immunization saves the State from inordinate hospital and non-

preventative health expenses. It oxygenates job creation and consequently promotes investment.

3. Social Dimension: Immunization serves as a massive protective shell for all our citizens; one

must recall the social contract between all elected officials and their respective constituents.

Thanks to this strategy, the DRC delegate enumerated several results that these efforts have

generated:

Insertion of a guaranteed national immunization budget line

Since 2012, DRC purchases an increasing portion of its vaccines

Intelligible increases in disbursement rate from projected figures (80% in 2013)

4 During an introductive briefing between REPACAV and the Health Minister the following January, he emphasized the necessary role a bipartisan membership plays for the coalition.


Progressive extension of the coalition down to the provincial level and well-mobilized

provincial legislators

In the coming years, REPACAV intends to accelerate the health law drafting process (which contains a

section on immunization), improve budget tracking to improve the disbursement rate, and establish a

distinct yet parallel coalition among provincial legislators.

Cameroon

Advocacy efforts in Cameroon focus on vaccine independence following Gavi withdrawal, according to

the Cameroonian presenter. The peers realize their goals through transforming prospective actors in

ministries, parliament, the 368 United Towns and Communities of Cameroon (CVUC) into focal points

within each entity. These transformations are made during training seminars, in August 2014 for

instance, organized by the MOPH in collaboration with Sabin. The results: parliamentarians and CVUC

participate in budget preparations every year and the allocated immunization budget has consequently

increased.5 The Cameroonian delegation then recognized that advocacy initiatives must be incorporated

into the cMYP and that the peers must produce an analytical text on the cost-effectiveness of

immunization in order to sharpen their weak advocacy messaging. In conclusion, the presenter

considered the involvement of local communities in the capitalization in the Special Allocation Account

as a key advocacy innovation to cultivate.

Congo

Like the Cameroonian delegation, the Congolese presenter defined the country’s advocacy strategy in

terms of sustainable financing facing Gavi withdrawal. Through information sessions, advocates from

the MOPH, MOFP, Health, Economy & Finance Committees from both chambers, and the Presidential

Health Council sensitize parliamentarians on general financing issues, district councils on local

immunization financing, and gas & mobile phone firms on their respective roles as investors in

immunization. The delegation enumerated the following results from their advocacy initiatives:

parliamentary ownership of immunization matters, the insertion of a vaccine purchase budget line, a

Gavi transition plan, and the financing of operational costs by councils from three health districts.

Unfortunately, advocates are faced with meager interest from decision-makers concerning immunization

matters and weak support for a law guaranteeing sustainable immunization financing within the MOPH.

Nevertheless, the peers were successful in advocating for financing from local communities and the

private sector (gas and mobile phone).

Mali

On the other hand, the Malians are currently focusing their advocacy activities entirely on the adoption

of a law guaranteeing sustainable immunization financing. Advocates from MOH, MOF, and the

National Assembly orchestrate legislative workshops with MPs, ministerial officials, the private sector,

5 In December 2014, several days later, the MOPH in coordination with the aforementioned actors defended a budget increase before all stakeholders before submitting the proposed budget to parliament.


and civil society, the latest of which took place in November 2014. The peers now wield a draft law on

immunization. During these working sessions, the MOH evaluates the existing legislative provisions, the

MOF participates in the drafting process, and the National Assembly acts in support. To facilitate the

legislative process, the aforementioned advocates persuade municipalities to prioritize immunization

whilst preparing their budgets. Mali has established a new parliamentary immunization advocacy

coalition which aims to reposition the EPI within the MOH to accelerate the legislative process.

Senegal

The Senegalese delegation considered the adoption of an immunization-specific law as a determining

factor for the sustainable financing of their program as well. The National Assembly (including Health

and Finance Committees), the MOPH (EPI), MOEF, WHO, UNICEF, USAID, and PATH participate in

the steering group that is led by the advocacy focal points in the EPI, PTF, parliament, and the MOEF.

This group is broken into three divisions: health, finance, and parliament. In the second SIF workshop in

Yaoundé, Cameroon, the group issued a resolution on the necessity to legislate for immunization

financing, and consequently established a drafting committee, who has since finalized the first draft law.

The delegation also ascribed the budget line increase in 2010 from CFA 800 million to CFA 977 million

to the steering group. An assortment of stakeholders are involved in the steering group: UNICEF played

a decisive role in establishing the group, WHO sensitizes MPs on immunization, the MOEF monitors

the immunization budget line, parliament encourages its colleagues to increase the budget as

appropriate, and the MOH is designated as the impetus for the entire process. The presenter recalled that

CSOs are neglected during these efforts and challenges his counterparts to establish a more inclusive

steering group.

Madagascar

The Malgache advocates aim to generate an adequate familiarity among decision-makers with

immunization financing matters to guarantee the EPI’s viability and durability. MOH, MOFB,

parliament, and technical & financial partners organize informational and sensitization workshops

targeting the President, parliament, the Prime Minister, the MOFB, and all other relevant ministries. To

optimize their messaging during these sessions, the peers evaluate the gaps in their messaging. A

technical drafting & implementation group has been established to sharpen messaging. These efforts

generated a coherent advocacy document, partner assistance in assessing options for a National

Immunization Fund (FNV), and an EPI budget increase.

Day 3: Peer Review and Next Steps The final activity of the workshop entailed a peer assessment of each other’s institutional innovations

using a standard peer review guide (Annex F). Eighteen delegates from the six countries participated in

the peer review session. Standard templates were used for countries to prepare their presentations.

