MINISTRY OF HEALTH · The estimated cost of KEPI was US$ 17.75 million for the year 2000 with vaccines costing $ 3.3 million or 18% of the total programme costs. Personnel emoluments

GOVERNMENT OF KENYA_____________________________

MINISTRY OF HEALTH

KENYA EXPANDED PROGRAMME ON IMMUNIZATION

Financial Sustainability Plan

Submitted to GAVI

November 2002.

_______________________________________________________________________

ii

Signatures of the Government

Minister Of Public Health Minister Of Finance andPlanning

____________________________________________________________

Hon. Prof. Sam K Ongeri EGH, MP Hon. Mr Chris Obure EGH, MP

……………………………………,2002 …………………….……………………….,2002

_______________________________________________________________________

iii

Table of Contents

ACKNOWLEDGEMENTS .......................................................................................................................... IV

EXECUTIVE SUMMARY .............................................................................................................................V

ABBREVIATIONS AND ACRONYMS .................................................................................................... VIII

1.0 COUNTRY AND HEALTH SYSTEM CONTEXT....................................................................................1

INTRODUCTION ...................................................................................................................................................11.2 ECONOMY .....................................................................................................................................................11.3 DEMOGRAPHIC AND HEALTH INDICATORS....................................................................................................21.4 POVERTY.......................................................................................................................................................31.5 PUBLIC SECTOR REFORMS.............................................................................................................................31.6 ROLE OF THE PRIVATE SECTOR.....................................................................................................................6

2. BUDGETING FINANCIAL MANAGEMENT AND PROCUREMENT................................................... 7

2.2 FINANCIAL MANAGEMENT ............................................................................................................................72.2 BUDGETING...................................................................................................................................................72.3 PROCUREMENT..............................................................................................................................................8

3 PROGRAM CHARACTERISTICS, OBJECTIVES AND STRATEGIES ................................................. 9

3.1 QUALITATIVE AND QUANTITATIVE INFORMATION ABOUT PROGRAM PERFORMANCE AND TARGETS .............93.2 POSSIBLE CHANGES IN PROGRAM OBJECTIVES IN THE LIGHT OF FINANCIAL CONSTRAINTS..........................123.3 GOVERNANCE AND MANAGEMENT OF THE IMMUNIZATION PROGRAMME....................................................133.4 ROLES AND RESPONSIBILITIES OF PARTNERS IN IMMUNIZATION FINANCING AND SERVICES DELIVERY .......13

4 BASELINE AND CURRENT PROGRAM COSTS AND FINANCING..................................................15

4.1 PRE-VACCINE FUND (BASELINE) PROGRAM COSTS AND FINANCING PATTERNS...........................................154.2 CURRENT EXPENDITURES AND FINANCING PATTERNS .................................................................................16

5 FUTURE RESOURCE REQUIREMENTS AND PROGRAMME FINANCING ....................................20

5.1 COSTING SCENARIOS...................................................................................................................................205.1.1: SCENARIO A – TARGETING 90% COVERAGE – IMPLEMENTING THE KEPI STRATEGIC PLAN 2001-2005:..........................................................................................................................................................................205.1.2: SCENARIO B - THE 80% COVERAGE TARGET ..........................................................................................275.2. SUMMARY..................................................................................................................................................31

6. SUSTAINABLE FINANCING STRATEGIC PLAN AND INDICATORS .............................................. 32

SUSTAINABLE FINANCING STRATEGIC PLAN.................................................................................... 34

7 STAKEHOLDERS ENDORSEMENT......................................................................................................38

8: PREPARATION AND REVIEW TEAMS:.............................................................................................. 39

_______________________________________________________________________

iv

ACKNOWLEDGEMENTS

The Ministry of Health would like to express gratitude to all the individuals and thevarious development partners particularly WHO, DFID, UNICEF and GAVI forvaluable technical support in the development of this Financial Sustainability Plan(FSP) and also members of the ICC and Task Force for their review and input in thefinalization of the plan.

The participation and efforts of the KEPI Central Management Unit officers and theMOH core-working group is highly appreciated. The contribution made by twoconsultants hired for the assignment and funded by the DFID is acknowledged. Alsoappreciated is the contribution made by two officers from the Ministry of Financeand Planning towards the compilation of this FSP.

This plan will support the efforts of the MOH in implementing its policy to providequality immunization services for the protection of all children under 5 years of ageand all women of child bearing age from vaccine preventable diseases.

Special thanks go to our development partners who have contributed in one way oranother towards the provision of the health care services in the country. Similarly, arequest is put forward to willing bilateral and multilateral partners and individualswithin and outside Kenya to come up and support this plan in any capacity or withany resources at their disposal at whatever level.

_______________________________________________________________________

v

EXECUTIVE SUMMARY

This Financial Sustainability Plan for the Kenya Expanded Programme onImmunization covers three distinct periods: the pre GAVI (2000-2001), the GAVIthe funding period (2002-2006) and the post GAVI period (2007-2009).

The Global Alliance for Vaccines and Immunization (GAVI) requires all countriesseeking its support to prepare a financial sustainability plan (FSP) after the first twoyears of support. This Plan examines the base year (i.e. pre-GAVI) estimates ofnational costs of the immunization program, the projected future costs of runningthe programme and the various options available to improve the financing andsustainability of the programme.

Apart from the support being received through GAVI, there is a wide spectrum ofimmunization services development needs such as improvement of cold chain,capacity building and social mobilization, that Kenya will need to address on its ownfunds and, in part, with assistance from development partners.

The Plan links domestic and international funds. It envisages that by the end of thePlan period, the Government of Kenya will, to some extent, put immunizationservices financing on a sustainable basis.

Scope of the Plan

The FSP assesses the cost and funding of the Kenya Expanded Programme onImmunization and the projected program’s resource needs. The Plan reportcomprises six main parts:

Country and health system context (Chapter 1)Financial, Budgeting and Procurement (Chapter 2);Programme characteristics, objectives and strategies (Chapter 3);Baseline and current programme costs and financing (Chapter 4);Future resource requirements and programme financing (Chapter 5);Sustainable financing strategic plan and indicators (Chapter 6) and

The baseline year is 2000. Projections cover the period 2002-2009. The distinctionis maintained between secure funding (how much funding has a very high chance ofbeing made available); probable funding (how much funding is likely to be available,but not guaranteed in any way) and possible funding (how much funding may beavailable, but not particularly likely).

Program objectives for expansion and improvement

Kenya targets to immunize 90% of its children aged less than one year against theeight vaccine preventable diseases. These include the traditional six antigens namely:measles, polio, diphtheria, whooping cough (Pertusis), tetanus and tuberculosis.Through the GAVI support, Hepatitis B and Haemophillus Influenza type Bvaccinations have been introduced into the Programme (with effect from December2001).

_______________________________________________________________________

vi

In order to raise coverage, the programme will endeavour to improve communityawareness through intensive social mobilization, motivation of health workers throughtraining and intensified supervision, allocation of funds to enable districts carry outoutreach services and distribute supplies and do minor repairs on their available transport.The programme will also look into ways in which locally available support can be mobilizedwith a view of strengthening it.

Autodisable syringes were introduced to the KEPI together with the pentavalentvaccines. There are plans to fully introduce Autodisable syringes for all injectablevaccines within the programme starting from 2003.

The programme will ensure improvement in timeliness and completeness of routinereporting from the districts to 90% with view to identifying weak areas in routineimmunization, vaccine management, detection and response to outbreaks vaccinepreventable diseases. The issue of wastage will be addressed with the aim of reducingthe rate significantly.

Current programme costs and sources of financing

The estimated cost of KEPI was US$ 17.75 million for the year 2000 with vaccinescosting $ 3.3 million or 18% of the total programme costs. Personnel emolumentscost $9.1 million (49.2% of the total). Overall, the funds for the immunizationprogramme were mainly from the Government, which contributed 55.7% of the total.Japanese Government, the primary donor, contributed 15.0 % of total cost in 2000.

Routine services increased to $19.2 million in 2001 from $13.4 in 2000 largely onaccount of introduction of new vaccines, which accounted for 15% of the total costs in2001. Polio NIDs costs reduced almost by half ($2.2 million) in 2001 compared to $4.1 million in 2000 as not all districts were covered in 2001 (focus was on borderdistricts and large urban districts). Overall, total costs in 2001 increased by 17% fromthe previous year.

On the whole, the government made a substantial contribution to the nationalimmunization program through purchase of BCG vaccine, yellow fever vaccine, partof the routine polio and measles vaccines and meeting personnel emoluments amongothers. Donors, on their part, played a very important role in providing support toKEPI including financing vaccines and cold chain equipment, vehicles, training andsocial mobilization/communications.

Projected gap in resources during and after the remainder of vaccinefund supportThe projection covers the time period 2002-2009 and uses 2000-2001 as the baseline years. Projected numbers rely on the assumed expansion and the structuralchange in the EPI. Specifically, to make these assumptions as explicit as possible, andto allow for a range of possibilities, two cost scenarios have been considered. Theseare:

Scenario A assuming 90% coverage target;Scenario B assuming 80% coverage target;

For scenario A, the expenditure on EPI is expected to total $184 million during the

_______________________________________________________________________

vii

2002-2006 period. Vaccines (traditional 6 antigens - 3.2% of total, new andunderused- 39.8%) account for 43% of the total cost. In 2003, the cost ofsupplemental immunisation activities will decrease as a result of reduced activities.

