Bosnia and Herzegovina THE FINANCIAL …...Bosnia and Herzegovina THE FINANCIAL SUSTAINABILITY PLAN THE FINANCIAL SUSTAINABILITY PLAN v 1.23 ICC 1 Bosnia and Herzegovina version “FSP

Bosnia and Herzegovina THE FINANCIAL SUSTAINABILITY PLAN

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v 1.23 ICC

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TABLE OF CONTENTS Executive Summary......................................................................................................4 Section 1. Impact of Country and Health System Context on Immunization

Program Costs, Financing and Financial Management .......................6 1 Summary ........................................................................................................6 2 Country profile...............................................................................................6 3 Description of the health care system ............................................................6 4 Financing and financial management ............................................................7

4.1 The Federation of Bosnia and Herzegovina.......................................................8 4.2 Republika Srpska ...............................................................................................9

5 Health care reforms......................................................................................10 5.1 Overview..........................................................................................................10 5.2 The Federation of Bosnia and Herzegovina.....................................................11 5.3 Republika Srpska .............................................................................................12

Section 2. Program Characteristics, Objectives and Strategies ..........................16 1 The Federation of Bosnia and Herzegovina.................................................16

1.1 Immunization coverage....................................................................................19 1.2 Reporting of vaccine preventable diseases ......................................................20 1.3 Recommended actions .....................................................................................21

2 Republika Srpska .........................................................................................21 2.1 Immunization coverage....................................................................................23

Section 3: Current Expenditures and Financing ..................................................24 1 Summary ......................................................................................................24 2 The Federation of Bosnia and Herzegovina.................................................25

2.1 Introduction......................................................................................................25 2.2 Cost structure ...................................................................................................25

2.2.1 Vaccines ........................................................................................................... 26 2.2.2 Personnel.......................................................................................................... 27

2.3 Major trends .....................................................................................................27 3 Republika Srpska .........................................................................................29

Section 4: Future Resource Requirements and Program Financing / Gap Analysis ...................................................................................................33 1 Summary ......................................................................................................33 2 The Federation of Bosnia and Herzegovina.................................................33

Bosnia and Herzegovina THE FINANCIAL SUSTAINABILITY PLAN v 1.23 ICC

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2.1 Basic scenario ..................................................................................................34 2.1.1 Resource requirements ..................................................................................... 34 2.1.2 Funding gap...................................................................................................... 35

2.2 Alternative scenarios........................................................................................36 3 Republika Srpska .........................................................................................37

3.1 Basic scenario ..................................................................................................38 3.1.1 Resource requirements ..................................................................................... 38 3.1.2 Funding gap...................................................................................................... 38

3.2 Alternative scenarios........................................................................................40 Section 5: Sustainable Financing Strategy, Actions and Indicators ...................42

1 The Federation of Bosnia and Herzegovina.................................................42 1.1 Review of major findings – SWOT analysis....................................................42 1.2 Strategy Options...............................................................................................43 1.3 Action plan and indicators ...............................................................................47

2 Republika Srpska .........................................................................................51 2.1 Review of major findings – SWOT analysis....................................................51 2.2 Strategy options ...............................................................................................51 2.3 Action plan and indicators ...............................................................................53

Section 6: Signatures and Stakeholder Comments...............................................55 A n n e x e s..................................................................................................................57