Each peer was randomly assigned to evaluate three countries. Raters used a standard discussion guide to

examine the innovative practices that governments and parliaments are developing, or have developed,


to move their countries closer to the sustainable immunization financing goal. New practices were

classified in terms of functional area (finance, budget, legislation, advocacy), developmental

mechanism (top-down, bottom-up, third party), duration (less than one year, 1-2 years, 3 years or more),

level (international, national, subnational), the institutions involved (government, legislature, non-

governmental) and current level of development (in discussion, being tried, becoming institutionalized,

fully institutionalized).The guide included several open-ended and multiple choice questions and a list of

ten items scored on a Likert scale.

The peer review activity was divided into two consecutive 30-minute sessions. In the first session,

reviewers interviewed their peers from C1, C2 and C3. In the second round, peers from those countries

interviewed their peers from C4, C5 and C6. In addition, raters jotted down comments and

recommendations for the presenters. Completed forms (n=51) were collected at the end of each session.

Scores were tabulated by Sabin staff. Results are summarized below.

Results

All but one workshop participants participated in the peer review exercise. Twenty-six of the 51 raters

(51%) represented ministries of health. Eleven (22%) were MPS and 9 (18%) represented ministries of

finance. Two raters (4%) represented other government ministries and 3 raters (6%) did not identify

their home institutions. Of the 18 raters, 16 completed the three assessments assigned to them.

Raters classified the practices they assessed as budget-related (22%), financing (8%), domestic advocacy

(24%), legislative (22%) or some combination of the four areas (8%). Seventy-five percent of the

practices were occuring at national level, 10% at subnational level; 14% involved international

activities.

Sixty-six percent of the assessments identified more than one public institution involved in the new

practice. Most frequent were ministries of health (84%), followed by ministries of finance (66%) and

parliaments (49%). Non-government institutions were involved in 11/51 (22%) of cases. Most

commonly mentioned were community service organizations (82%), followed by businesses, at 46%,

(5/11) and other groups (18%).

The practices tended to originate in top-down fashion (88%); just 6/50 (12%) emerged from the bottom-

up. No innovations originated through outside organizations or institutions. Thirty-eight percent of the

practices (18/48) began within the past 1-2 years with 63% (30/48) ongoing for three years or more.

The raters determined that 20% of the new practices (10/49) were already fully institutionalized, i.e.,

they were no longer innovations. Some 59% of the innovations (29/49) were still in trial phase or in the

process of becoming institutionalized. Nine cases (18%) were still in the talking stage while one

innovation (2%) had been blocked.

The ten subjective Likert-scaled items are described in Table 2 Raters assigned each item a score of 1-5,

with 1 being “No chance”, 2 “Not likely”, 3 “Unsure”, 4 “Likely” and 5 “Almost certain”. Inter-rater

reliability is a concern for data such as these. Different numbers of raters rated each case. Raters likely

differed in systematic ways in how they assessed a given country’s innovation. The intra-class

correlations shown in Table 2 indicate how similarly (reliably) the raters rated each item for each


country. Six ICCs are statistically significant, however, they are relatively low, ranging from 0.63

(no_cost) to 0.34 (resist). The six reliably measured variables are further described below.

resist: In 16/51 assessments (31%), raters perceived that resistance to the innovation was likely

to certain. Resistance was least evident in Mali (0/9 assessments) and Senegal (2/9).

approach. In 18/51 assessments (35%), raters felt another approach to the innovation might have

been better. No country received a unanimous score on this indicator. The country where the

approach was judged most appropriate was Madagascar (5/7).

mix_inst. Seventy-seven percent of assessments (39/51) concluded the right mix of institutions

was involved in the innovative practice. Scoring highest on this variable were DRC (7/8), Mali

(7/9) and Republic of Congo (8/9).

no_cost. More often than not, the raters concluded that the innovations they assessed would

entail additional costs : 25/51 said likely or very likely (49%) versus 8/51 unlikely (16%).

Additional costs were judged least likely in Republic of the Congo, DRC and Madagascar.

sustain. In 40/51 assessments (78%), raters felt the innovation will help the country reach

sustainable immunization financing sooner. Scores on this variable were highest for Cameroon

(9/9), Mali (9/9) and Senegal (8/9).

inst_nation. Seventy-eight percent of assessments (40/51) predicted the innovation would

ultimately be institutionalized nationwide. Raters were unanimous on this for Mali and Senegal.

Table 2. Scoring results per subjective item on Likert Scale | Francophone Africa Peer Review Workshop, Kribi, Cameroon. 2014.

Item Description of Item Obs. Mean Std. Dev.

Min Max Intra-Class Correlation

(rho)

95% C. I.

concept The innovation is well conceptualized. The proposed solution matches the problem or opportunity it addresses.

49 4.3 0.95 2 5 0.03

(0.16) (0.00, 0.34)

approach Another approach would have been more suitable for solving the problem/improving the sustainability of the immunization.

48 3.6 1.17 1 5 0.42** (0.16)

(0.10, 0.73)

mix_inst The right mix of institutions is or was involved in developing the innovation.

48 4.1 1.02 1 5 0.48*** (0.15)

(0.18, 0.78)

resist There is or was a lot of resistance to this innovation. 47 2.7 1.35 1 5 0.34** (0.17)

(0.01, 0.67)

no_cost This innovation is or was carried out without incurring significant new costs.

47 3.7 1.09 2 5 0.63*** (0.12)

(0.39, 0.88)


sustain This innovation will help the country reach sustainable immunization financing sooner.

48 4.2 0.76 2 5 0.61*** (0.13)

(0.36, 0.86)

inst_nation The innovation will ultimately be institutionalized nationwide.

47 4.3 0.95 1 5 0.45** (0.16)

(0.15, 0.76)

owner If successful, the innovation will increase country ownership of the immunization program.

