ARIVAS Project - Final Report
- November 2000 -
1. General overview of the ARIVAS project
The EDF regional project of Support for Reinforcing Immunization
Independence in Sahelian Africa (Appui au Renforcement de l’Indépendance
Vaccinale en Afrique Sahélienne, ARIVAS), for which the financing agreement
was signed in April 1996 between the European Commission (EC) and eight countries
of the Sahel - Burkina Faso, Cape Verde, Gambia, Mali, Mauritania, Niger, Senegal
and Chad, was executed between March 1997 and December 2000.
The project aims to support the efforts of the eight beneficiary countries
in the implementation of the strategy of integrating and taking overall responsibility
for The Expanded Programme of Immunization (EPI) within basic health care systems.
As stipulated in the project’s financing agreement and the Terms of Reference
of the Technical Assistance (cf. Annexe
1), it is directed along two complementary axes as follows :
- Improving the management of the various steps from supply to administration
of the vaccine
- Guaranteeing the supply of EPI priority vaccines where countries are found
to be unable to provide them from their own funds (including budgetary assistance).
The project derives its originality from the fact that, for
the first time, it encourages a group of low-income countries to include as priorities
in their recurrent budget the recurrent expenditure linked to the programmes defined
in their health policy, in this case those of vaccines and consumable items.
The initial duration of the project was for three years (from
March 1997 to February 1999). Following the recommendations of the mid-term evaluation,
the end of this first phase was prolonged up to the end of December 2000. The
overall cost of the project amounted to 9.5 million euros (about 6.2 billion FCFA)
financed from the Regional Indicative Programme (8.5 million euros) and the National
Indicative Programmes of the eight beneficiary countries (1 million euros).
The financial instrument for vaccines and consumable items envisages :
- The inclusion in the recurrent budget of the Ministry of Health of sufficient
funds to cover expenditure on vaccines and consumable items; the use of these
funds follows the procedural rules of each country’s public funding
- Securing this expenditure on the Counterpart Funds (CF) of the European Commission’s
Support for Structural Adjustment
- The use of the Guarantee Fund located at UNICEF/Copenhagen to pre-finance
purchases of vaccines and consumable items
- Payment by the country in local currency of the invoice corresponding to deliveries
of vaccines and consumable items , on a special account of the UNICEF representative
in the country; the Guarantee Fund is reconstituted by a compensatory transfer
of the sums required for UNICEF’s current operations
- A "Regional Reserve" is provided to deal with situations in which
a country is outside Structural Adjustment and therefore has neither CF to finance
vaccines and consumable items, nor the ability to meet this expenditure from the
public treasury resources; this reserve is mobilized through a Special Import
Programme (SIP) whose counterpart in local currency (CF) is used to secure the
routine EPI’s expenditure on vaccines and consumable items
The supply of vaccines and consumable items is arranged via
UNICEF for reasons of regularity , guaranteed quality and price. To this end,
the government and UNICEF sign an agreement (for two or three years according
to the country) specifying the conditions relating to this transaction. Only the
six classical antigens of the routine EPI, along with yellow fever vaccine and
injection and sterilisation materials, are eligible.
The project is coordinated and led by a Regional Technical Support Unit (Cellule
d’Appui Technique Régionale, CATR), composed of (i) three long term
experts, of whom two are public health doctors and one is a health economist,
and (ii) a local support staff comprising an accountant, a secretary, a communication
officer and a driver/office boy.
The mission of the CATR is: (i) to provide technical support to the EPI and
facilitate dialogue and exchange between the national services; (ii) to assist
the Ministries of Health in establishing protocols and procedures aimed at taking
responsibility for the financing of vaccine supply; (iii) to act in harmony and
in a complementary manner with the support provided by UNICEF , WHO and USAID;
and (iv) to develop operational research projects.
The project is carried out by the management consultancy UNECIA, which set
up the CATR and provides it with technical and administrative support. A Technical
Assistance contract links this management consultancy with the project ‘owner’,
the Ministry of Economy and Finance of Burkina Faso, which is also Regional Authorising
Officer (RAO) for the project. The Muraz Centre acts as project manager; in this
capacity, it has signed a protocol with the RAO setting out the conditions for
providing the base for the CATR. The CATR’s operation is regulated by a
programme budget which is drawn up and executed jointly by the RAO (Cooperation
Directorate) and the EC’s Delegation to Burkina Faso.