Under scenario B, the routine EPI vaccines are projected to cost $ 12.3 million in2002 increasing to $16.8 by 2006 for a total cost of $146 million for the 2002-2006period. About 87% of the funds are secured. The gap increases from $ 1.3 million in2002 to $ 24 million by 2009 for a total of $78 million. As in scenario A, the largegap will exist due to lack of committed financing for purchase of vaccines beyond2006.

Strategic priorities for financing sustainability

Among the many actions Kenya government will take to move towards higher andmore stable levels of funding for immunization services, the following stand out asthe ones with the highest potential impact:

Mobilize adequate resources

� Increase domestic resources to health through advocacy at inter-ministeriallevel, local authorities, local corporate and individuals;

� Expand the ICC membership in an effort to solicit their support for the EPI;� Engage development partners in discussion of resource requirements and seek

commitments to cover major funding gaps;� Create enabling environment so as to attract foreign funding;� Considering the importance of EPI in the prevention of diseases, the Ministry

of Health will review it’s priority ranking. Currently, EPI is ranked 5th in theessential health package.

Increase reliability of resources

� Donor commitments assured� Establishment of an enabling political and economic environment

Increase efficient use of resources

� Create an environment to allow flexible operation of donor funds� Establish a system of accountability and transparency� Develop and impliment programs to reduce wastage� Establish proper reporting and feedback� Management of resources

_______________________________________________________________________

viii

Abbreviations and acronymsAFP Acute Flaccid ParalysisAIDS Acquired Immune Deficiency SyndromeAIE Authority to Incur expenditureBCG Bacille-Calmette-Guerin vaccine for TuberculosisCBS Central Bureau of StatisticsCIDA Canadian International Development AgencyDANIDA Danish International Development AgencyDFID Department for International DevelopmentDPT Diphtheria, Pertussis, Tetanus VaccineEPI Expanded Program on ImmunizationFIC Fully Immunized ChildFSP Financial Sustainability PlanGAVI Global Alliance for Vaccines and ImmunizationGDP Gross Domestic ProductGNP Gross National ProductGoK Government of KenyaHep B Hepatitis B VaccineHib Haemophilus Influenzae Type B VaccineHIV/ AIDS Human Immunodeficiency Virus / Auto-Immune Deficiency SyndromeICC Inter-Agency Coordinating CommitteeIEC Information, Education, CommunicationsJICA Japanese International Cooperation AgencyKDHS Kenya Demographic Health SurveysKEPI Kenya Expanded Programme On ImmunizationMoFP Ministry of Finance and PlanningMoH Ministry of HealthMTEF Medium Term Expenditure frameworkNCPD National Council for Population and DevelopmentNGOs Non-governmental organizationsNHSSP National Health Sector Strategic PlanNID’s National Immunization DaysNIP National Immunization ProgrammeOPV Oral Polio VaccinePRSP Poverty Reduction Strategy PaperSIA Supplementary Immunization ActivitiesSNID’s Sub National Immunization DaysSWAP Sector-Wide ApproachTB TuberculosisTT Tetanus ToxoidUNICEF United Nations Children’s’ FundUSAID United States Agency for International DevelopmentVVM Vaccine Vial MonitorWHO World Health Organization

_______________________________________________________________________

1

1.0 COUNTRY AND HEALTH SYSTEM CONTEXT

Introduction

National governments in the recent years, have become increasingly concernedwith the issues of financing immunization activities. In Kenya, despite thetremendous gains achieved in immunization coverage in the early 1990s followingthe establishment of the Kenya expanded Programme on Immunization in 1980,immunization coverage rates in the late 1990s showed some decline. This declinemay have resulted from a number of factors including reduced donor funding forthe immunization programme, declining national health budgets due todeteriorating economic conditions and focusing on other national healthpriorities.

GAVI requires all countries seeking its support to prepare a financialsustainability plan (FSP) after the first two years of support. This Plan examinesthe base year (i.e. pre-GAVI) estimates of national costs of the immunizationprogram, the projected future costs of running the programme (under variousscenarios); and the various options available to improve the financing andsustainability of the programme. These options include: increasing centralgovernment allocations to KEPI, ensuring efficient use of the available resources,increasing the role of the private sector in immunization service delivery, andmobilizing resources from other potential players in health service provision.

The first section of the Plan describes the country and health system context,while the second chapter presents the financial management. The third andfourth chapters present programme characteristics, objectives and strategies andinformation on expenditures and costs of the programme as well as sources offinancing respectively.

The fifth chapter describes the future financing requirements, sources,mechanisms of financing, and risk assessment while the sixth chapter focuses onsustainable financial strategic plan and indicators.

1.2 Economy

During 1996, a growth rate of 4.6% was recorded but declined substantially to2.4% in 1997 closing with a negative growth rate of 0.2 per cent in the year 2000.The growth, however, recovered to record a modest rate of 1.2 % in 2001. Thedeceleration was occasioned by a decline in almost all the key sectors of theeconomy and was largely attributed to the prolonged drought of 1999-2000,inadequate power supply, and deterioration of infrastructure and low aggregatedemand. Table 1.1 provides the details.

Table 1.1: Selected Macroeconomic Indicators for Kenya

Indicator 1997 1998 1999 2000 2001Gross Domestic Product Growth Rate (%) 2.4 1.8 1.4 -0.2 1.2

_______________________________________________________________________

2

GDP at market prices (US$ billion) 9.9 11.2 10.2 10.2 11.4GDP per capita (US$) current 304.5 332.8 298.0 301 320.9GDP per capita (US$) Constant prices 57.0 57.3 48.2 43.9 43.5GNP (US$ Billion) 9.7 11.0 10.0 10.1 11.3Inflation Rate (%) 11.2 6.6 3.5 6.2 0.8Debt service charge as % of GDP 4.3 4.2 4.2 4.3 1.8Estimated population (million) 28.1 28.8 29.5 30.2 30.8Exchange Rate: 1 US Dollar for Kenya shillings 62.7 61.9 72.9 78.0 78.2Source: Ministry of Finance and Planning- Central Bureau of Statistics: Economic Survey,2002.

The year 2002 is an election year. Inflation is projected to rise to 2 percent and theeconomy is expected to register a real GDP growth of 2 percent in 2002.Kenya is not among the countries likely to benefit from debt relief (HIPC) in theforeseeable future. The relief would have, no doubt, resulted in increased revenueflows. The current debt burden accounts for about 4% of GDP. This means thatgiven the low current funding of health services, non-debt relief would negativelyaffect EPI future funding, as well as constrain the available resources.

The projected growth targets for Kenya are shown in Table 1.2. The growth of Kenyaeconomy is expected to average 4% during the Plan period. This may increasefunding flow to the health sector, but not sufficient enough to address the under-funding problem.

Table 1.2: Projected Growth targets (2000-2008)

YearReal GDP at1982 prices(US$ million)

GDP percapita (US$)Currentprices

Population(million)

2002 1,390 303 312003 1,439 306 322004 1,490 311 322005 1,549 316 332006 1,615 323 332007 1,688 331 342008 1,771 341 35Source: National Development Plan 2002-2008

1.3 Demographic and Health Indicators

Good health is a pre-requisite for socio economic development of the country. Thetotal fertility rate, the average number of children per woman, went down from 7.6 in1969 to 4.7 in 1998 while infant mortality rate reduced from 119 per 1,000 in 1969 to74 per 1,000 in 1998.

Problems in the health sector include increased emergence of diseases, inadequatefunding and high cost of health care. Table 1.2 shows the key demographic indicatorsfor Kenya.

_______________________________________________________________________

3

Table 1.2: Key Demographic and health indicators for KenyaYear 1969a 1979 a 1989 a 1993 § 1998 §

Crude birth rate* 50 52 48 35.8 34.6Crude death rate * 17 14 10 na naInfant Mortality rate ** 119 104 66 62 74Under 5 mortality 113 93 105Total Fertility Rate 7.6 7.9 6.7 5.4 4.7Contraceptive Use (%) 7(1977) 17(1984) 27 33 39

Note: * - per 1,000 population, na- not availablea Kenya Population Census, § - Kenya Demographic and Health Survey; ** per 1,000 live births.

1.4 PovertyPoverty is a profound problem in Kenya and the major obstacle to development.There has been a substantial increase since 1992 in the number of poor people (45%),and by 2001 social demographic indicators showed that 56% of the population livebelow the poverty line.

Poverty has been worsened by an increased lack of employment due to, among otherfactors, economic restructuring and the privatisation of public enterprises. TheGovernment, through a participatory process, has drawn a Poverty ReductionStrategic Paper (PRSP) as part of its effort to address this problem.

However, the high poverty levels are a hindrance to the utilization of immunizationservices as mothers/guardians lack resources to maximize use of the services(especially time and transport costs).

1.5 Public Sector reforms

The year 2000 saw major reforms in the public service. This resulted in reduction inthe number of staff in the public sector as part of a “right sizing” initiative. Theresulting implication for the Ministry of Health was that health services includingimmunization services were affected. Fewer health workers have had to deal withincreased workload.Recently, the situation has been recognized as an impediment to the provision ofquality health care and although a general Government embargo on recruitment hasbeen in place, the Ministry of Health, as a key sector, has been authorized to employnurses among other key health cadres, albeit, on small scale.

Another step to improve the performance of the National Immunization Programme(NIP) is the implementation of the performance improvement initiative. In thisinitiative, staff will be trained on how to improve performance on health care servicedelivery including immunization services.

Following the reduction in the number of staff in year 2000, the governmentimproved the remuneration of staff including housing and other allowances to ensurethe staff are adequately motivated.

_______________________________________________________________________

4

1.5.1 Health financing

In the public health sector, health finance is derived from three sources: directallocations from the Treasury, the National Health Insurance Fund and revenuegenerated by health facilities through user fees.