47 4.6 0.58 3 5 0.09

(0.17) (0.00, 0.41)

likely Considering all the factors, how likely is the innovation to succeed, to become institutionalized?

47 4.3 0.75 1 5 0.22

(0.17) (0.00, 0.55)

own_likely This innovation would likely succeed in your own country.

46 4.3 0.90 1 5 0.03

(0.17) (0.00, 0.35)

*not significant p>0.05; **significant at 0.001<p<0.05 level; ***significant at p<0.001

The six items were then rescaled to the (-2,2) interval and the scores were summed for each country. The

next step was to find the best combination of items to make an overall innovativeness index. Factor

analysis revealed that four items made the best index (mix_inst, resist, no cost, sustain, alpha=0.53).

Mean scores and ranks for each index item and for the overall innovativeness index are shown in Table

3. The country raters found most innovative was DRC, followed by Madagascar and Congo.

Table 3. Countries ranked by averages of five innovativeness variables | Francophone Africa Peer Review Workshop on Sustainable Immunization Financing, Kribi, Cameroon. 2014.

Right institutional mix Resistance to innovation Minimal added costs

Rank Country Average Rank Country Average Rank Country Average

1 RDC 1.70 1 RDC -0.42 1 Madagascar 1.67

2 Congo 1.50 2 Congo -0.28 2 Congo 1.43

3 Madagascar 1.33 3 Madagascar 0.16 2 RDC 1.43

4 Mali 0.89 4 Cameroun 0.22 3 Cameroun 0.11

4 Sénégal 0.89 5 Sénégal 0.77 4 Sénégal 0.11

5 Cameroun 0.67 6 Mali 1.00 5 Mali -0.11

Sustainability of innovation Average innovativeness

Rank Country Average Rank Country Average

1 Cameroun 1.56 1 RDC 0.64

2 Mali 1.44 2 Madagascar 0.58

3 Sénégal 1.22 3 Congo 0.54

4 RDC 1.00 4 Cameroun -0.25

5 Madagascar 0.5 4 Sénégal -0.25

6 Congo 0.13 5 Mali -0.42


In Figure 3, the countries’ innovativeness indexes are plotted against their 2013 gross national incomes.

Countries in the top half of the graph have the highest innovativeness scores; those to the right have the

highest incomes. The pattern shows that innovativeness is not dependent on wealth.

Figure 3.

In their comments and recommendations, the raters offered useful feedback to their peers. Some

examples:

Cameroon, observed one rater, has been innovating in the areas of legislation (to create a

national immunization fund) and advocacy for the past 1-2 years. The innovations are coming

from the Ministries of Health and Finance working together at national level. In particular, the

rater commented, the joint subcommittee on immunization financing formed by the two

ministries is itself an important innovation. The rater recommended that members of this

subcommittee “…advocate to the minister with technical arguments to support the initiative and

confront resistance thereto”.


The problem Senegal is facing, wrote one rater, is poor immunization budget execution. The

innovation: develop a new resource tracking tool. The innovation is rolling out in top-down

fashion, at national level, supported by the Ministry of Health. It is still just in the talking stages.

The rater commented that the new tool must include an explicit “financial domain”.

For over three years, peers in Mali have been advocating for a specific annual budget line item

for the national immunization program. Ministries of Health and Finance as well as Parliament

have been working together on the project. Progress is being made, the rater noted, adding that

the peers should keep up the pressure.

The DRC is coming to terms with its chronically low immunization budgets, noted one rater,

through the sustained (3 years+) efforts of peers in the Ministry of Health, Ministry of Finance,

Parliament and other government entities. Community service organizations have also been

involved. MPs have taken the lead in advocating that local (provincial) authorities establish

budget lines for immunization. This advocacy innovation to increase subnational immunization

budgets is well on the way to becoming institutionalized, commented the rater.

Peers in the Congo Republic are just beginning a new resource tracking effort for the

immunization program, noted one rater. The effort is being led by the Ministry of Health. New

tools are being tested. In the rater’s opinion, they need further conceptualization.

For three years plus, the Ministry of Health of Madagascar has been leading an effort to enact

new immunization legislation. The effort, noted one rater, has suffered from high turnover of key

institutional actors yet now stands to succeed for that very reason. Prospects for success,

however, are uncertain. “The innovation is one that has evolved from but one man. Since it's just

the Health Minister and [now] Prime Minister, all gains may be lost if he leaves before his goals

are realized.”

Discussion

A rapid peer review exercise was organized during a workshop on sustainable immunization financing

for six Francophone African countries in Kribi, Cameroon. Eighteen peers participated, both as raters

and presenters of their respective country innovations.

Results show the peers generally understand the concept of institutional innovations. Most of the

innovations they examined had been underway for two or more years,at national level, with multiple

public institutions involved.

Whether relatively wealthy or poor, the raters decided, a country can innovate to improve immunization

financing. This is a welcome finding.


A number of limitations threaten the validity of these findings. The presentation templates were

distributed to help delegates showcase their national innovations but may have imposed structural biases

on the content presented. Important concepts were likely omitted. The presenters were not necessarily

personally involved in the practices they presented. Additionally, as raters, some participants clearly

misunderstood some of the concepts they were measuring. Time allotted for the review may have been

insufficient.

On balance, the peer assessment succeeded in generating new insights and documenting previously

overlooked details of the institutional change processes currently underway in the study countries. In

future, more time should be devoted to developing more robust assessment tools and to better orienting

the participants. Sabin will provide the participants summary reports of each study country. Participants

will be invited to a subsequent peer review exercise in the coming months.

Major Challenges that Remain and Next Steps

The major challenges that remain in executing sound advocacy in SIF countries are:

1. Convince leaders at the highest level (Prime Ministers, Presidents) of the importance of

immunization and the potential benefits a sustainable immunization financing mechanism

guaranteed by a legal framework holds.