2. The Project’s Achievements
- Acceptance by governments of immunization as a high priority , and as one
of the most cost effective measures of public health. This political will is demonstrated
by the taking of total responsibility for expenditure on vaccines and consumable
items in countries’ recurrent budgets; this was not an easy decision for
any of the countries concerned given the difficult choices all have to make between
a multitude of high priority needs - but the courage and political will shown
by governments has prevailed
- The ‘ownership’ of the Vaccination Independence Initiative (VII)
approach by national officers and political and administrative authorities at
the highest level. As a result of this political ownership, national officers
in charge of the management of immunization programmes are increasingly called
to account in respect of the performance of their immunization programmes and
the transparency of the way in which they manage the resources put at their disposal
by governments
- A fundamental transformation in the perception of their respective roles by
countries and development partners
- The organization, jointly with other supporting agencies, of EPI reviews in
seven of the eight countries
- The acceptance and recognition by the international partners of the added
value of the ARIVAS project and of the CATR
- The securing of targeted budget lines on the CF of the EC’s Support
for Structural Adjustment. This has allowed a high level of budgetary implementation
- 87.22% paid out on average over the period
- A positive trend of the financing mechanism towards complete sustainability
of the financing of vaccines and consumable items by the countries themselves,
even though countries are not all at the same stage, and that monitoring or support
is necessary for some countries
- The existence of cooperation agreements between governments and UNICEF for
the supply of vaccines and consumable items. These agreements have produced some
stability in the supply of vaccines and consumable items, and the purchase of
vaccines of guaranteed quality at prices which are both competitive and affordable
by countries
- The establishment of a fruitful dialogue between the Ministries of Health
and Finance, and between the EPI and the Financial Directorate within the Ministry
of Health, to take immunization forward. This dialogue, demonstrated particularly
by the setting up of VII monitoring committees, has resulted in a better costing
of needs for vaccines and consumable items, better monitoring of supply operations
and of EPI overall
- A start on collaboration between the countries concerned, notably through
exchange of expertise, loans of vaccines in case of shortage, the publication
of the information and liaison news sheet on VII and above all the organization
of annual inter-country meetings. These last, by common accord, offer an unique
framework for the exchange of experiences and a concerted approach to the issues
of implementing VII and EPI
- A developing synergy of action with the other agencies intervening in the
sub-region and beyond. Meetings to harmonize strategy and to plan work have been
organized, and joint missions and reviews have been carried out in those countries
where the EPI requires particular attention. The CATR’s role has been greatly
appreciated, particularly the added value it has been able to contribute to this
inter-agency cooperation in the domain of EPI financing
- A strengthening of the management skills of national staff, particularly in
the areas of needs planning, supply and distribution, and stock management: 759
officers involved in immunization activities have been trained in these subjects.
Moreover, a training manual has been produced and distributed, and national immunization
guides have been developed or updated, and distributed among immunization staff
- The carrying out of some 30 studies in various areas of concern to countries:
financing and cost of EPI; estimation of vaccine wastage rates; drawing up guides
on immunization and on vaccine supply and distribution plans; injection safety;
socio-anthropological studies. The aim of these studies has been: a consistent
pattern of organizing EPI financing, using available resources and existing finance
potential as well as possible, and sharing responsibilities equitably between
staff; rationalization of the use of vaccines and consumable items; improved injection
quality and safety; and better immunization coverage
- The creation within EPI teams of a dynamic towards initiating operational
research projects in the areas covered by the EPI, particularly in respect of
improving immunization coverage
- The enhancement of skills within each country and the region: some 20 sub-regional
experts have been used in carrying out studies in areas of concern.
3. The Project’s Weaknesses and Constraints
-
Immunization coverage - the main indicator of EPI’s
effectiveness - remains very low, less than one child in two being fully immunized
against the EPI target diseases in most countries. The lack of any major improvement
over the time scale of the project can perhaps be explained by the complexity
of the factors involved. It underlines, however, the crucial need for the new
project, in collaboration with all partners - traditional and new - to tackle
all the problems which hamper improvement of immunization coverage
-
Defects remain at the level of the operational management
of the overall programme. Of particular note are: weaknesses in planning activities;
the inadequacy - even total absence - of supervision; the inadequacy of training
- both basic and updating; the dilapidated condition of cold chain and IT equipment;
staff changes; poor staff motivation; the inadequacy of action to raise the awareness
of communities and involve them in the programme; concerns over injection safety;
and weaknesses in national information systems
-
National VII monitoring committees are not working satisfactorily,
despite the existence of active key players
-
Many of the recommendations made by the CATR following studies
carried out with countries have not so far been put into action. The greater awareness
shown by teams of a variety of aspects has been a real achievement of the project,
but sustained follow-up will be needed to ensure that appropriate action follows.