The National Health Sector Strategic Plan (1999-2004), however, highlights a rangeof health care financing strategies including increased cost recovery and socialinsurance scheme.

The Ministry of Health is, therefore, in the process of developing a social healthinsurance strategy with a view to providing cover for minimum health essentialpackage to all Kenyans including immunization services. However, this process islikely to take a while to be fully operational and hence the need for externalassistance.

There are also a number of firms providing private medical insurance. Unfortunately,these do not cover preventive services. The Government is, therefore, in the processof formulating a regulatory framework to control the services of these privateproviders. It is envisaged that when the framework is ready, they will be compelled tocover preventive services including immunization.

1.5.2 Decentralisation

The day-to-day management of health services was delinked from the nationalcontrol to district level control in 1995 through the formation of District HealthManagement Boards, Hospital Management Boards, Health Centre and DispensaryManagement Committees. As such health services in all 77-health districts in Kenyaare presided over by these bodies.

The only aspect of health services provision that is yet to be decentralised ispersonnel management (recruitment and termination of services) that is stillgoverned nationally by the Directorate of Personnel Management.

However, management of human resources is a major component in a decentralizedsystem. For health personnel to achieve high performance in a decentralised system-training on performance management and target setting at all levels is being givenpriority.

Both the Boards and Committees are custodians of the locally generated revenues,and have to approve proposed budgets of the District/Hospital/Facility HealthManagement Teams, before any expenditure can be made.

Plans of activities (and budgets) are drawn up by the various health managementteams and are based on health service priorities and needs. These include curativeand preventative services. Although EPI services always feature in the plans ofaction, the allocations they receive varies with the current competing priorities andavailability of funds.

_______________________________________________________________________

5

Local authorities are authorized to raise their own revenue. In the major urban areasof Nairobi, Mombasa and Kisumu, these local authorities provide support forimmunization costs, mostly to cover personnel, transport and injection supplies – allvital to high coverage and delivery of safe vaccination services. Due to low revenuecollection base, these local authorities have limited capacity to absorb further costs tosupport immunization programme activities; and to demand increased contributionswould be unreasonable. The Ministry of Health provides some support, includingthe provision of transport and vaccine supplies to these local authorities. Indeed,rather than expecting to mobilize increased resources from these local authorities,the Central Government will need to continue to provide supplementary support.

The Medium Term Expenditure framework (MTEF), a new budget approach, is alsoaddressing improvement in the provision of immunization services (immunization isone of the six essential packages). The MTEF is geared towards poverty reductionand thus immunization is expected to receive reasonable support as part of PovertyReduction Strategic Paper (PRSP) initiative.

A notable development beginning the financial year 2002/03 is the governmentintroduction of budget lines for vaccines and other immunization activities.

1.5.3 National Health Sector Strategic Plan 1999-2004

A five year National Health Sector Strategic Plan (NHSSP) has been developed bythe Ministry of Health for the period of 1999–2004. One of the main objectives of theNHSSP is to enhance equity, quality, accessibility and affordability of health carethrough better targeting of resources to the poor.

National Health resources are currently heavily allocated to curative servicescompared to preventive/promotive services (70% vs. 30%) the will to shift from thisdisparity remains so as to provide maximum benefits to the majority of the vulnerablegroups who form a larger proportion of our society.In the context of EPI services, the NHSSP recommends decentralization of all aspectsof EPI program planning, monitoring and evaluation. While the national level willcontinue to be responsible for development of policies and standards, donorcoordination, vaccine procurement, technical assistance to lower levels, operationalresearch, monitoring and evaluation, responsibilities will be devolved to theprovinces, districts and health facilities for efficient management of immunizationservices. It is expected that the decentralization will have the net effect of improvedimmunization coverage.

Immunization has proven to be one of the most effective public health measures inpreventing deaths and illnesses from vaccine preventable diseases. Immunizationcoverage is, therefore, a major development indicator within the current healthsystem.

The Ministry of Health, however, also recognizes the important role played by otherhealth programmes in the reduction of morbidity and mortality. The Kenya EPIworks in collaboration with other preventive health programmes such as theReproductive Health Programme to reduce the risk of maternal and neo-nataltetanus infection through quality birthing practices and vaccination. KEPI is

_______________________________________________________________________

6

currently working on a proposal with the Malaria Control Programme to integrateimmunize services with promotion of insecticide treated bed nets.

Finally KEPI participates in all training activities for the introduction and implementation of theIntegrated Management of Childhood Illnesses Programme.

1.6 Role of the Private SectorIn Kenya, the private sector can be divided into non-profit providers and profitproviders. The non-profit providers are non-governmental organizations (NGOs) andare important providers of health services both in rural and urban areas and hencekey players in immunization services. The profit private sector provides mainlycurative care services, but also provides services such as family planning andimmunizations, with major providers being located mainly in urban areas.

The scarcity of government resources means that an increasing share ofcurative/preventive services is delivered by the NGO/Private sector. Althoughcontracting out to the private health sector is not envisaged in the short term, thegovernment will wish to see the sector playing a more prominent role in the deliveryof health services including expansion of immunization services.

The Ministry of Health continues in a limited way to support the private sector in theprovision of vaccines, and cold chain equipment. The Government indeed recognizesthe participation of, particularly the mission non-governmental organizations(NGOs), who provide health services in remote areas which are generally neglectedby the for profit providers. However, with low funding situation facing the Ministryof Health, there are insufficient resources to adequately support all logistics for EPI.Nevertheless, the private sector will continue offering health care services to thosewho can afford to pay.

It is expected that the cumulative effort of the private /NGO sector and the publicsector will translate into improvement in immunization coverage.

_______________________________________________________________________

7

2. BUDGETING FINANCIAL MANAGEMENT AND PROCUREMENT

2.2 Financial management

Logistical support for the Kenya EPI has largely been through external donorfunding. These funds have been used to purchase vaccines, support cold chainsystem and transport. The high dependence on donor funds has created a situationwhere the Ministry of Health does not demand for a vigorous costing and budgetingfor this program. However, with diminishing donor funds, the Governmentcontributions to the program have been enhanced and are likely to improve in future.

2.2 BudgetingThe Government has introduced a new budgetary system commonly known asMedium Term Expenditure Framework (MTEF). Under the new budgetaryframework, the health sector receives funding from three areas. These are publicadministration (for salaries and related items), human resource development (forprogram funds including immunization) and physical infrastructure (for funds todevelop infrastructure network).

The health sector continues to enjoy high priority in line with the Poverty ReductionStrategy Paper, where the public ranked health third in order of priority (afteragriculture and education). In the last few years, health is the only GovernmentMinistry, which has received increased allocations. These increases have now beentranslated into increased resource flow to the immunization program.

The budgeting for the health sector is incremental and additional resources aredistributed proportionately to all the programmes across the board. This is partlybecause no data is available on financial requirements to fully operationalise theprogram. Efforts are being made to calculate the cost of delivering the six essentialpackages, which includes immunization. When this costing exercise is complete itwill be possible to use cost of service delivery inputs for programme budgeting.During the development of this proposal, the cost of inputs to the EPI programmehave been estimated and this will form the basis for budgeting and advocating foradditional resource flow to this area.

One of the constraints to the budgeting of the EPI services is lack of accurateinformation on shared costs. These costs, which are not known are met by respectiveinstitutions providing immunisation and are very difficult to isolate.

Funds for the support of EPI activities are channelled to the program managersbased at the district level. The GAVI support is a supplement to a routinegovernment allocation issued directly to districts for the running of general healthservices. The government allocation for EPI is however issued twice yearly, and isrestricted to transport operating expenses and the procurement of liquid petroleumgas for gas operated refrigerators.The GAVI support to the districts started in 2001 and allows for more flexibility ofuse.

_______________________________________________________________________

8

The program managers are responsible for planning on how to utilize these fundsbased on needs. To some extent this has enhanced efficiency in utilization of EPIfunds, since decisions are made at the point of delivery.

The release of GAVI funds to the districts is done in trenches and expenditurereturns are required at the national level. This ensures easier access of funds atlower level for accelerated immunisation activities. This could have contributed toincrease in immunisation coverage witnessed over the last one year.

The flow of Government funds from the National Level to the Provincial and Districtlevels is often not timely. National funds are released to other levels through aninstrument/document known as an “Authority to Incur Expenditure” commonlyreferred to as an A.I.E. An AIE is a an accounting document which allows theimplementors to incur expenditure when funds are available This delaysimplementation of planned activities and occasionally at the end of the financial yearnot all of EPI funds may be utilized.

2.3 Procurement

The procurement of vaccines for KEPI is largely procured by UNICEF from reliablemanufacturers of vaccines recommended by WHO and periodically through otherdevelopment partners. It is assumed that this process gives us the best value for ourmoney. However, procurement of cold chain equipment has been irregular becauseof reliance on donor goodwill. Although the quality of equipment purchased to datehas been good, it has not been possible to ascertain whether they were bought at abargain price. Again since the government does not depreciate equipment in use it isdifficult to plan for new ones. This irregular supply and maintenance of cold chainand other supplies is probably the biggest constraint facing immunization program.

_______________________________________________________________________

9

3 PROGRAM CHARACTERISTICS, OBJECTIVES AND STRATEGIES

3.1 Qualitative and quantitative information about program performance andtargets

Ministry of Health through KEPI designs planning, monitoring and evaluation toolsfor all the aspects of quantitative and qualitative performance. The data is analysedby the districts to identify weaknesses in the specific areas of routine immunization,vaccine management, detection and response to outbreaks of vaccine preventablediseases.