2. Escalate the administrative position of the EPI within each ministry as a manifestation of the

political prioritization of immunization.

3. Secure commitment from the Ministry of Finance to increase fiscal space for immunization.

4. Dedicate resources for advocacy initiatives within the cMYP.

5. Produce a document on the cost-effectiveness of immunization.

These challenges require both the leadership of the Health Minister and resilient advocacy targeting the

President and Prime Minister.

By the end of discussions, and in averting their gazes to the long journey towards achieving sustainable

immunization financing, the participants unanimously recommended the following next steps:

1. Conduct a systematic literature review or pilot a study on the socio-economic impact of

immunization in order to demonstrate to the Health Minister that immunization is a sound

investment.

2. Orchestrate a series of advocacy initiatives so that draft laws and law proposals are examined

and adopted by the end of 2015, at the latest.

3. Organize informational sessions with the Expanded Strategic ICCs and all stakeholders on the

evolution of technical and financial indicators at least one month before budget negotiations.

4. Systematize budget tracking mechanisms by the end of 2015 in such a way that all financial data

is integrated into EPI performance reports.


5. Establish an inclusive advocacy network if one doesn’t exist already.

6. Institute a parliamentary coalition to strengthen advocacy efforts if one doesn’t exist already.

ANNEXES

Annex A : List of participants

Name Title/Institution Country Mr. Jules Baganda Section Director, Ministry of Budget DRC

Hon. Gregoire Lusengue National Assembly Member DRC Mr. Benjamin Matata

Finance Section Director, Ministry of Health DRC

Dr. Audry Wakamba Mulumba EPI Manager, Ministry of Health DRC Dr. Louis Marius Rakotomanga

EPI Manager, Ministry of Public Health Madagascar

Mrs. Noeline Victoire Raveloarijao Representative, Ministry of Finance and Budget

Madagascar

Dr. Aro Tafohasina Rajoelina Representative, Prime Ministry Madagascar

Dr. Lova Herizo Rajaobelina Health Committee President, National Assembly

Madagascar

Dr. Hermann Boris Didi-Ngossaki EPI Manager, Ministry of Health Congo

Mr. Jean Fenelon Kanda Officer, Budget & Public Portfolio Section, Ministry of Finance

Congo

Dr. Ousseynou Badiane EPI Manager, Ministry of Health & Social Action

Senegal

Hon. Elene Tine MP, Health Committee Member Senegal Mr. Mahamadou Sidibe Health Focal Point, Budget Directorate

General, Ministry of Economy, Finance, and Budget

Mali

Hon. Abdoulaye Dembele Health Committee Member, National Assembly

Mali

Dr. Alimata Naco Diallo Interim EPI Manager, Ministry of Health and Public Hygiene

Mali

Dr. Marie Kobela EPI Manager, Ministry of Public Health Cameroon

Mr. Cyrille Effila Officer, Budget Section, Ministry of Finance Cameroon Hon. Gaston Komba Former Health Committee Member, National

Assembly Cameroon

Dr. Ngwen Ngangue Representative, Ministry of Economy and National Planning

Cameroon

Dr. Remy Mwamba UNICEF West & Central Africa (WCARO) Focal Point

Senegal

Mr. Jonas Mbwangue Sabin/SIF Senior Program Officer Cameroon Dr. Helene Mambu-Ma-Disu

Sabin/SIF Senior Program Officer DRC


Annex B: Agenda

Day One:

Time Presentation Presenters Location/Notes

8:00-8:30 Registration

Plenary

8:30-8:40 Welcome, workshop objectives

National Assembly, Ministry of Public Health 8:40-10:00

Opening ceremony Address by Sabin, WHO, UNICEF, World Bank Address by the National Assembly Allocution par l’Assemblée Nationale Opening address by the National Assembly

10:00-10:15 Coffee break

Theme I : Budgeting and Resource Tracking

10:15-10:40 Immunization budgeting and resource tracking: Concepts and applications Sabin

Plenary

10:40-11:00 Discussion Country delegates/Sabin

11:00-11:10 Cameroon : Budgeting and resource tracking practices

Cameroonian delegation

11:10-11:20 Congo: Budgeting and resource tracking practices

Congolese delegation

11:20-11:30 Madagascar: Budgeting and resource tracking practices

Malgache delegation

11:30-11:40 Mali: Budgeting and resource tracking practices

Malian delegation

11:40-11:50 RDC: Budgeting and resource tracking practices

DRC delegation

11:50-12:00 Senegal : Budgeting and resource tracking practices

Senegalese delegation

12:00-12:20 Discussion Delegates

12:20-12:30 Recapitulation and small group work instructions (first round)

Sabin

12:30-13:30 Lunch Break

13:30-14:30

Small Group Work (first round) : Approaches for and experiences in filling budget tracking tools and leveraging them for advocacy purposes ; documentation of best practices in resource tracking

Small groups Separate rooms

14:30-15:30 Panel presentation: Best practices in budgeting and resource tracking (20 minutes per group) Country delegates Plenary


15:30-15:45 Coffee break

15:45-16:30 Recapitulation and discussion of Theme I Sabin Plenary

Theme II : Immunization Legislation

16:30-16:45 Overview of model immunization laws and the legislative process

Sabin Plenary

16:45-17:00 Discussion Country delegates/Sabin 17:00 End of Day One

Day Two:

Time Presentations Presenters Location/Notes Theme II : Immunization Legislation (continued)