TABLE OF FIGURES Figure 1: Country profile...................................................................................................14 Figure 2: FBiH – Immunization calendar 2004.................................................................17 Figure 3: FBiH - Immunization Calendar 2005 ................................................................18 Figure 4: FBiH - Coverage rates of the immunization program for 2003.........................19 Figure 5: FBiH - Coverage targets by antigens .................................................................20 Figure 6: Vaccination schedule - RS.................................................................................22 Figure 7: BiH – past and current expenditures by entities ................................................24 Figure 8: FBiH - Cost Profile (Shares in %) .....................................................................26 Figure 9: FBiH - Trend in Past Cost by Category (US$ Millions)....................................28 Figure 10: FBiH - Trend in Past Financing by Source (US$ Millions) ..............................29 Figure 11: RS - Cost Profile (Shares in %) .........................................................................30 Figure 12: RS - Trend in Past Cost by Category (US$ Millions)........................................30 Figure 13: RS - Trend in Past Financing by Source (US$ Millions) ..................................31 Figure 14: RS – Financing of the NIP by sources in 2003..................................................32 Figure 15: FBiH – description of scenarios by....................................................................33 Figure 16: Projection of Future Resource Needs (US$ Millions) .......................................34 Figure 17: FBiH – Future Secure Financing and Gaps (US$ Millions) ..............................35 Figure 18: FBiH - Secure and Probable Funding and Gaps (US$ Millions).......................36 Figure 19 RS – description of scenarios.............................................................................38 Figure 20: RS - Projection of Future Resource Needs (US$ Millions)...............................38 Figure 21: RS - Secure and Probable Funding and Gaps (US$ Millions)...........................39 Figure 22: RS - Future Secure Financing and Gaps (US$ Millions)...................................40 Figure 23: FBiH – summary of findings (SWOT) ..............................................................42 Figure 24: FBiH – assessment of the strategy option 1 – “advocacy” ................................44 Figure 25: FBiH – assessment of the strategy option 2 – “efficiency” ...............................45 Figure 26: FBiH – optimal strategy.....................................................................................47 Figure 27 FBiH – action plan and indicators .....................................................................48


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Figure 28: RS – summary of findings (SWOT analysis) ....................................................51 Figure 29: RS - assessment of the preliminary strategy elements.......................................52 Figure 30 RS – action plan and indicators .........................................................................53 Figure 31: FBiH - past and current costs.............................................................................57 Figure 32: RS – past and current costs ................................................................................57 Figure 33: FBiH – future resource requirements.................................................................58 Figure 34: RS – future resource requirements.....................................................................59

Table 1: BiH – share of expenditures on vaccines in total NIP costs by type of entities,

type of vaccines and years .................................................................................24 Table 2: FBiH – costs of traditional vaccines by antigens and years...............................26 Table 3: FBiH – costs of most expensive vaccines by antigen and years........................27 Table 4: BiH – future resource requirements (in thousand US$).....................................33 Table 5: FBiH – comparison of alternative scenarios by future resource requirements by

years ...................................................................................................................37 Table 6 RS - comparison of alternative scenarios by future resource requirements by

years ...................................................................................................................40

LIST OF ACRONYMS

BiH Bosnia and Herzegovina

FBiH Federation of Bosnia and Herzegovina

FM Family Medicine

FSIF The Federation Solidarity Insurance Fund

HIF Health Insurance Fund

HSEP Health Sector Enhancement Project

MoF Ministry of Finance

MoH Ministry of Health

NIP National Immunization Program

RS Republika Srpska

SITAP Social Insurance Technical Assistance Project

VF Vaccine Fund


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Executive Summary The key program objectives of immunization programs in the Federation of Bosnia and Herzegovina and Republika Srpska are the maintenance of high level of coverage and improvement in quality and efficiency.

The macroeconomic growth prospect is conducive to the availability and allocation of public resources to health sector and preventive measures specifically. Moreover, the public spending on health care as a percentage of GDP is about 8 % while total spending, including out of pocket spending is among the highest in Europe – around 13%. Total nominal spending is not as high due to the low GDP

Both administrative entities of Bosnia and Herzegovina opted for social health insurance that finances curative and partly preventive medical services. Immunization is financed partly from the Health Insurance Funds (HIF) and partly from general resources.

The administration and financing of health care system is very complex due to the decentralization of the Federation of Bosnia and Herzegovina in 10 cantons with own health ministries and health insurance funds. The Federation Solidarity Insurance Fund was established to cover catastrophic risks as well as to finance some programs including immunization (to minimize inequality between cantons). The decentralization of health care system imposes high burden on the effective administration of the immunization program, including planning, storage and distribution of vaccines. The Institute of Public Health of the FBiH together with cantonal institutes of public health is in charge of the administration of the immunization program in the Federation. The administration is more straightforward in RS with centralized entities in charge of health policy development, financing of health care and implementation of the NIP.