The expected improvements during the Plan period include:

• Increased demand for immunization to be created by effective advocacy andsocial mobilization at all levels;

• Improved districts’ capacity to manage vaccines and reduce wastage, throughthe use of new guidelines;

• Improved district coordination of EPI activities through logistical integrationwith other health activities.

• Health workers clear on the use of operational manuals and performance-monitoring tools through training;

Strengthening the collaboration and coordination of stakeholders’ support for EPIactivities at national, district and community levels.

3.1.1Performance Targets• Increase coverage for all antigens to at least 90% in all districts by 2005;• Improved timeliness and completeness of routine reports from the district to

90%;• Reduce drop out rates;• Coverage for fully immunized children (FIC) 90%

Kenya intends to immunize 90% of its children aged less than one year against theeight vaccine preventable diseases. These include the traditional six antigens namely:measles, polio, diphtheria, whooping cough (Pertusis), tetanus and tuberculosis.Through GAVI support, Hepatitis B and Haemophillus Influenza type B vaccinationswere introduced into the Programme in December 2001. Autodisable (AD) syringeswere introduced to KEPI together with the pentavalent vaccines and are currently inuse. Plans are at an advanced stage to fully introduce Autodisable syringes for allinjectable vaccines within the programme starting from 2003.

Through the immunization schedule, the government has continued to record animprovement in child health indicators, especially a reduced infant mortality rate. Thecurrent immunization policy allows immunizations to be given daily, though in practicemost vaccinations are administered only five days per week. The current immunizationschedule for the administration of the vaccines is shown in Table 3.1.

Table 3.1: Immunization Schedule, Kenya

Age ANTIGENAt birth BCG and Birth OPV

_______________________________________________________________________

10

6 weeks DPT/HepB/Hib 1 and OPV 110 weeks DPT/HepB/Hib2 and OPV214 weeks DPT/HepB/Hib 3 and OPV 39 months Measles9 months Yellow Fever (in the four endemic districts of Baringo,

Koibatek, Keiyo and Marakwet).

The GAVI funds that the programme has received have been utilised to accelerate routineimmunization coverage. The coverage had showed some decline after 1994. The centralgovernment is increasing its funding to the programme mostly in purchase of vaccines andcold chain preventive maintenance while development partners are giving aid and supportin many forms. It is envisaged that the coverage is going to improve substantially in thePlan period.

In order to improve the coverage, the programme is planning to improve communityawareness through intensive social mobilization, motivate health workers throughtrainings and intensified supervision, allocate funds to enable districts carry out outreachservices and distribute supplies and do minor repairs on their available transport. Theprogramme is also looking into ways in which the locally available support can bemobilized with a view of strengthening it.

The programme mission is to offer immunization services through four guiding principlesof making immunization services accessible, affordable, available and attractive to allchildren of Kenya with the ultimate goal of reducing or eliminating childhood immunizablediseases to a level they will no longer be a public health problem. This is a big challengethat requires careful planning and substantial amount of resources to attain the set goalsand objectives.

One of the main milestones toward the diseases reduction and elimination is to raise theimmunization coverage levels of all antigens to a level that the diseases causative agent willbe totally disrupted or its transmission cycle destroyed or the environmental conditionmade completely unfavourable for the diseases transmission continuity.

Table 3.2 shows the immunization coverage targets based on the past performance of theprogramme (it has not been possible to reach 90% coverage levels for all antigens exceptfor BCG).

Table 3.2: Immunization coverage targets

No Antigen 2002 2003 2004 2005 2006 2007 2008 20091 BCG 95% 95% 95% 95% 95% 95% 95% 95%

2DPT-HepB+Hib

75% 80% 85% 90% 95% 95% 95% 95%

3 Measles 75% 80% 85% 90% 95% 95% 95% 95%4 TT 60% 70% 80% 90% 95% 95% 95% 95%5 Polio 75% 80% 85% 90% 95% 95% 95% 95%

_______________________________________________________________________

11

The latest Kenya demographic Health Survey (1998) indicated negative trend on nationalimmunization coverage from 79% for fully immunized children in 1994 to 65% in 1998.This has been a worrying situation and a lot of effort has been put to reverse the trendthrough the material and financial support received from GAVI and other Partners toaccelerate the immunization activities by carrying out outreach and mobile services to thedisadvantaged and hard to reach population.

Data completeness and timeliness has been one of the obstacles in assessing the actualcoverage through the administrative methods. However, the reporting rate has improvedfrom 51% to 78% by the end of August 2002. With the current 82% reporting response, itis estimated that the current level of fully immunized children stands at about 75%. All thedistricts will continue to carry out their daily immunization services supplemented with atleast one outreach or mobile per month.

The most crucial thing is to reach the set targets and maintaining them within the setperiod of time. This will require more resources and participation of all. Monitoring of theactivities coupled with the regular programme review to give the direction of theprogramme will be undertaken. Appropriate action will be taken as necessary.

Community surveys carried out in the past have been more reliable in presenting accuratesituation of immunization coverage. Table 3.3 shows the estimated immunisation coverageassessment based on routinely reported (administrative) data. The low coverage is mainlydue to low reporting rates, which range between 30% and 75%.

Table 3.3: Estimated immunization coverage (%) assessment based onroutinely reported (administrative) data

YEAR BCGCoverage

OPV – 3Coverage

DPT – 3Coverage

MeaslesCoverage

FullyImmunized

1988 47 25 31 29 291989 55 35 42 37 371990 57 46 43 42 421991 49 44 41 37 371992 46 40 40 36 361993 50 43 42 38 381994 63 53 51 48 481995 53 39 47 41 411996 55 43 46 39 391997 52 43 43 46 461998 50 43 45 38 381999 64 55 55 45 452000 50 49 51 45 452001 71 58 68 52 42(Source, KEPI Health Information System, Administrative Data)

3.1.2 Vaccine wastage

The programme has now developed guidelines to monitor vaccine wastage includingthe necessary tools. This has become necessary due to the high cost of vaccines aswell as the need to monitor programme efficiency.

_______________________________________________________________________

12

3.2 Possible changes in program objectives in the light of financial constraints

Since the introduction of the new DPT-HepB-Hib vaccine, the Kenya EPI is heavilydependant on the GAVI and other partners for the support of purchase of vaccinesand necessary logistics. However, the Kenya Government through the Ministry ofHealth, currently supports the following:

• Purchase of BCG vaccine;• Purchase of yellow fever vaccine for routine services;• Purchase of part of the routine OPV vaccine;• Purchase of part of the routine TT vaccine;• Purchase of part of the disposable needles & syringes for routine services;• Purchase of liquid petroleum gas for cold-chain refrigerators;• Maintenance of cold-chain equipment and preventive maintenance;• Transport operating expenses for government vehicles involved in EPI service

provision• General operating costs of the KEPI Management Unit.• Payment of salaries for all government health workers

In the event of constraint in the availability of finances for EPI services the greatestimpact would be on:• Availability of vaccines and other related supplies;• General operational expenses;• Programme operational strategies;• Cold chain maintenance and sustainability.

The program objectives most likely to be affected by any constraint of finances are;• The increase and sustaining of national immunization coverage of 90;• The increase of access to immunization services nationally to 90 and above.

3.2.2 Vaccine Stock-outsThe effect of vaccine stock out, as experienced in 2001 with BCG, would result in:

• A decline in coverage most probably due to increased missed opportunities,• Institutionalisation of cost-sharing for immunization services,• Increased dropout rates probably due to financial barrier leading to reduced

access and lack of motivation or knowledge among the parents to finish theimmunization schedule.

• Reduced wastage of vaccines as health facilities resort to reducing the number ofimmunizing days per week so as to maximize use of the limited stocks of vaccinesand support supplies

3.2.3 General operations

• Reduced Ministry of Health allocations to districts for EPI operational expenses;• Reduced KEPI supervision support to provinces and districts;

3.2.4 Changes of strategy

_______________________________________________________________________

13

Again from past experience in the operations of the EPI services in Kenya, financialconstraints affect the strategies used for service delivery in the following ways:

• Outreach/mobile services → usually stopped altogether,• Supermarket approach at static immunizing sites → vaccination restricted to

specific days of the week,• “Open-vial” policy → vaccinators wait until there is a “quorum” for each

vaccine,• Quality supervisory visits to immunizing facilities → revert to unpredictable

visits during distribution of vaccines/supplies/drugs,• Regular update training of vaccinating staff → suspended or minimized.

3.3 Governance and management of the immunization programme

There are no major governance or management changes planned for KEPI in theimmediate future. KEPI is a division within the Ministry of Health, with well-definedroles and responsibilities. There are no immediate or long term plans to delink itfrom the governance of the Ministry of Health.

The organisational structure of KEPI is line with WHO recommendations, with aManager as the head, assisted by a deputy manager, a logistician, social mobilizationofficer, data management officer, training officer and surveillance officers amongothers.

It is however felt that the KEPI Management Unit has outgrown its current physicalfacilities for administrative and storage services. Any changes of location, however,would most likely be supported through external assistance. Subsequently, therunning costs would still be borne by the Ministry of Health and are not expected tobe significantly different from current costs.

3.4 Roles and responsibilities of partners in Immunization financing andservices delivery

Immunization services delivery is the basic responsibility of the Government andsupplemented by individuals, donors, NGOs, Bilateral Agencies, and close Partnersand to less extent private sectors.

The EPI in Kenya is now about twenty years since it was officially started in thiscountry. During the first three phases (pilot, implementation and consolidation), ofthe programme about 90% both the capital and recurrent costs (excluding personnelsalaries) were borne by the donors especially DANIDA and UNICEF. WHOcontinued to give mainly technical support until early 1995 when the Polio Initiativewas started in this country and WHO started fully financing all the surveillance andall activities related to the polio eradication initiative? These activities have eitherbeen funded by DFID, JICA and CIDA through WHO or UNICEF.