Examples include the use made of the results of studies of vaccine wastage rates,
and of economic considerations when taking decisions
-
The use made of operational research as a tool for improving
EPI performance is still limited. Despite recent efforts to encourage and train
national teams in the importance of this tool, few countries make use of it except
in very limited domains
-
Certain practices still in evidence run counter to the improvement
in clarity of budget lines and in developing a culture of transparency in the
use of credits. Such clarity and transparency are essential to ensuring that resources
placed at the disposal of the EPI are used for the purposes intended
-
Despite progress made at central, intermediate and district
levels, the strengthening of staff skills in needs planning and management of
vaccine and consumable stocks needs further effort at all levels, particularly
that of primary health care centres
-
Despite recent simplification in UNICEF’s internal
procedures, the supply systems for vaccines and consumable items through UNICEF
still encounter difficulties - of which some are due to current tensions in the
vaccine market. Close follow-up and concerted action with UNICEF are needed
-
A major feature of the current environment of the EPI is
the introduction of a variety of initiatives :
- Polio eradication
- Elimination of neonatal tetanus
- Measles control coupled with the fight against vitamin A deficiency, and more
recently the Global Alliance for Vaccines and Immunization (GAVI). However, while
this multitude of initiatives reflects a renewed interest of the international
community in immunization, it also gives rise to problems of coordination and
to competition for the available resources, which are often difficult for countries
to manage. Without constant vigilance, these difficulties can even place at risk
the progress towards immunization independence. It has been noted in several countries,
for example, that routine EPI vaccines have been used for polio eradication campaigns,
with no provision made for these stocks to be reimbursed. In other countries,
some of the funds intended for vaccines and consumable items for the routine EPI
have been used to meet local expenses incurred by governments in national polio
immunization days
-
National immunization days (NID) organized within the polio
eradication programme have negative repercussions on the routine EPI. These relate
to the time absorbed in preparing, carrying out and evaluating the NID, the use
of routine vaccines and, this year, the use of funds intended for routine EPI
vaccines and consumables
-
The exchange of information and experience between countries
- other than through the annual inter-country meetings - has not realised its
full potential. The project offers an important opportunity for exchange between
countries concerning problems which confront all of them. The means of such exchange
- the newsletter, for instance - have so far been exploited relatively little
-
The frequent changes in staff involved in carrying out the
VII has often hampered sustained collaboration. Indeed, three quarters of EPI
Directors in these Sahel countries have changed within the last three years
-
The CATR’s mandate has been ambiguous in respect of
the project’s range. The first "specific objective" of the logical
framework of the finance agreement relates to an "improvement in the implementation
of immunization activities", and the terms of reference of the Technical
Assistance to be provided to the CATR specify in detail a wide range of aspects
necessary for an effective EPI, down to such factors as staff training and community
involvement. Officers of the EC have often indicated to the CATR, however, that
the project concerned almost exclusively the financing and supply of vaccines
and consumable items (the second ‘specific objective’ of the logical
framework). The confusion, and even conflict, which this inconsistency has caused
have at times hampered the effective implementation of the project
-
Inadequate human resources, and over optimistic planning
of activity compared with the availability of EPI officers, have somewhat hampered
the fullest achievement of the CATR’s initial ambitions concerning its programme
of support to countries.
4. Recommendations
4.1 Maintaining the project’s visibility
The abandonment by some countries of targeted budget lines,
in the framework of budgetary support, and thus the abandonment of direct securing
of expenditure on vaccines and consumable items, removes from the project an important
means of pressure and a clear visibility.
To fill this gap, programmes of Support to Structural Adjustment
could include among their performance criteria immunization coverage rates, in
respect of the immunization element, and conditions for releasing tranches of
funds tied to the correct execution of budget lines for priority expenditure including
that on vaccines and consumable items. It is not a question of returning to targeting,
but of obtaining from governments a commitment to carry out appropriately the
expenditures specified in the budget, and of verifying that these commitments
have been honoured by carrying out a mini-review of public expenditure before
releasing the next tranche.
4.2 A mandate, and a programme, which cover
all essential aspects
The coordination team cannot do everything and must guard against
dispersing its efforts too widely. However, given the key importance of tackling
all the elements essential for an effective and durable EPI, it must :
- Make sure that it has a clear and comprehensive mandate, and that the different
players have the same understanding of it
- Make sure that it has adequate resources for the team’s own responsibilities
(including ‘peripheral’ tasks such as newsletter publication and translation
of documents)
- Agree with the development partners a programme able to support a durable
relaunch of the EPI
- Adopt a project management system which monitors progress on all aspects
- Agree with the countries involved terms of reference for EPI reviews which
cover all essential factors and involve all the Ministries concerned.
4.3 A greater involvement
A greater involvement in the implementation of the ARIVA project
of those Advisers who have had responsibility for the ARIVAS file in EC Delegations
appears to us desirable.