Reimbursement of health care providers in both entities is not performance based and doesn’t include any incentives favorable for high immunization coverage.

Donor support (UNICEF and GAVI) is used to finance traditional vaccines and Heb B, while other new vaccines are procured by the government in the FBiH. The share of external financial support is quite low even after GAVI support (<6% in the FBiH and 20% in RS).

There are two main constraints associated with the budgeting and procurement: 1) the responsibility of the social insurance agents to finance the NIP, and 2) how the NIP budget is calculated, are not defined clearly in the legislation; In addition the new legislation on public procurement has not yet been applied regarding purchase of vaccines directly from UNICEF bypassing an obligatory tender procedure.

The total program cost in BiH was 2.34 million US in 2004: 1.46 million in the FBiH and 0.87 million US$ in RS. The expenditures on vaccines amounted to 1.18 million US$ - almost a half of the total program cost. The total NIP costs constituted 0.3% of the government health expenditures in RS and 0.4% in the FBiH in 2003. Cost per fully immunized child was 78 US$ in BiH and 56 US$ in RS in 2004.

The future total cost of the programs in both entities increases from 2.33 million US$ (3,72 million BAM) in 2004 to 2.93 million US$ (4,26 million BAM) in 2010 (according to the baseline scenario). The share of vaccine costs remains approximately 50%.

There is no funding gap during GAVI support and three years after the end of the support if both probable and secure financing is considered. If entities opt for more efficient scenarios the current level of government’s spending is enough to meet the future needs in vaccines and injection supplies.


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Therefore, the financial sustainability in BiH is understood as securing public resources (increasing its reliability) and improving both technical and allocative efficiency.

Priority elements of the financial sustainability strategy in both entities are as follows: • To ensure that responsibilities for the financing of the NIP are clearly defined in the

legislation and enforced • Vaccines are procured at the lowest cost (close to UNICEF rates) • Revision of the vaccine schedule is made primarily on the basis of cost-benefit analysis

One more strategy element particularly in the FBiH is social mobilization (continuous professional training and information campaigns) to avoid an explosion of negative public attitude toward certain antigens resulting in the failure of planned routine vaccination and/or introduction of extremely costly alternatives. Short and medium term activities to implement the financial sustainability strategies in each entity

include are shown in Figure 27 “FBiH – action plan and indicators” (on page 48) and

Figure 30 “RS – action plan and indicators” (on page 53).


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Section 1. Impact of Country and Health System Context on Immunization Program Costs, Financing and Financial Management

1 Summary • The main problem for the sustainability of financing of immunization programs is not as

much the lack of public resources as the low efficiency of their allocation due to: o the extreme decentralization of governance and financial management primarily in the

FBiH o ambiguity in responsibilities of relevant state agencies in the planning and financing

immunization program making the financing of immunization programs insecure o lack of link between ambitious objectives and realistic means of implementation,

along with a weak administrative capacity in public sector • The ongoing health care reform, namely the development of social health insurance and

family medicine may have a two-fold effect on the financial sustainability of the national immunization program: o Health expenditure in BiH is very high (~13% of GDP) but its sustainability is very

fragile. The health reform can have positive impact on the financial sustainability of the entire health sector if it addresses inter alia the following issues: a) fragmentation of health care delivery, b) inefficient allocation of resources and c) weak administration of the sector as a whole

o The introduction of family medicine may have positive effect on the immunization activities if effective reimbursement mechanisms are applied creating favorable incentives for the provision of preventive services and if immunization performance is seen and used as one of the overall quality indicators for primary health/ family medicine

2 Country profile Bosnia and Herzegovina comprises two entities: the Federation of Bosnia and Herzegovina (FBiH) and Republika Srpska (RS) with the population approximately 3.9 mln. There is also the independent administrative District of Brčko with the population of 90 thousand not subordinated to either entity. For the purpose of the FSP the District of Brčko will not be discussed separately since the calculations in the FSP will only be marginally affected by data from the District and it was considered in the calculation whenever possible.