UNICEF is committed to EPI services delivery in the country through:

• Survival, protection and development of children as universal developmentimperatives that are integral to human progress;

_______________________________________________________________________

14

• Mobilization of political will and materials resources to help ensure a first callof children and to build capacity to form appropriate policies and deliverservices for children and their families.

Since DANIDA withdrew national support to the programme, UNICEF, DFID, JICAand recently GAVI are providing financial support particularly for vaccinesprocurement, strengthening of cold chain and acceleration of the immunizationactivities in the Districts. The Government of Kenya has also taken keen interest infinancing the EPI activities as part of the poverty reduction effort by ensuring thatthe children of Kenya continue enjoying the immunization services. Through thiseffort, the Government has continuously enhanced its annual funding of both therecurrent and development allocation to KEPI by almost 10 and introduced somemore budget lines in recurrent vote. This is the right direction towards theprogramme sustainability and Government commitment in financing its ownprogramme.

Several discussions held between the Government of Kenya and various donoragencies have indicated the difficulties in pledging their tangible commitments forthe coming years because of their different planning cycles. However, they haveindicated their commitment in supporting KEPI as long as there will be, good andrealistic and strategic annual work plans, which can be discussed and agreed upon inthe monthly ICC meetings.

Despite the government wish to finance the immunization services in the country, itmay not be operationally possible due to other national social and economicobligations and the current economic situation. This means, therefore, donoragencies, private sectors and individuals will be called upon to give the necessarysupport toward the immunization services delivery in this country.

_______________________________________________________________________

15

4 BASELINE AND CURRENT PROGRAM COSTS AND FINANCING

This section provides a picture of financing levels and patterns before the VaccineFund (baseline year 2000), and how these have changed with the addition of VaccineFund support during the current year 2001.

This section, therefore, provides the basis for the assessment of how resourcerequirements are likely to grow in the future as examined in Chapter 5, which coversthe Vaccine Fund and Post-Vaccine Fund periods.

4.1 Pre-Vaccine Fund (baseline) program costs and financing patterns.

Table 4.1 presents the immunisation specific costs for 2000 as the base year. Theinformation includes both the program-specific inputs as well as costs of sharedinputs. The estimated cost of the programme was US$ 18 million for whichvaccines accounted for $ 3.3 million or 18% while personnel emoluments cost $9.1million (49.7% of the total).

Table 4.1: Immunization Specific Costs -Base year 2000. (FSP Table 1.1.1)

BASE YEAR2000

TOTAL IMMUNIZATION SPECIFIC COST.

ItemNo.

Component Routine Services Polio NIDs-SNIDs Other SIA* Total

[A] Operational Cost US$ US$ US$ US$Required Information1 Vaccines1.1 Vaccines (traditional 6

antigens)1,400,758 1,144,600 800,025 3,345,383

1.2 Vaccines (new and underused vaccines)

2 Injection supplies 530,730 530,7303 Personnel 120,118 1,215,448 1,335,5664 Transportation 76,923 648,660 725,5835 Maintenance and

overhead145,312 145,312

6 Short-term training 358,763 358,7637 IEC/social mobilization 440,610 440,6108 Monitoring and

surveillance293,568 68,428 361,996

9 Others/ Audit 98,500 98,500Optional information10 Shared Personnel10.1 -Salaries 5,256,893 5,256,89310.2 -Incentives/per diems 2,539,019 2,539,01911 Others - including shared

overheads624,543 624,543

Subtotal Operational 10,987,864 3,975,009 800,025 15,762,898[B] Capital CostRequired Information13 Vehicles 146,844 146,84414 Cold Chain Equipment 285,564 142,502 428,066Optional information15 Building 1,269,044 1,269,04416 Other Equipment 119,896 119,89617 Long-term training 25,641 25,641

Subtotal Capital 1,846,990 142,502-

1,989,492

GRAND TOTAL 12,834,853 4,117,511 800,025 17,752,389

Table 4.2 shows the immunisation costs by source of funding. Overall, the funds forthe immunization programme came mainly from the Government (mostly personnel

_______________________________________________________________________

16

and infrastructure), which contributed 53.2% of the total. Japanese Government, theprimary donor, contributed 19.5% of total cost in 2000.

Table 4.2: Immunization Specific Costs- Base year 2000 by Source (FSP Table 1.1.2)

TOTAL FINANCING BY SOURCES FOR NATIONAL IMMUNIZATION PROGRAMMEItemNo.

Component Nat'l Gov PrivateSector

UNICEF DANIDA DFID JAPAN WHO Total

[A] OperationalCost

US$ US$ US$ US$ US$ US$ US$

Required Information1 Vaccines1.1 Vaccines

(traditional 6antigens)

154,098 276,700 458,960 511,000 1,944,625 3,345,383

1.2 Vaccines (new and underused vaccines)2 Injection

supplies 27,000 503,730 530,7303 Personnel

120,118 1,215,448 1,335,5664 Transportation 76,923

648,660 725,5835 Maintenance

and overhead 103,108 42,204 145,3126 Short-term

training 358,763 358,7637 IEC/social mobilization

1,333 286,667 152,610 440,6108 Monitoring and surveillance

68,428 293,568 361,9969 Others/ Audit

98,500 98,500Optionalinformation10 Shared

Personnel -10.1 -Salaries 5,256,893

5,256,89310.2 -Incentives/per

diems 2,539,019

2,539,01911 Others - incl.

shared o/heads 624,543

624,543SubtotalOperational

8,874,7021,333 590,367 458,960 3,053,409 2,448,355 335,772 15,762,898

[B] Capital CostRequired Information13 Vehicles

146,844 146,84414 Cold Chain

Equipment 25,500

223,344 36,720 142,502 428,066Optionalinformation15 Building 1,269,044

1,269,04416 Other

Equipment 119,896 119,89617 Long-term

training 25,641 25,641SubtotalCapital 1,414,440 - 223,344 - 36,720 314,987 - 1,989,492GRANDTOTAL 10,289,142 1,333 813,711 458,960 3,090,129 2,763,342 335,772 17,752,389

4.2 Current expenditures and financing patterns

_______________________________________________________________________

17

Table 4.3 shows the current expenditures and financing patterns, including theVaccine Fund resources.

Routine services increased to $19.2 million in 2001 from $13.4 in 2000 largely onaccount of introduction of new vaccines, which accounted for 15% of the total costs in2001. Polio NIDs costs reduced almost by half ($2.2 million) in 2001 compared to $4.2 million in 2000 as in latter year not all districts were covered. Overall, total costsin 2001 increased by 17% from the previous year.

Table 4.3: Immunization Specific Costs- Current year 2001 (FSP Table1.2.1)

CURRENTYEAR 2001

TOTAL IMMUNIZATION SPECIFIC COST

ItemNo.

Component RoutineServices

Polio NIDs-SNIDs

Other SIA* Total

[A] Operational Cost US$ US$ US$ US$Required Information1 Vaccines1.1 traditional 6 antigens

1,743,333 354,050 84,100 2,181,483

1.2 new and underusedvaccines

3,248,684 3,248,684

2 Injection supplies394,004

394,004

3 Personnel166,026 847,990

1,014,016

4 Transportation152,564 605,174

757,738

5 Maintenance andoverhead 25,848

25,848

6 Short-term training98,090 197,553

295,643

7 IEC/social mobilization55,776 110,605

166,381

8 Monitoring andsurveillance 612,989 41,656

654,645

9 Audit76,923

76,923

10 Accelerated Immun.Activities 1,164,588

1,164,588

Optional information10 Shared Personnel -10.1 -Salaries 5,256,893 5,256,89310.2 -Incentives/per diems 3,695,674 3,695,67411 Other (incl. shared

o/heads) 717,205 717,205

Subtotal Operational17,331,674 2,233,951

84,100 19,649,725


248,188 248,188

14 Cold Chain Equipment420,295

420,295

Optional information15 Building

1,229,877 1,229,877

Subtotal Capital1,898,360 -

- 1,898,360

_______________________________________________________________________

18

GRAND TOTAL19,230,034 2,233,951

84,100 21,548,085

Table 4.4 presents the costs by source of financing for 2001. The sources of funds forthe immunisation programme in Kenya can be divided into two broad types-government sources and external sources. The external sources comprise all thedonor agencies providing funds for the programme.

The government made a substantial contribution (60%) to the nationalimmunization program both through its recurrent and development budgets. Fromthe revenue budget, it purchased BCG vaccine, yellow fever vaccine, and part of therequirements of OPV vaccine and part of the requirements of measles vaccine amongothers.

Donors, on their part, have played a very important role in providing support toKEPI including financing vaccines and cold chain equipment, vehicles, training andsocial mobilization/communications.

Table 4.4: Immunization Specific Costs- Current year 2001 by Source(FSP Table 1.2.2)

CURRENT YEAR 2001

TOTAL FINANCING BY SOURCES FOR NATIONAL IMMUNIZATIONPROGRAMME

ItemNo.