8:30-8:40 Summary of Day One Sabin

Plenary

8:40-8:50 Overview of immunization legislation Cameroonian delegation

8:50-9:00 Overview of immunization legislation Congolese delegation 9:00-9:10 Overview of immunization legislation Malgache delegation 9:10-9:20 Overview of immunization legislation Malian delegation 9:20-9:30 Overview of immunization legislation DRC delegation 9:30-9:40 Overview of immunization legislation Senegalese delegation

9:40-10:10 Discussion Sabin

10:10-10:15 Small group work instructions 10:15-10:30 Coffee break

10:30-11:30 Small group work (second round) : Comparative evaluation of vaccine legislation and regulatory documents (1) ; (2) ; (3)

Small groups Separate rooms

11:30-12:30

Panel presentation : Conclusions and recommendations from the evaluation : (10 minutes per group, 30 minutes of open discussion)

Small groups Plenary

12:30-12:45 Discussion Delegates 12:45-13:45 Lunch break

13:45-14:30 Small group work (third round) : Delineate legislative case studies

Small group work Separate rooms

14:30-15:30 Panel presentation : Legislative case studies (10 minutes per country)

Group reporters/Sabin Plenary

15:30-15:45 Coffee break 15:45-16:15 Discussion and Recapitulation of Theme II Country delegates/Sabin Plenary

Theme III : Advocacy in Practice

16:15-16:30 Advocacy for sustainable immunization financing

Sabin Plenary


16:30-17:30 Small group work (fourth round) : Delineating advocacy case studies by country Small group work Separate rooms

17:30 End of Day Two Plenary Day Three:

Time Presentation Presenters Location/Notes 8:30-8:40 Summary of Day Two Plenary

Peer Review: Innovations in Sustainable Immunization Financing 8:40-9:10 Peer review, part I : (Group A) Country delegates

Plenary (Note : Use the SIF guide for the peer review)

9:10-9:40 Peer review, part II : (Group B) Country delegates

9:40-12:00 Recapitulation of workshop proceedings Workshop evaluations and next steps

Sabin

12:00-1:00 Closing words Sabin, country delegates 13:00 End of workshop

Annex C: Small Group Instructions Overview 1. There will be four rounds of small group work. In Round One (Day 1), delegates are pre-assigned

to three country pairs. Each pair consists of a country that has completed a budget flow analysis

and a country that has yet to do so. In Round Two (Day 2), countries are again paired such that

one has vaccine-related legislation in place and the other does not. In Rounds Three and Four

(Day 2), there are six small groups; delegates work by country.

2. Groups will consist of no more than nine members.

3. The groups will use the nominal group method, described below.

Methods 1. Round One (immunization budget resource tracking)

1.1. First Step: Before going into small groups, each delegate will receive a blank notecard. On

that card, each delegate will write a sentence or two describing one problem (constraint)

that impedes the completion of the SIF budget flow analysis sheet. On the other side of the

card, delegates are asked to write a sentence or two describing a positive factor that

facilitates the completion of the budget flow analysis in his or her country. Problems should

be expressed in performance terms by stating, for example, the difference between what is

occurring vs what should be occurring and identifying which institutional practices can be

and should be changed to produce a better outcome.


1.2. Second Step: In the small group, each delegate reads what is on his or her card. There can

be brief discussion about the problem (constraint) - but not the proposed solutions. (That

comes in Step Five.) Similarly, facilitating factors should merely be read aloud. In the

discussion, the facilitator makes sure it is clear to everyone else what each person means to

say. The recorder writes the responses on the flipchart. When a page is full, it is removed

and taped to the wall and a second page is begun. When finished, there should be several

pages filled out and displayed on the wall. There should be no more than two responses per

delegate- one problem/constraint and one facilitating factor.

1.3. Third Step: The facilitator asks delegates to group and to reduce the responses to just a few

key concepts. The recorder makes notes on the pages showing which responses are to be

combined. Two new pages are produced, one with the shortened list of

problems/constraints, the other with the shortened list of facilitating factors.

1.4. Fourth Step: Ranking. The facilitator asks delegates to score each problem/constraint,

according 3 points to the most important, 2 points to the second most important and 1 point

to the third most important. The process is repeated for the facilitating factors. The recorder

calls on each person one by one, writes the scores and totals them for each

problem/constraint and for each facilitating factor. The maximum score any item can

receive is: 3 x no. of delegates (ie, 27 pts for a nine-person group). This one is ranked the #1

problem/constraint. The next two highest scoring items are ranked second and third most

important. The ranking process is then repeated for the facilitating factors. By the end of

this step, up to three problems/constraints and up to three facilitating factors will have been

ranked.

1.5. Fifth Step: This step focuses just on the problems/constraints. The recorder writes each of

the top three problems/constraints on its own blank flipchart page. Facilitator now asks

delegates to think of realistic solutions, or approaches or specific steps to take to each

problem, starting with the one given the highest rank. This time the discussion is more in-

depth. The delegates will have different suggestions because they come from different

institutions and different countries. The recorder writes the proposed solutions,

approaches and specific steps on the page for each problem. At least two, and ideally all

three, problems will be addressed before time runs out. The group then nominates a

spokesperson who will present their results. This step concludes the small group work.

1.6. Summary of Results: After the delegates have left, facilitator, recorder and elected

spokesperson work together for a few minutes to prepare their group presentation. The

report should be short- just 4 PowerPoint slides. The first slide identifies the theme,

countries in the group and spokesperson. The second slide lists the group members. The


third slide lists, on the left panel, the three reduced/ranked problems from most to least

serious. On the right-side panel, the facilitating factors are listed. On the fourth slide,

problems/constraints are again listed on the left panel with corresponding proposed

solution(s) are listed on the right panel.