The administrative division and governance practice is very complex and needs to be described briefly in order to understand how the health care system is managed and financed. Administratively the FBiH comprises 10 cantons while Republika Srpska is divided in 7 regions and there are 156 municipalities in total. There are 13 ministries of health: one in each of 10 cantons, one of the FBiH, one of the RS and the last one of the Brčko district. According to the Law on Ministries from 2003, the Ministry of Civil Affairs has a responsibility for coordinating health matters at the state level. Health sector is governed independently in each entity and its structure and financing differs significantly.

3 Description of the health care system Health care system is decentralized in the FBiH while it is centralized in RS.


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The responsibility to manage the health care system is shared between the central Ministry of Health of the Federation of Bosnia and Herzegovina and 10 cantonal Ministries of health. The central Ministry is located in Sarajevo and coordinates cantonal ministries of health who are responsible for the provision of primary and secondary health care in respective cantons. The central Ministry has no authority over the cantonal ministries and its competence is limited to policy making (monitoring of health outcomes, legislative activities, etc) and certain functions which can not be fulfilled by health administration at the canton level.

In contrary to the FBiH the health care system of Republika Srpska is managed by one agency – the Ministry of Health and Social Affairs located in Banja Luka responsible for planning and regulation.

The main similarity between health care systems of the FBiH and RS is that they both opt for a Bismarck model of financing. Compulsory health insurance contributions (from 15 to 18 percent of payroll) are channeled directly to health insurance funds. Similar to the administrative structure, there is one health insurance fund in RS with 8 regional branches, while in the FBiH each canton has its own health insurance fund plus one federal health insurance fund. Including the District of Brčko there are 13 health insurance funds in BiH.

Health authorities in the FBiH and RS have defined their own basic benefit packages, which are covered by the compulsory health insurance. The basic benefit package should be uniform assuring equal access to everybody across the Federation while in RS only insured will be eligible for the basic benefits and the government has to finance services for vulnerable groups. Basic packages have not been effectively put in place in either entity – they are still proposals waiting for the implementation. Although there are no hard data available, health insurance coverage seems to be an issue of growing importance. Informed opinion suggests that up to 20% of the BIH population has no health insurance.

Primary health facilities (health centers and stations) are owned by municipalities or in the case of F-BiH by cantons. They provide medical services necessary for immunization.

In the FBiH public health services are carried out and supervised by 10 cantonal and one federal Public Health Institute. Pediatricians and nurses at primary health care facilities provide the immunization services.

The three-tier public health network of RS consists of the pediatric and epidemiology services at primary health care facilities (responsible for vaccination), six regional public health institute in charge of epidemiological surveillance and the Public Health Institute of RS located in Banja Luka responsible for health planning, disease surveillance, supervision of immunization, etc.

The Public Health Institute has started an evaluation of the performance of health centers contracted by the Health Insurance Fund to implement the programs of prevention of non-communicable diseases. The results of the evaluation should determine the amount of funds to be paid by the Health Insurance Fund to its contractors for the specific preventive services.

4 Financing and financial management Fiscal management and planning is complicated by the high level of decentralization – 55% of budgetary expenditures are made at the local (cantonal and municipal) level in the FBiH, while it is only 22% in RS (municipal level) Budget planning process in BiH suffers from the following weaknesses: • Absence of a comprehensive resource framework for the budget; • Weak enabling framework for sound budget planning;


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• Weak capacity for budget and sector policy planning in the MoFs and line ministries; • Fragmentation in policy formulation and decision-making processes.

The development and endorsement of a Mid-term Development Strategy of Bosnia and Herzegovina (PRSP) this year is very important step forward and address most of the abovementioned weaknesses.

The Mid-term Development Strategy of Bosnia and Herzegovina (PRSP) for 2004-2007 (March 2004) calls for a 5-5.5% GDP growth rate to achieve 70% of the pre-war GDP by the end of 2007. Besides, it considers necessary to decrease total public expenditure from 46% to 43% of GDP by the end of 2007.