Component Nat'l Gov GAVI /VaccineFund

UNICEF DANIDA DFID JAPAN WHO Total

[A] Operational Cost US$ US$ US$ US$ US$ US$ US$ US$Required Information1 Vaccines1.1 traditional 6

antigens 1,327,092 323,027 98,600 160,000 272,764 2,181,4831.2 new and underused vaccines

3,248,684 3,248,6842 Injection supplies

161,758 198,576 33,670 394,0043 Personnel

166,026 847,990 1,014,0164 Transportation

152,564 605,174 757,7385 Maintenance and

overhead 25,848 25,8486 Short-term training

- 98,090 197,553 295,6437 IEC/social

mobilization - 55,776 110,605 166,3818 Monitoring and

surveillance - 117,952 41,656 495,037 654,6459 Audit

- 76,923 76,92310 Accelerated

Immun. Activities 516,885 647,703 1,164,588Optional information10 Shared Personnel10.1 -Salaries

5,256,893 5,256,90310.2 -Incentives/per

diems 3,695,674 3,695,68411 Other (incl. shared

o/heads) 717,205 717,205

_______________________________________________________________________

19

SubtotalOperational


248,188 248,18814 Cold.Chain

Equipment 411,707 8,588 420,295Optional information15 Building

1,229,877 1,229,877Subtotal CapitalGRAND TOTAL

12,982,886 4,199,145 331,615 98,600 2,039,901 471,340 1,424,598 21,548,085

_______________________________________________________________________

20

5 FUTURE RESOURCE REQUIREMENTS AND PROGRAMMEFINANCING

5.1 Costing scenarios

In developing the financial sustainability plan costs and sources of finance identifiedin chapter 4 were projected specifically for the two-time periods; Vaccine Fund (VF)period 2002 - 2006 and Post VF period 2007 – 2009.

In order to achieve this, a number of assumptions require to be made about themanner in which KEPI will function over the projection period. The assumptions arebased on:

• Existing policies and practices;• Population growth – which increases the annual cohort of newborns;• Adoption of new and underused vaccines;• Adoption of injection safety and safe disposal measures;• Modifications to the immunization schedule, and• Inflation, which is assumed away by use of constant 2002 prices (on all items)

and fixed exchange rate of Ksh.78.5: 1US $

Two scenarios have been considered.

• Scenario A: 90% coverage target• Scenario B: 80% coverage target

The assumptions underlying each of these scenarios are detailed in the following sub-sections.

5.1.1: Scenario A – Targeting 90% coverage – Implementing the KEPI strategicplan 2001-2005:

This scenario takes as its starting point the target of achieving a 90% fullyimmunisation coverage by one year of age by 2006 and sets out to cost the inputs tothe activities which would make attainment of this target feasible. It is inevitablethat unit costs (cost per fully immunised child) will rise rapidly in this scenario,largely because the gap between current coverage and target coverage consists mostlyof the “hard to reach” infants, located mostly in remote areas and urban slums. Italso assumes that a combination of outreach efforts, programme accessibility andsocial mobilisation efforts will be essential to reach the demanding coverage targetand each element of this package is potentially very expensive when compared withexisting practice. For example, if static clinics, in the “hard-to-reach” areas, are toprovide immunisation services daily, it is inevitable that vaccine wastage rates (andhence costs) will be higher than if immunisation is offered only on selected days.

Although the assumption is that unit costs will rise sharply, in all areas ofprogramme implementation, there is no empirical information available on whatinputs are actually required to achieve any given coverage targets in differentecological zones in Kenya.

_______________________________________________________________________

21

Table 5.1 shows the projected costs of maintaining the EPI over the vaccine fundperiod (2002-2006). The cost of the programme is estimated at about $184 millionover the five years. Vaccines (traditional 6 antigens - 3.2% of total, new andunderused- 39.8%) account for 43% of the total cost. Secured funds account for 82%of the total.

TABLE 5.1: TOTAL IMMUNIZATION SPECIFIC COST Projections - VFperiod 2002-2006 SCENARIO A (FSP Table 2.1.1)

ItemNo.

Component ProjectedRequirements forVF-Period

Total SecuredFinancing(Sum of all 1s)

Total ProbableFinancing(Sum of all 2s)

TotalPossibleFunding (Sum of all 3s)

[A] Operational Cost US$ US$ US$ US$Required Information1 Vaccines1.1 Vaccines(traditional

6 antigens) 5,307,729 4,803,859

503,8711.2 Vaccines(new

& underused) 73,213,872 63,528,199 9,685,673

2 Injection supplies 5,363,922 4,354,349 1,009,5733 Personnel 55,452,459 55,452,459

-4 Suppl. Immu.

Activities 14,853,840 7,777,989 4,745,610 2,330,241

5 All otheroperatioal costs

23,364,886 13,713,708 3,795,403 5,855,775

6 Outreach 1,297,884 1,297,885-

-

SubtotalOperational

178,854,592 150,928,44819,740,130

8,186,016

[B] Capital CostRequired Information7 Vehicles 2,227,375 107,000

- 2,120,375

8 Cold ChainEquipment

2,213,750 398,750 300,000 1,156,250

Subtotal Capital 4,441,125 505,750 300,000 3,276,625

Total Cost 183,295,717 151,434,198 20,040,130 11,462,641

_______________________________________________________________________

24

Table 5.2: TOTAL IMMUNIZATION SPECIFIC COST Financing Projections VF period: 2002-2006-SCENARIO A(FSP Table 2.1.2)

ItemNo.

ComponentGovernment

Risk(Type1, 2or 3)

GovernmentRisk(Type1, 2or 3)

GAVI /VaccineFund

Risk(Type1, 2 or3)

DONORS Risk(Type1, 2or 3)

DONORS Risk(Type1, 2 or3)


UNFUNDED Risk(Type1, 2or 3)

Total

[A] Operational Cost US$ US$ US$ US$ US$ US$ US$ US$Required Information1 Vaccines1.1 Vaccines(traditional

6 antigens) 2,574,700 1

2,229,159 1

503,871 2 3

(1) 3

5,307,7291.2 Vaccines(new &

underused) - 63,528,199 1

9,685,673 2

73,213,8722 Injection supplies

- 4,354,349 1

1,009,573 2

5,363,9223 Personnel

55,452,459 1

55,452,4594 Suppl. Immu.

Activities 400,400 1

7,377,589 1

4,790,948 2 3

2,284,903 3

14,853,8405 All other operatioal

costs 1,959,754 1

1,845,403 2

9,529,954 1

2,224,000 1

1,950,000 2 3

5,855,775 3

23,364,8866 Outreach

- 1,297,885 1

1,297,885 SubtotalOperational 60,387,313 1,845,403 78,710,387 11,830,748 7,244,819 - 18,835,923 178,854,593


107,000 1 2

1,050,000 3

1,070,375 3

2,227,3758 Cold Chain

Equipment 398,750 1

450,000 2

350,000 3

1,015,000 3

2,213,750 Subtotal Capital

- - - 505,750 450,000 1,400,000 2,085,375 4,441,125

Total Cost60,387,313 1,845,403 78,710,387 12,336,498 7,694,819 1,400,000 20,921,298 183,295,718

_______________________________________________________________________

25

Table 5.3: TOTAL IMMUNIZATION SPECIFIC COST Projections Post VFperiod: 2007-2009 SCENARIO A (FSP Table 2.2.1)

TOTAL IMMUNIZATION SPECIFIC COSTItemNo.

Component ProjectedRequirementsfor VF-Period

Total SecuredFinancing(Sum of all 1s)

Total ProbableFinancing(Sum of all 2s)

Total..PossibleFunding(Sum of all 3s)


2,296,446 1,375,800 - 920,646

1.2 new & underused56,579,667 - -

56,579,667

2 Injection supplies4,450,443 - -

4,450,443

3 Personnel44,689,723 44,689,723 -

-

4 Suppl. Immu. Activities5,607,776 - -

5,607,776

5 All other operational costs18,296,001 180,000 5,442,805

12,673,196

6 Outreach1,418,587 - -

1,418,587

Subtotal Operational133,338,642 46,245,523 5,442,805

81,650,315


576,250 - 150,000 426,250

8 Cold Chain Equipment1,113,750 - 150,000

963,750

Subtotal Capital1,690,000 - 300,000

1,390,000

Total Cost 135,028,642 46,245,523 5,742,805 83,040,315

_______________________________________________________________________

26

Table 5.4: TOTAL IMMUNIZATION SPECIFIC COST Financing Projections Post VF period: 2007-2009-SCENARIO A (FSP Table 2.2.2)

ItemNo.

Component Government Risk(Type1, 2or 3)

GAVI /VaccineFund

Risk(Type1, 2or 3)

DONORS Risk(Type1, 2 or3)


UNFUNDED Risk(Type1, 2or 3)

Total

[A] Operational Cost US$ US$ US$ US$ US$ US$1 Vaccines1.1 traditional 6 antigens

1,375,800 1

920,646 3 2,296,446

1.2 new & underused- 56,579,667

3 56,579,667

2 Injection supplies- 4,450,443

3 4,450,443

3 Personnel44,689,723

1-

44,689,723

4 Suppl. Immu. Activities-

15,607,776

3 5,607,776

5 All other operatioal costs3,941,765

21,501,040

2180,000

112,673,196

318,296,001

6 Outreach- 1,418,587 1,418,587

Subtotal Operational50,007,287 1,501,040 180,000 81,650,315

133,338,642

[B] Capital Cost7 Vehicles

150,000 2

426,250 3 576,250

8 Cold Chain Equipment150,000

2963,750

31,113,750

Subtotal Capital- - - 300,000 1,390,000 1,690,000

Total Cost50,007,287 1,501,040 180,000 300,000 83,040,315

135,028,642

_______________________________________________________________________

27

The cost projections indicate a total immunization programme cost of US$ 321million for the period 2002 up to 2009 against an estimated secure and probablefinancing (risks 1 & 2) of US$224 million, which indicates a financing gap of US$ 97million as illustrated in Figure 5.1. Vaccine purchases will account for 43.7% of totalcosts. The secured funds clearly decline from 92% in 2002 to only 36% by 2009

Figure 5.1

5.1.2: Scenario B - The 80% coverage target

This scenario assumes a target of 80% of the birth cohort attaining fully immunisedchild status by 2006. It makes the same assumptions about the productivity ofincremental resources as Scenario A.