1.7. Reporting of Results: After the small group work, a panel consisting of the three

spokespersons will present the small group results in plenary. A moderator will guide the

group discussion. Each spokesperson will present that country’s legislative project

narrative. The PowerPoint slides will be displayed as the spokespersons speak. Each

spokesperson will speak no more than 10 minutes. After the panel presentations and coffee

break, the moderator will ask for questions from the audience. Spokespersons will respond.

Q/A will last up to 30 minutes total.

2. Second round (legislation)

2.1. First step: Delegates will again work in country-pairs. The same procedure will be followed

as in Round One: Each delegate will write a sentence or two describing one problem

(constraint) that impedes the completion of vaccine-related legislation. On the other side of

the card, delegates are asked to write a sentence or two describing a positive factor that

facilitates the completion of their legislative project.

2.2. Second through Fifth Steps: Follow the same procedures as in Round One.

3. Third round (legislative case studies)

3.1. Background: Delegates will work by country. Each of the six groups will document the story

of its country’s immunization-related legislative project. The projects may involve

freestanding laws specific to vaccines or immunization or broader laws containing vaccine-

relevant provisions. They may be about regulations or presidential or ministerial decrees.

These may be new bills or acts or amendments to existing ones. They may be completed or

still in process. The aim is to capture the story of which public (or other) institutions acted,

or are acting, to make the legislative projects happen and how they did it.

3.2. First Step: Each delegate will be asked to describe the legislative project he or she feels is

most relevant for achieving sustainable immunization financing in their country. The

facilitator guides the conversation, making sure that each delegate participates and is fully

understood by the others. The recorder writes the key points on the flipchart. When a page

is full, it is removed and taped to the wall and another page is begun.


3.3. Second Step: Going back over the narrative, the moderator asks the delegates to put the

main points in sequence. How did the idea of the legislation begin? Which groups carried it

forward? What were the formal steps followed? Is the law, decree or regulation fully

written? Has it been approved and enacted? Has it been effective? The recorder rearranges

or numbers the sheets in chronological order and adds supplementary notes derived from

the discussion. The group then nominates a spokesperson who will present their results.

This step concludes the small group work.

3.4. Summary of Results: The report should be short- just 3-4 PowerPoint slides. The first slide

identifies the country and spokesperson. The second slide identifies the group members.

The remaining slides describe the legislative project in chronological fashion using no more

that 4-5 bullet points per slide.

3.5. Reporting of Results: After the small group work, a panel consisting of the six

spokespersons will present the results in plenary. A moderator will guide the group

discussion. Each spokesperson will present that country’s legislative project narrative. The

PowerPoint slides will be displayed as the spokespersons speak. Each spokesperson will

speak no more than 10 minutes.

4. Fourth round (advocacy case studies)

4.1. Background: Delegates will again work by country. Each of the six groups will document

its best examples of local advocacy practices for sustainable immunization financing. The

focus is on public institutions- ministries, parliaments, local governments and the

individuals within them who have taken the initiative to convey information about

immunization financing to key audiences in new ways. The audiences may be in other

institutions involved in financing decisions or they may be the public at large. Think of new

practices that have increased support within the government, parliament or the public at

large for sustainable immunization financing.

4.2. First Step: Each delegate will be asked to describe the advocacy work or practice he or she

feels is most relevant for achieving sustainable immunization financing in their country. The

facilitator guides the conversation, making sure that each delegate participates and is fully

understood by the others. The recorder writes the practices described by the delegates on

the flipchart. When a page is full, it is removed and taped to the wall and another page is

begun.

4.3. Second Step: The facilitator asks delegates to group and to reduce the number of practices

to just three. The facilitator guides the exercise by asking a series of questions for each


named practice, such as how the practice began, which individuals or institutions carried it

out and how effective it has been in increasing support for immunization and immunization

financing. The recorder makes notes on the pages showing which practices are to be

combined. The group again nominates a spokesperson who will work with the facilitator

and recorder to document their results.

4.4. Third step: The delegates discuss each practice in detail, generating short narratives

(vignettes) describing each one. The spokesperson takes notes and from these notes will

compose each vignette. Each vignette is one paragraph long and describes the advocacy

practice in narrative fashion.

Summary and Reporting of Results: The report will consist of the 3 short vignettes. Working with the moderator, the spokesperson will outline the main points (ie, how it began, who carried it out, effectiveness) from each vignette and enter them on a slide. There will be one slide for each advocacy practice. There will be no plenary presentation. Instead the six country reports will be compiled overnight and a document will be distributed to participants later summarizing the results.

Annex D: Small Group Work I Results, Budgeting and Resource Tracking

Cameroon

Strengths Weaknesses Innovations Necessary Improvements

-First lady is an EPI

sponsor

-Budget line for

vaccine purchase

-Involvement of MPs

at every stage of

budget preparation

-Release of

immunization funds

is dependent on the

release of the larger

treasury category in

which they are

situated

-EPI is reduced to a

subdirectorate and is

omitted from the

MOPH organigram

-Prime Minister

established

interministerial

committee to

elaborate the draft

immunization law

with the introduction

of a Special

Allocation Account

for vaccine & anti-

retroviral purchase

-Make States prioritize the EPI. Should

be instituted as a National

Immunization Agency (as is the case in

Benin).