BiH health system still has serious, deep-rooted problems. These are reflected in its high costs: public spending on health was 7.7 percent of GDP in 2000, compared with a recent average for comparator Central and Eastern European Countries (CEEC) in transition of under 5 percent. In 2002, spending on health rose to 7.9 percent of GDP. These high averages are driven by the high costs of operating in the decentralized and fragmented structures of FBH, where spending rose from 8.4 to 9.1 percent of GDP. In contrast, health spending in the RS fell slightly, from 5.8 percent to 5.6 percent of GDP. When payments for private services and legally mandated co-payments for public services and other out-of-pocket payments are included, total costs are still higher. As a result, financial sustainability of the system remains a serious issue. Achievements in health finance have also been limited.

4.1 The Federation of Bosnia and Herzegovina Health care budgets are prepared by canton health insurance funds in the FBiH (a so called compulsory insurance scheme financial plan) and submitted to cantonal ministries for the approval. In case of funding deficit the gap is supposed to be covered by canton and municipal budgets.

Payment schemes vary across cantons. In some cases the payment is made based on the services delivered by an institution covers by the health program. In other cantons health insurance fund covers all expenses including operational and salaries. Finally, the payment could be also made based on standards and norms.

Financing of health services by the Federation Solidarity Insurance Fund is done on a case-to-case basis for individual health services. The issue of designating the general budget managed by the MoF or the Federation Solidarity Insurance Fund (under the auspices of the MoH) for the financing of direct routine costs (such as vaccines) is not finalized (and fixed as a policy decision). Considering very high public expenditures financed from insurance contributions the MoF is reluctant to provide extra financial support from the budget. Besides, the MoF is in charge of financing other competing priorities in the intense development period. Therefore, if the responsibility to finance immunization lies again with the MoF it may threaten the financial sustainability of the NIP.

Health insurance funds pay a fixed amount of money for the services included in health programs regardless of their true cost or calculations made by the health care institutions.

Health care organization's are compensated either by unit of service or by the cost of the agreed (or approved) program. Existing payment mechanisms do not encourage health care providers to improve either quality of services or efficiency. However, some new approaches to the reimbursement of family medicine services are introduced in pilot areas under the World Bank supported SITAP project. The piloted payment mechanisms create an opportunity to generate incentives among family practitioners concerning immunization. Therefore, if the needs of the NIP in terms of assuring high coverage are considered properly


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during the transformation from the specialized immunization services to family medicine, it can have positive impact on the achievement of the NIP objectives and sustainability. A new project supported by the WB (Health Sector Enhancement Project) intends to replicate the piloted payment schemes all over the country (see more details in sub-section 5 “Health care reforms” on page 10). Therefore, there is enough room and right time to bring the needs of immunization into policy making process and assure that proper incentives and financing mechanisms critical for immunization are embedded in the reform policy. From the standpoint of the financial sustainability of the NIP it calls for more active participation of all stakeholders concerned in immunization in the reform processes (through advocacy and policy advice).

It is rare that cantonal insurance companies evaluated the volume and quality of services provided under the contract to insured persons because they don't have enough qualified staff to carry out these tasks.

Health care institutions (hospital, health centers/stations) have branched collective bargaining agreements on the rights and obligations of employees and employers in health sector with the approval from trade unions and employees of each institution that provides a framework for the regulation of all aspects of labor relationships including the level of basic wage, the methods of adjustments of wages, evaluation of complexity of jobs, determination of methods of calculation of work history, etc. On the basis of the branch bargaining agreement each institution prepares its own internal rulebook on operations and systematization of jobs (job descriptions, performance appraisal, and salary rates). Therefore each institution decides itself how much and which way their medical and non-medical staff can be paid. Therefore the employees have basic wages plus compensations corresponding to the complexity of their work and special circumstances (like a night shift) and bonuses to create motivations linked to performance and quality of work. The bonuses are proposed by immediate supervisors or directors.

The actual wage is calculated by applying agreed coefficients to the reference bases (average salary). The actual wage can depend upon the availability of resources of health care institution, sources of funding from cantonal insurance fund and own sources.

Public health institutes prepare their budgets and negotiate every year with the cantonal insurance funds. The budgets are constructed considering the following factors: the amount of resources allocated to the public health/preventive programs by the health insurance fund; projected revenues from own sources/services.