Under this scenario, the programme is projected to cost $12.3 million in 2002increasing to $16.8 million in 2006 to a total cost of $146 million for the period ofwhich 87% of the funds are secured.

Projected Financing Scenario A

0

5

10

15

20

25

30

35

40

45

50

2002 03 04 05 06 07 08 09

Proj

ecte

d C

osts

($ ,0

00,0

00)

Govt secure Gavi secure Donors secure Govt probable Donors probable FINANCING GAP

_______________________________________________________________________

28

TABLE 5.5: TOTAL IMMUNIZATION SPECIFIC COST Projections - VFperiod 2002-2006 SCENARIO B (FSP Table 2.1.1)

ItemNo.

Component ProjectedRequirementsfor VF-Period

Total SecuredFinancing (Sum of all 1s)

TotalProbableFinancing (Sum of all 2s)

TotalPossibleFunding (Sum of all 3s)


5,062,218 4,564,980 497,239 01.2 new & underused

66,460,824 63,518,399 2,942,4262 Injection supplies

5,058,299 5,058,299 -3 Personnel

32,578,191 32,578,190 -4 Suppl. Immu. Activities

14,853,840 7,777,989 4,745,610 2,330,2415 All other operatioal costs

17,839,254 12,746,940 3,795,403 1,296,9116

-Subtotal Operational

141,852,627 126,244,797 11,980,678 3,627,153


1,711,375 107,000 1,604,3758 Cold Chain Equipment

1,593,750 368,750 450,000 760,000Subtotal Capital

3,305,125 475,750 450,000 2,364,375

-Total Cost

145,157,752 126,720,547 12,430,678 5,991,528

_______________________________________________________________________

29

Table 5.6: TOTAL IMMUNIZATION SPECIFIC COST Financing Projections VF period: 2002-2006- SCENARIO B(FSP Table 2.1.2)

ItemNo.

Component Government RiskType1, 2or 3

Government RiskType1, 2or 3

GAVI /Vaccine

Fund

RiskType1, 2or 3

DONORS RiskType1, 2or 3

DONORSRiskType1, 2or 3


UNFUNDEDRiskType1, 2or 3

Total

[A] OperationalCost

US$ US$ US$ US$ US$ US$ US$ US$

Required Information1 Vaccines

1.1 traditional 6antigens 2,529,038

12,035,942

1497,239

20

35,062,219

1.2 new & underused63,518,399

12,942,426

266,460,825

2 Injection supplies5,058,299

15,058,299

3 Personnel32,578,190

132,578,190

4 Suppl. Immu.Activities 400,400

17,377,589

14,745,610

22,330,241

314,853,840

5 All otheroperatioal costs 1,959,754

11,845,403

28,563,186

12,224,000

11,950,000

21,296,911

317,839,254

SubtotalOperational 37,467,382 1,845,403 77,139,884 11,637,531 7,192,849 - 6,569,579 141,852,628

[B] Capital CostRequired Information

7 Vehicles107,000 1 2 886,375 3 718,000 3 1,711,375

8 Cold Chain Equipment368,750 1 450,000 2 237,500 3 522,500 3 1,578,750

Subtotal Capital- - - 475,750 450,000 1,123,875 1,240,500 3,290,125

Total Cost37,467,382 1,845,403 77,139,884 12,113,281 7,642,849 1,123,875 7,810,079 145,142,753

_______________________________________________________________________

30

Table 5.7 shows the cost projections for the post vaccine fund period (2007-2009). Overall,the cost reduced to $34.2 million in 2009 from $ 36.5 million in 2002 mainly on account ofreduced supplemental immunization activities.

Table 5.7: TOTAL IMMUNIZATION SPECIFIC COST Projections Post VFperiod: 2007-2009- SCENARIO B (FSP Table 2.2.1)

ItemNo.

Component ProjectedRequirements forVF-Period

Total SecuredFinancing (Sum of all 1s)

Total ProbableFinancing (Sum of all 2s)

Total PossibleFunding (Sum of all 3s)

[A] Operational Cost US$ US$ US$ US$Required Information1 Vaccines1.1 traditional 6 antigens 2,302,836 1,375,800 927,0361.2 new & underused 52,942,637 52,942,6372 Injection supplies 4,294,607 1,965,230

778,861 1,550,5163 Personnel 20,339,255 20,339,2554 Suppl. Immu. Activities 5,607,776 5,607,7765 All other operational costs 14,272,523 1,736,996

3,941,765 8,593,762

Subtotal Operational 99,759,634 25,417,281 4,720,626 69,621,728

[B] Capital CostRequired Information7 Vehicles 576,250

150,000 426,250

8 Cold Chain Equipment 668,750150,000 518,750

Subtotal Capital 1,245,000-

300,000 945,000

Total Cost 101,004,634 25,417,281 5,020,626 70,566,728

The attainment of 80% coverage assumes a lower capital outlay of $72 million tothat of scenario A and allows for the available funds, especially those committed byGAVI, to be spread beyond the 5 year VF support period. This has the effect ofreducing the financing gap by a considerable margin.

Table 5.8: TOTAL IMMUNIZATION SPECIFIC COST FinancingProjections Post VF period: 2007-2009 SCENARIO B (FSP Table 2.2.2)

ItemNo.

ComponentGovernment

RiskType1,2or 3

GAVI /VaccineFund

RiskType1, 2or 3

GAVI /VaccineFund

RiskType1, 2or 3


UNFUNDEDRiskType1, 2or 3

Total

[A] OperationalCost

US$ US$ US$ US$ US$ US$

RequiredInformation1 Vaccines1.1 traditional

6 antigens1,375,800 1 927,036 3 2,302,836

1.2 new & underused 52,942,637 3 52,942,6372 Injection

supplies1,229,681 1 1,514,410 2 1,550,516 3 4,294,607

3 Personnel 20,339,255 1 20,339,2554 Suppl..Immu.

Activities5,607,776 5,607,776

_______________________________________________________________________

31

5 All otheroperatioalcosts

3,941,765 2 1,556,996 1 180,000 1 8,593,762 3 14,272,523

SubtotalOperational

25,656,820 2,786,677 1,514,410 180,000 69,621,728 99,759,634

[B] Capital CostRequiredInformation7 Vehicles 150,000 2 426,250 3 576,2508 Cold Chain

Equipment150,000 2 518,750 3 668,750

SubtotalCapital

- - - 300,000 945,000 1,245,000

Total Cost 25,656,820 2,786,677 1,514,410 480,000 70,566,728 101,004,634

Figure 5.2 illustrates the projected financing sources and gaps for scenario B overthe 2002 to 2009 period. The gap increases from $ 1.3 million in 2002 to $ 24million by 2009 for a total of $78 million. As in scenario A, the large gap will existdue to lack of committed financing for purchase of vaccines beyond 2006.

Figure 5.2

5.2. Summary

Projected Financing Scenario 'B'

0

5

10

15

20

25

30

35

40

2002 03 04 05 06 07 08 09

Proj

ecte

d C

osts

($ ,0

00,0

00)

Govt secure Gavi secure Donors secure Govt probable Donors probable FINANCING GAP

_______________________________________________________________________

32

In the two scenarios above, there are certain common cost drivers. The first of theseis population growth, which is increasing the annual cohort of newborns by justfewer than three per cent per annum. The second is the decision to adopt the moreexpensive pentavalent vaccine (DPT + HepB + Hib) in place of DPT. The newvaccine was introduced from December 2001, and therefore the higher level of costsis only marginally reflected in baseline period expenditures. The third factor is theadoption of injection safety measures, including auto-disable syringes and safedisposal measures. A fourth factor is inflation. Although all monetary values areexpressed in current US dollars, with conversion from Kenya shillings at the current(2002) exchange rate - Ksh.78.5: 1US $, this does not completely remove the impactof inflation. While no projection is made of future inflation, the large increase intotal KEPI programme costs in 2001 over 2000 is largely explained by a hugeincrease in nominal and real staffing costs associated with adjustments to housingallowances.

Few of these cost drivers are considered reversible. Population growth rates aredetermined extraneously. Vaccine choice and injection safety measures are policydecisions. Modifications to the immunisation schedule are prompted by efficacy orsafety considerations, but are usually cost enhancing. Inflation is assumed away bythe recommended use of constant prices. Figure 5.3 depicts the comparative cost ofthe base and current years and the projected costs for scenarios A and B.

Figure 5.3

6. SUSTAINABLE FINANCING STRATEGIC PLAN AND INDICATORS

Alternative Programme Costs

0

5

10

15

20

25

30

35

40

45

50

2000 ,01 ,02 ,03 ,04 ,05 ,06 ,07 ,08 ,09

years

cost

s ($

,000

,000

)

Scenario A Scenario B Base & Current Years

_______________________________________________________________________

33

In order to strengthen the immunization program over the Plan period, funding gapswill primarily affect the purchase of basic EPI vaccines, cold chain, transportcapacity, laboratory capacity, injection safety and coverage.

The introduction of new vaccines presents significant financial challenges, not leastof which is finding a balance between expanding the program with limited funds, andconsolidating and strengthening it. Thus, the Government will implement policydecisions to improve financial sustainability, accountability, and equitable access toimmunization service.