-Budgetary circular with the MOFB to

track budget execution

-Involvement of MPs throughout the

entire process

-Creation of a Multisectoral Ad Hoc

Budget Tracking Committee (Health,

MOFB, parliament, Prime Ministry…)

-Adoption of an immunization law;

institution of a National Immunization

Fund (FNV)

Congo


-Unspent EPI budget

carries over every

year

-Lack of vaccine

purchase budget line

-Advocacy for a vaccine purchase

budget line


-MOPH authorities

strongly commit to

EPI

-Strategic partnership

with UNICEF for

vaccine purchase

-Current budget

provisions

insufficient to cover

cofinancing & RI

-Lack of coherent

immunization

resource tracking

mechanism at

intermediary & local

levels

-Lack of formalized

advocacy network

-Lack of

immunization law

guaranteeing public

financing

-Establishment of resource tracking

mechanisms at the local level

-Establishment of an inclusive

immunization advocacy coalition

-Establishment of an inclusive

immunization information network

(MPs, civil society, PTF, private

sector)

-Adoption of an immunization law

which guarantees immunization

financing

-Establishment of a financial data

collection mechanism at intermediate

and local levels

Madagascar


-First lady is a

maternal & child

health sponsor

-Immunization is an

official State priority

(PGE)

-cMYP is signed by

the Health and

Finance Minister

-Budget line secured

-Obligatory expense

for the MOFB

-Budget not

guaranteed by the

MOH

-EPI is governed by a

Directorate

-MPs not involved in

budgetary process

-Creation of a

circulatory budget

which specifies that

vaccines, cold chain,

and gas are

obligatory expenses

as per the Amended

Finance Act to be

executed by the

MOFB

-Governmental

council note for the

Exemption of Taxes

for the Import of

Vaccines and

Immunization-

Related Equipment

-Make States prioritize the EPI. Should

be instituted as a Directorate.

-Budgetary circular with the MOFB to

track budget execution

-Involvement of MPs throughout the

entire process

-Creation of a Multisectoral Ad Hoc

Budget Tracking Committee (Health,

MOFB, parliament, Prime Ministry…)

-Adoption of an immunization law;

institution of a National Immunization

Fund (FNV)

Mali


-Budgets activities

through the cMYP

-Existence of

Operational Plan

(PO)

-Vaccine purchase

budget line

-EPI has weak

institutional position

-EPI doesn’t partake

in budget

preparations

-Weak financial

reporting

-Produce legislation which improves

the EPI’s institutional position

-The EPI should participate in

budgetary preparations

-Adopt an immunization law


-Vaccine purchase

budget line increase

-Budget line for

“purchase of gas for a

functioning cold

chain in regions,

villages, and

communities)

-100% budget

execution (regular,

regulated, and

protected budget line)

-Involvement of

communities

-Lack of an

immunization law

-High dependency on

foreign aid

-Increase the allocated immunization

budget or establish a National

Immunization Fund

DRC


-Budgets activities

through the cMYP

-Existence of an

Annual Operational

Plan (PAO)

-Vaccine purchase

budget line

-Vaccine &

campaigns budget

line increase

-Directorate general

-Existence of a

parliamentary

coalition involved in

immunization efforts

up until the

implementation phase

-Disbursement

difficulties (irregular

and delayed)

-Lack of an

immunization law

-High dependency on

foreign aid

-Lack of a coherent

budget execution

approach within the

EPI

-Establishment of a

parliamentary

coalition involved in

immunization that

has expanded to

include local entities

from EPI budget

preparation to

disbursement

-Strengthen advocacy by making each

EPI credit line obligatory expenses

-Advocate for an immunization-related

law

-Increase the allocated immunization

budget or create a National

Immunization Funds

-Incorporate the new law on public

finance to resource tracking efforts

Senegal


-Budget line for

vaccines and

consumables

-Capable of

mobilizing the entire

budget line

-Vaccine purchase

budget line stagnation

-Insufficiency of

national funds for

EPI operational costs

-Lack of a coherent

resource tracking

mechanism at the

-Strengthen advocacy to MOH and

parliament

-Escalate the EPI’s institutional

position

-Establish resource tracking

mechanisms at the peripheral level

-Establish an inclusive immunization

advocacy coalition


-Strategic partnership

with UNICEF for

vaccine purchase

intermediate and

local levels

-Weak institutional

position of EPI

-Lack of formalized

advocacy network

-Lack of

immunization law

guaranteeing public

immunization

financing

-Establish an inclusive immunization

information network (MPs, civil

society, PTF, and the private sector)

-Adopt an immunization law

guaranteeing public immunization

financing

-Implement financial data collections

mechanisms at the intermediate and

local levels

Annex E: Small Group Work II Results, Immunization Legislation

Cameroon


-Prime Minister

established an

Interministerial

Committee to draft

the law

-Technical sub-

committee of this

Committee is

operational

-Cumbersome

advocacy process to

change the minds of

two key decision-

makers (supported by

technical arguments)

Instability of key

actors in the

processes

-Draft law is being

finalized

-Submit the law to and secure approval

from the government by February 2015

-Submit it to parliament before its June

2015 session

Congo


-Existence of specific

laws (HIV, tobacco)

-Strong commitment

from MPs for the law

-Existence of a draft

law

-Financing, equity,

and service quality

provisions

-Weak commitment

from the Public

Health Minister for a

specific law

-Lack of a formalized

advocacy coalition

-Establishment of a formalized

advocacy coalition targeting the law

-Advocacy to the Public Health Minister

Madagascar


-Commitment from

the Health Minister

who is

simultaneously the

-Lack of a technical

scientific committee

-Turnover of

parliamentary

-Draft law being

finalized

-Submission of law to government in

2015

-Submission to parliament’s first

ordinary session in 2015


Prime Minister to

support the draft

-Commitment from

the National

Assembly Health

Committee, former

MPs

-Commitment from

the Finance & Budget

Minister who jointly

signed the cMYP

with the Health

Minister

champions following

elections (lack of

continuity of

responsibility)