The Federal Public Health Institute as well as two other state health institutions (Institute of Drug Control and Institute of Transfusion Medicine) is mainly financed from the federal budget. However, the Federal Public Health Institute covers 35% of funding through revenues from its own services.

4.2 Republika Srpska Health care in the Republic of Srpska is financed through the RS Health Insurance Fund. The planned revenues from the contributions were 180 million BAM (120 million US$) in 2004. The government of RS (the Minister of Finance?) had to transfer from the state budget to the RS Health Insurance Fund 18 million BAM (12 million US$) to cover the cost of medical services for special categories of uninsured population (military invalids, refugees and IDPs and the unemployed registered with the Employment Fund. 17 700 000 KM has been spent.

The Health Insurance Fund allocates funds for the procurement of vaccines based on the request of the Public Health Institute (on annual basis) plus contracts the institute to cover


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costs of handling and distributing vaccines. Other costs necessary for the immunization are integrated in the payments for preventive and primary care services made by the Health Insurance Fund to health centers and stations. The health insurance fund pays primary health care institutions a fixed amount of money based on the number of insured living in the catchment area. The payment is not linked to either inputs or work load/performance such as a number of registered insured, number of visits, etc.

The Health Insurance Fund contracted suppliers for the procurement of vaccines at the value of 435 thousand BAM (~290 thousand U$) in 2004. The RS Health Insurance Fund and the RS Public Health Institute signed a contract for 2004 in which inter alia the Fund is committing to pay 56,000 BAM (40 thousand US$) to the Institute for the storage and distribution of vaccines to regional offices. Medical institutions are in charge of the transportation of vaccines from the regional offices of the Public Health Institute.

The Public Health Institute in RS has three sources of financing: up to 16% of the financing comes from the state budget, approximately a half of financing (48%) is generated through the provision of services (such as microbiological tests, inspection of water, air, food, etc) and 36% of funds were received from the RS Health Insurance Fund (in 2003 and 2004).

For 2005, the RS Public Health Institute submitted to the Ministry of Health and the RS Health Insurance Fund the request to allocate 600,000 BAM (400,000 US$) for vaccines for all children, regardless of whether they are covered by the insurance or not.

5 Health care reforms

5.1 Overview Over the past several years, both entities have initiated wide-ranging reforms in the health sector aimed at increasing sectorial efficiency, strengthening financial sustainability, and improving quality of care. Today, reforms in the health sector are more advanced than in the other social sectors. This includes introduction of solidarity funds, establishment of cantonal health insurance funds, introduction of a new contracting mechanism in pilot areas, development of a family medicine delivery model etc.

These efforts notwithstanding, prevailing weaknesses in efficiency, equity, and quality of health services call for deeper reforms. Key issues include: • limited institutional capacity and institutional fragmentation; • financial instability • inefficient service delivery • Unequal access to health care

While many countries initiate their reforms from the secondary care level, BIH opted to start the reform at the primary health care (PHC) level largely because of high political divisions that prevented rationalization of hospital services in the past. The model of health care of former Yugoslavia, fostered over-specialization in PHC giving prestige to specialists over general practitioners. It also gave prestige to the hospital sector over PHC.

Development of a PHC system based on Family Medicine started in 1995 with multiple agencies and donors providing training of different quality to the doctors in PHC. This diversity was resolved under the World Bank-financed Basic Health Project (BHP) when the whole country introduced a single curriculum with the same educational standards. Today, acceptance of the family medicine (FM) model has grown well beyond the demonstration sites supported by the BHP. The model of PHC based on fragmented specialists care in the primary health care settings simply does not allow for further integration among different


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levels of care. The FM approach to PHC is providing the foundation for resolving inefficiencies in service delivery and particularly in respect to the continuum of care. The FM system is expected not only to ensure adequate primary care, but also to promote patient management, practice effective referrals and thus help render the system more cost-effective.