This involvement could take the following form :
- Organizing the coordination team’s visits: briefings and debriefings
at the Delegation, contact with national bodies for the organization of the mission,
possibly accompanying the team for audiences with highly placed officials involved
in the implementation of VII, etc.
- Taking part regularly in meetings of the monitoring committees of VII implementation
- Continuous monitoring of the implementation of the initiative and of action
on the recommendations arising from the coordinating team’s visits; regular
contact with the key players is desirable
- Taking part in inter-country meetings
- Ensuring consistency with the EC’s other support initiatives, notably
support to structural adjustment
4.4 Continued efforts towards stabilising supplies
The supply of vaccines and consumable items has certainly improved,
but it remains subject to market tensions, particularly in respect of oral polio,
DTP and BCG. These tensions are the result of the high demand produced by the
renewed interest in immunization expressed in the GAVI initiative and the polio
eradication campaign.
Moreover, given the time required for an increase in production (two years)
and for setting up new production lines (five years), one must assume that current
tensions will continue in the medium term - ie throughout the duration of the
ARIVA project - and that it will affect the other antigens. The following measures
could attenuate the expected perturbation of supply to each country:
- Increasing the emergency stock from three to six months
- Accelerating the negotiations with producers which are envisaged in the context
of the EC’s campaign against infectious diseases; success in these negotiations
would offer countries an alternative which could reduce delivery times while offering
the same conditions accorded to UNICEF
4.5 Ways to achieve rapid and durable improvement
in immunization coverage
a) Supporting operational activities
The following activities appear to us likely to have a positive
impact on immunization coverage at relatively low cost :
- Setting up a system to find those people of whom the system has lost sight,
in countries having a low completion rate for antigens requiring multiple contact:
the cost of such a measure could be borne centrally by cost recovery and therefore
would pose no problem of sustainability
- Supervision at all levels: the impact of this on immunization coverage and
quality is very real
- Operational planning: supporting the project in seeking to define health zones
could improve both the quality and effectiveness of planning at all levels
- Training those who carry out immunizations, whatever their qualification:
shifting the orientation of training programmes so as to target the people who
actually carry out immunizations on the ground, with the help of locally available
materials - existing or new - would have a better chance of producing a positive
change in behaviour and improving immunization coverage and quality. To achieve
this, training must include, in addition to technical aspects: real communication
and mutual respect with those coming for immunization; correct completion both
of registers and of the ‘immunizations’ section of individual health
records - on which depend, respectively, reliable national data, and ‘ownership’
on the part of mothers of their own health and that of their children
- Establishing a real dialogue between health workers and the community. This
dialogue would allow improvements in the organization and planning of immunization
sessions, taking account in particular of people’s culture and occupations
- Continuing training in needs planning and stock management of vaccines and
consumable items for staff at national, regional, district and health centre levels
- Seeking the systematic involvement of schools of public health to ensure sustainability
of achievements
b) Devising and applying strategies which
are both effective and suited to the local and regional context
Strategies will need to be developed having regard to current
EPI performance, the country’s geo-demographic characteristics and the capacity
of the country and its constituent parts to meet the expenditure incurred from
its own resources.
4.6 Operational research as a means of developing
and putting into practice effective strategies suited to the local and regional
context
It is highly desirable that small operational research projects
should be developed, particularly to seek innovative strategies for immunization
coverage of communities inadequately covered by classical strategies. These projects
should preferably be carried out at the local or regional level and evaluated
at central level.
4.7 Support to national health information systems
(HIS) and epidemiological surveillance
The project should aim to address particularly the following
concerns expressed by countries:
- The evaluation of HIS and of the surveillance systems existing in each country,
and the identification of measures and actions to make them more effective
- The review of data collection instruments, and training staff in their use
- Improving availability of management aids at all levels
- Training staff at all levels in the use of these aids and in using data for
improved management of their immunization activities
- The prior establishment, in liaison with ECHO, of stocks of those vaccines
and pharmaceuticals needed for epidemics. The overall resources required for appropriate
action in the event of an epidemic will need to be quantified and included in
the recurrent budget, to allow countries to undertake the initial intervention
while awaiting the arrival of emergency external aid. The expenditure incurred
could be either directly secured or monitored as part of support to structural
adjustment. The EC possesses a clear added value in this area through the ARIVAS
project.
4.8 Continue to promote dialogue and exchange
This aspect has been one of the major achievements of the project. The new project
should use to greater effect existing means - inter-country meetings, workshops,
newsletter - and establish new ones, in order to reinforce the exchange of
ideas and experiences between staff at all levels.
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