Mali


-MOH has completed

draft law

-Existence of a

structured, yet non-

operational network

-MP membership

-General

immunization law

-Instability of actors

-Sluggish legislative

process

-Weak EPI position

in MOH

-High level advocacy to accelerate the

process

-Advocate for the administrative

repositioning of the EPI

DRC


-Law proposal has

been sent to the

National Assembly

-Existence of a

structured and

operational MP

Network

-Sufficiently

advanced legislative

process

-Extension of the

Network to the

provincial legislators

-Sluggish legislative

process

-High level advocacy to accelerate the

process

Senegal



-Existence of specific

laws (HIV, tobacco)

-Strong political

commitment to

immunization

-Draft law sent to the

government

-Provisions on

financing, equity,

import tax

exemptions, express

pick-up of vaccines

& equipment, service

quality

-Membership of

opinion leaders to

network

-Lack of a formalized

immunization

advocacy coalition

-Sluggish process

-Establishment of a formalized inclusive

advocacy coalition for the law

-High-level advocacy to the President to

accelerate the process

Annex F: Peer Review Guide Description Since 2009, the Sabin Sustainable Immunization Financing (SIF) Program has been working with African and Asian countries to develop institutional innovations- new ways of working, new practices- that will lead to sustainably financed national immunization programs. In today’s peer review session, delegates are presenting their innovations in three broad areas: budget/resource tracking vaccine legislation local advocacy activities This checklist was prepared to help you perform this peer review. Our main interest is documenting innovations by state institutions, i.e., government agencies and elected bodies, whose responsibilities include the planning, financing, delivery or oversight of public immunization services. These institutions may include ministries of health, finance, planning or other ministries and agencies. The institutions may operate at national level, sub-national level or both. We wish to understand how the innovation began. Was it proposed by an individual in a particular institution? Was it proposed by a group of champions representing two or more institutions?


The innovation may or may not have succeeded. A successful innovation is one that has ceased to be new and has become institutionalized- it has become a routine practice. Perhaps the innovation you discuss today is still developing. Many, perhaps most, innovations ultimately fail. The ideas behind it may not have been well adapted to the local context or not thought through well enough. There could have been resistance to it. Perhaps key people changed positions and support for the innovation was lost. Other background factors might have changed such that the innovation lost relevance. We are interested in documenting innovations whether or not they succeeded. Methods The peer review will take place in two consecutive 30-minute sessions. In the first session, reviewers will assess the countries in “Group A”. In the second session “Group B” countries will be assessed. Each peer reviewer is asked to prepare three innovation case studies- one per country. The goal is to generate at least 9 independent assessments per country. All assessments will be anonymous. Information for the peer assessments will be obtained through discussion with the country delegates. Each reviewer should interview two or three delegates from each country being reviewed. Simultaneous interpretation will be available as needed. Conversations must be kept short. Ten minutes have been allotted for each assessment. Peer reviewers should complete three checklists- one for each country being reviewed. Completed checklists should be deposited in the indicated collection box.


SABIN SUSTAINABLE IMMUNIZATION FINANCING INNOVATION PEER REVIEW GUIDE ********************************************************************************************** Reviewer’s country: _______________________________________________ Reviewer’s home institution (check one):

___Min health ___Min finance ___parliament ___other (specify: ___________________) ___Partner agency counterpart

Country studied: ___________________________________________ ********************************************************************************* Classify the innovation by functional area (check one or more):

___ financing ___ budget, resource tracking ___ legislation ___advocacy activity ___other (specify: ________________________________________________________)

In the presenters’ words, what problem or opportunity does the innovation address? In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): When- how long ago- did the innovation begin (check one)? ___three or more years ago ___past 1-2 years ___this year How did the innovation begin (check one)? ___ Top -> down ___ Bottom -> up ___ Outside third party introduced it


On which level of governance did the innovation originate (check one)? _____ regional or sub-regional multiple countries) ___ national ___sub-national ___ both levels together

Which institutions are or were involved in developing the innovation (check one or more)? Government

___ ministry of health ___ ministry of finance ___ elected body ___ other government ministry or agency (identify: ___________________________________)

Non-government

___ community service organization (identify: ____________________________________) ___ domestic business sector (identify: ______________________________________) ___ other (identify: ______________________________________)

At this point, how advanced is the innovation (check one)?

___ people are just talking about it ___ the new practice(s) is (are) now being tried

___the new practice(s) is (are) becoming institutionalized ___the new practice(s) is (are) fully institutionalized

___ the innovation is being blocked

What feedback and recommendations do you wish to convey to these delegates about this particular innovation? (continue writing on back of page if needed)


On a scale of one to five, with 1 being no chance and 5 being almost certain, please answer the following questions. Circle one response per item.

Item

1 2 3 4 5 No chance Not likely Unsure Likely Almost certain

The innovation is well conceptualized. The proposed solution matches the problem or opportunity it addresses.

1 2 3 4 5

Another approach would have been more suitable for solving the problem/improving the sustainability of the immunization program.

1 2 3 4 5

The right mix of institutions is or was involved in developing the innovation.

1 2 3 4 5

There is or was a lot of resistance to this innovation.

1 2 3 4 5

This innovation is or was carried out without incurring significant new costs.

1 2 3 4 5

The innovation will help the country reach sustainable immunization financing sooner.

1 2 3 4 5

The innovation will ultimately be institutionalized nationwide.

1 2 3 4 5

If successful, the innovation will increase country ownership of the immunization program.

1 2 3 4 5

Considering all the factors, how likely is the innovation to succeed, to become institutionalized?

1 2 3 4 5

This innovation would likely succeed in your own country.

1 2 3 4 5

List below and briefly describe any other innovations you observed in this country.

Francophone Africa Peer Review Workshop on Sustainable Immunization Financing · 2015. 7. 20. ·...

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