The key elements of the Government’s health strategy are outlined in the PRSP approved in 2003, which defines the medium and long-term priorities for the sector. While expanding family medicine is at the core of the Government’s reform agenda, the Government recognizes that it must pursue a comprehensive approach to PHC in parallel with hospital restructuring and creating the interface between primary health care and higher levels of care. The key elements of the PRSP strategy are: • Reform of primary health care through the concept of family medicine • Reform of health financing system to promote equity and quality • Ensuring the quality of health care services • Strengthening of the role of public health and multi-sectoral cooperation • Human resources development • Reform of the pharmaceutical sector through establishment of a regulatory drugs body at

the State level

Entity specific health system reform issues are discussed below.

5.2 The Federation of Bosnia and Herzegovina Problems of the health care system to be addressed by the health care reform in the FBiH are as follows: • Insufficient coverage of health insurance and low control on collection of premiums • Loose functional links between health care systems of cantons and entities • Low allocative efficiency • Ineffective organization and delivery of medical services • Weak legislative basis for health care and threat of potential corruption in the system

The following priorities were identified for the health care reform respectively: • Develop legislation to extend and strengthen solidarity system • Assuring portability of health insurance across the federation • Implementation of new mechanisms for the allocation of resources • Rationalization of the network of health care providers • To carry out reform of primary care toward the establishment of family medicine • To implement necessary reforms in specialist-consultative services and ensure seamless

flow of patients through the system (primary/secondary interface) • To reform pharmaceutical sector • Strengthen the public health and multi-sectoral partnership • Stimulate further development of human resources • Assure quality health services

The health reform policy is to introduce a family practice as a conceptual basis of primary care. The family practice will be in charge of preventive, diagnostic and therapeutic and rehabilitative activities of health care, which entails allocation of larger share of resources to this level. Family medicine is piloted in some administrative units locally. The reform will take certain time because of needed investment in amount of 32 million US$ for the


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rehabilitation of medical institutions, installation of new medical equipment and education of medical personnel.

5.3 Republika Srpska On June 25th 1996, the National Assembly adopted the Development Strategy for Health Protection until 2000. The Strategy had determined 14 goals in the area of health and health protection. In 1999, the Law on Health Protection and the Law on Health Insurance were adopted, and in 2001 the Law on Medicines, the Law on Medical Chambers, the Law on Protection from Ionizing Radiation and the majority of envisaged bylaws were adopted.

Results achieved in the implementation of the goals of the Strategy are not satisfactory in the area of primary health care, reorientation of health services to the improvement of health and prevention of diseases and reorganization of hospital health services. The process of introduction of family medicine, as the incumbent of primary health care is unraveling at a slow pace, and the reform of the education system for health workers has also been delayed.

On September 20th 2002, the RS National Assembly adopted the Program of Health Policy and Strategy for health in the Republic of Srpska until 2010, in order to ensure that the problems whose resolution was envisaged by the Development Strategy until 2000, and that have not been resolved or have been resolved only partially, are resolved now as a matter of priority in the coming developmental period.

One of the main strategies within that Program is the Strategy for the reduction of differences in health status and accessibility of health care to the population.

In the first phase, i.e. in the first five years, conditions need to be created in order for the services of family medicine and primary health care as a whole are equally accessible to all inhabitants of RS, and in the second phase the differences are to be reduced in other modes of health care also.

Objective No. 9 of the main strategy is Financing health protection and allocation of resources. Within this aim: • The level of costs of health protection shall be adjusted to actual demand and possibilities

and the sources of financing from contributions, budget, sales tax on damaging substances and personal participation in costs of health care shall be ascertained.

• Allocation of resources shall be executed in accordance to priorities and on the basis of the principle of equal provision of costs per inhabitant in primary health care, and balances of ratios of primary health care, specialist and hospital services.

• The financing of health care shall be linked with performance, expressed as the result of health measures and services, i.e. the quality, efficiency and cost-effectiveness.

In order to fulfill that objective: • When adopting the budget, The RS Government shall determine the overall level of

resources for health care from contributions and other legally stipulated sources, together with giving its approval on the level of funds planned for health needs within the minimal package of basic health care, and on the provision on personal participation in costs of health care adopted by the Management Board of the Health Insurance Fund.