This section presents assessments with a view to strengthening sustainability of theimmunization programme financing. The section discusses policy issues, resourceallocation and management mechanisms that would enable higher and morepredictable funding of NIP needs.

Among the many actions Kenya government will take to move toward higher andmore stable levels of funding for immunization services, the following stand out asthe ones with the highest potential impact:

6.1 Mobilise adequate resources

� Increase domestic resources to health through advocacy at inter-ministeriallevel, local authorities, local corporate and individuals;

� Expand the ICC membership in an effort to solicit their support for the EPI;� Engage development partners in discussion of resource requirements and seek

commitments to cover major funding gaps;� Create enabling environment so as to attract foreign funding;� Considering the importance of EPI in the prevention of diseases, the Ministry

of Health will review priority ranking. Currently, EPI is ranked 5th in theessential health package.

� Allocation criteria of resources on the basis of poverty out patient cases amongothers factors have been developed. This will ensure districts get adequateresources and this will translate in immunization services benefiting.

6.2 Strategies and actions to increase the reliability of resources

� The government will endeavour to meet the agreed donor conditions;� Ensuring political and economic stability and good governance;

6.3 Strategies to increase efficient use of resources

� In order to implement programme activities with ease, special accounts ofdonor funds will be maintained in commercial banks with flexible operation;

� Improved accountability and transparency will be enhanced, as the spendinglevel against the EPI budget line (introduced during the financial year2002/2003 for the procurement of EPI vaccines and supplies and otheroperational costs as part of its long-term commitment to EPI activities) willtake responsibility for correct use of the funds. Specific EPI activity budgetlines will reduce the risk of funds being diverted to other expenditure areas;

_______________________________________________________________________

34

� Wastage rates are a useful financial management tool as good wastagemanagement facilitates accurate forecasting resulting in reduction inprocurement and distribution costs. Although wastage rates appear acceptableat the national level at the moment, an in-depth analysis at district level willhighlight regional discrepancies.

� The existing system of regular monitoring, reporting, and feedback will bestrengthened;

� Management of equipment: The immunization programme has substantialresources, which will be managed well to reduce costs. These include the coldchain, laboratory equipment and vehicles. All these have been put in theinventory. However, in the Plan period their functional status, performance,and maintenance schedule will be strictly monitored for optimal efficiency andlongevity. Reports on breakdown in the cold chain will be addressedpromptly. A national inventory and monitoring system will facilitate needs-based planning and make resource mobilization more efficient;

� Establish performance targets for all the districts.

Sustainable Financing Strategic Plan

Objectives Indicators Actions Means ofverification

Increase mobilization of resources

_______________________________________________________________________

35


� IncreaseGovernmentfinancialcontributions to the NIP

� National operatingexpenditure onimmunization as ofGDP

� Governmentexpenditure on NIPas of the healthbudget

� FSP incorporatedin to the nationalhealth plan;

� Disseminate andadvocate the FSP;

� Hold regular ICCmeetings.

� Integration ofthe FSP intoMOH plan;

� Number ofcopies of FSPdisseminated;

� Number of ICCmeetings held;

� Line allocationto NIPintroduced.

� Mobilizeexternalresources tofill financinggap

� Donor contributionas of financing

� Partnersparticipating inNIP planning;

� Submission ofproposals seekingadditional/Newfinancial support

� Number ofpartnersparticipating inNIP planning

� Number ofproposalssubmitted

� Mobilizelocal privateandcommunityparticipation

� Private enterprisesand NGO’sencouraged toparticipate in NIP

� Communityparticipationstrengthened

� Private enterprisesand Locally basedNGO’s included inthe ICC

� Communitiesrepresentation inlocal health boardsand committees

� Numberparticipating inICC;

� Activitiessupported;

� Numberparticipating inboards andcommittees.

Increase reliability of funds� Reduce

financingfluctuationson programperformance

� Mean number ofyears ofGovernment andDonorcommitments

� Disbursementmechanismsestablished

� Develop long-termcapital financing plan

� Build-up financialinformation andmonitoring systems

� Conditions met

� Existence oflong-termfinancing plan

� Existence ofdisbursementregulations

� Time needed totransfer funds

� Number of daysof delay in funddisbursement

� Improve programme efficiency� Program costs

reduced

� Critical

� Conduct cost-effective /cost-benefit analysis;

� Inventory of programinputs;

�

� Number ofstudiesconducted;

� Number ofupdates;

_______________________________________________________________________

36


Programmaticissues addressed

� Procurementmechanismsstandardized;

� Demand creation forservices;

� Implement WHOguidelines on vaccineutilization;

� Data qualityimproved;

� Regulate fundappropriationprocess;

� Implement stafftraining protocols;

� Use of appropriatetechnology.

�

� Purchases fromapprovedmanufacturers;

� Increasedcoveragerecorded;

� Vaccine wastagereduced

� Numbercomplete,accurate andtimely reports;

� Number ofaccountsaudited;

� Number of stafftrained;

� Numberequipment/vehicles meeting localconditions.

Indicators of Financial Sustainability

Dimension ofFinancialSustain-ability

Indicator Unit Explanatory Notes

Mobilization andUse of AdequateResources

Creation of Budget Line Item Yes The EPI budget line introducedduring the financial year 2002/03.It is expected to increase during thePlan period

Efficient Use ofResources

Purchase of quality vaccineswith use of internationalprocurement mechanism

Yes All the vaccine have been procuredthrough UNICEF

_______________________________________________________________________

37

Dimension ofFinancialSustain-ability

Indicator Unit Explanatory Notes


Existence of an accountingsystem for the immunizationprogram where expenditurescan be disaggregated byactivity

Yes The introduced EPI budget linesshow specific activities, which willensure the risk of funds beingdiverted to other expenditure areasis, reduce.


Trends in wastage rates overtime

The wastage rates will be monitoredas this will result in cost savings.


Trends of vaccine stock-outs byregion

Number, The vaccine stock outs will bemonitored.

Reliability ofResources

Share of actual domesticexpenditures on recurrentcosts of immunization programover recurrent amountbudgeted/allocated

The share will be monitored to reveal anyserious variances.

Reliability ofResources

Share of actual domesticexpenditures on capital costs ofimmunization program overthe amount budgeted forcapital costs.

The share will be monitored to reveal anyserious variances.

Self-sufficiency Share of caretakers (mothers,fathers and guardian)knowledgeable about at leastone benefit of immunizationservices

Knowledge, attitude and practice (KAP)studies will be undertaken

Self-sufficiency Plan of Action onCommunication for Demandcreation implemented

Yes In order to increase demand forimmunization (and hence improvedcoverage) communication strategies havebeen implemented and will be evaluated toassess their effectiveness.

_______________________________________________________________________

38

7 STAKEHOLDERS ENDORSEMENT

We, the undersigned members of the Inter-Agency Coordinating Committee endorsethis Financial Sustainability Plan. Signatures of endorsement of this document donot imply any financial (or legal) commitment on the part of the partner agency orindividual.

Agency/Organization

Name/Title Date Signature

Chairman, ICC Dr Richard O. Muga

British DFID Ms Trisha Bebbington

WHO- Kenya Dr Peter Eriki

UNICEF- Kenya Dr Nicholas Alipui

CIDA- Kenya Ms Eleanor Rose

JICA Mr Masaaki Otuska

PATH Ms Michelle Folsom

UNFPA Dr Sidiki Coulibaly

CHAK Dr Samuel Mwenda

USAID Mr Victor Masbayi

Commentaries:

_______________________________________________________________________

39

8: Preparation and Review Teams:

(A) National Technical Team:

1. Ms. A. G. W. Njiru - Chief Finance Officer (Chairperson) MOH2. Mr. S. N. Muchiri - Deputy Chief Economist “3. Mr. S. J. M. Kalama - Chief Health Administrative Officer “4. Dr. K. C. Koskei - Chief Pharmacist “5. Dr. T. Gakuru - Head, Health Sector Reform Secretariat “6. Dr. M. A. Hassan - Head, Preventive and Promotive Health Care “7. Ms. B. W. Gathirwa - Principal Accounts Controller “8. Mr. J. G. Kibera -Ag. Director, Kenya Medical Supplies Agency “9. Eng. M. Owino - Head, Dept. of Bio-Medical Engineering “10. Mr. J. M. N. Ole Kiu - Chief Clinical Officer “11. Mr. A. K. Langat - Chief Public Health Officer “12. Mrs. G. N. Kandie - Chief Nursing Officer “13. Mrs. A. Koori - Deputy Chief Economist MOF&P14. Mr. A. Runyago - Senior Economist “15. Mrs. G. C. Masese - MOLG16. Mr. Ng’ang’a - “17. Dr. S. Sonoiya - KEPI Manger (Secretary) MOH18. Dr. T. Kamau - Deputy KEPI Manager “

(B) Core Working Group:

1. Mr. G. M. Gachuhi Senior Health Administrative Officer (Team Leader) MOH2. Mr. G. Kimani Economist, Planning Dept. “3. Mr. D. Murigi - Accounts Dept. “4. Mr.M. Wheeler - DFID Consultant………5. Mr. A. Kimunya - DFID Consultant 6. Mr. S. M. Kamau - National Logistician, KEPI Management Unit “7. Mr. A. Chewya - i/c Central Vaccine Stores “ “8. Mr. A. Noor - Health Administrative Officer “ “9. Dr. J. Songa - WHO Kepi officer10. Dr. A. Munyiri - UNICEF Programme Officer

MINISTRY OF HEALTH · The estimated cost of KEPI was US$ 17.75 million for the year 2000 with vaccines costing $ 3.3 million or 18% of the total programme costs. Personnel emoluments

Documents