• The method of contracting health care and the price of hospital services shall be determined equitably by the Health Insurance Fund and medical chambers,

• Investments for health institutions and the introduction of new health technologies shall be realized in compliance with the midterm plan of the Ministry of Health and Social Protection and upon an approval of that Ministry.


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A new law on health insurance is under preparation. The law will define what are the obligations of the health insurance, how priorities are set and how allocation of funds will be consistent with these priorities. It is expected that the law will have positive impact on the financing of immunization program in terms of moving from ad-hoc decisions/allocation of resources to more long-term and secure financing.


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Figure 1: Country profile

1999 2000 2001 2002 2003 2004 2007

The Federation of Bosnia and Herzegovina

Population (millions) 2.315 2.323

GDP (in million BAM – current prices) 7,274 7,943 8,224

GDP per capita 2,577 3,142 3,419

% of GDP growth, in nominal terms

% of inflation

% of GDP growth, in real terms

Average net wages in BAM

Public health expenditure (in planned)1 367.6 486.1

Public health expenditure per capita ($) 88.0

Public health expenditures as % of GDP 8.0 8.79 9,46

Total health expenditures as % of GDP 8.8 9.5

P. Health expend. as % of state (entity) budget

Republika Srpska Population (millions) 1.43 1.43 1.45 1.45 1.5

GDP (in million BAM – current prices) 2,462 2,734 2,978 3,417 3,588 4,687

GDP per capita 1,722 1,912 2,054 2,348 2,392

% of GDP growth, in nominal terms 25.8 11.0 8.9 14.2 5.0

% of inflation 14.0 16.1 2.2 2.4 1.8

% of GDP growth, in real terms 11.8 -5.10 6.7 12.4 3.2

Average net wages in BAM 216 299 305 356 379

Public health expenditure (planned)1 132

Public health expenditure per capita ($) 49.7 88

Public health expenditures as % of GDP 6.7

Total health expenditures as % of GDP

P. Health expend. as % of state (entity) budget

Bosnia and Herzegovina Population (millions) 3.765 3.823

GDP (in million BAM – current prices) 10,691 11,531 12,9112 16,040

GDP per capita 2,840 3,016

% of GDP growth, in nominal terms 4.7 6.1 7.7

% of inflation

% of GDP growth, in real terms 3.5 5.1 5.5

Average net wages in BAM

Public health expenditure (planned) 1

1 in million US$ 2 Exchange rate in 2002: 1 US$ ≈ 2.1 BAM; 2003: 1 US$ ≈ 1.7 BAM; 2004: 1 US$ ≈ 1.5 BAM


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1999 2000 2001 2002 2003 2004 2007 Public health expenditure per capita ($) 114.9

Public health expenditures as % of GDP 8.5

Total health expenditures as % of GDP 13.0

P. Health expend. as % of the state budget


16

Section 2. Program Characteristics, Objectives and Strategies

1 The Federation of Bosnia and Herzegovina The strategy of controlling contagious diseases that can be prevented through immunization has a long tradition in BiH. Mandatory immunizations are administered against the following diseases: tetanus since 1946, diphtheria since 1948, whooping cough and polio since 1961, measles since 1971, mumps and rubella since 1980. A two-dose schedule of MMR was used until the war and then discontinued partly due to conflicting international recommendations regarding M and MMR schedules. With the objective of improving the protection of children, revaccination of seven year olds with the MMR vaccine was introduced in 2002. Hep B vaccination was introduced at 7 years of age in 1999, neonatal Hep B vaccine in May 2004. Hib vaccine was introduced in 2002. High coverage of immunization has, together with high quality vaccines, resulted in the eradication of polio (last case was registered in 1974), diphtheria (last case in 1980). Neonatal tetanus has not been registered in the last twenty years, and the number of patients suffering from measles and whooping cough is miniscule.

The immunization program falls under the scope of authority of the Federal Ministry of Health, Federal Health Insurance Fund and the Public Health Institute of the Federation of Bosnia and Herzegovina. The Decree on the program of Mandatory Immunizations of Population against Contagious Diseases, issued by the Ministry of Health each year, on the basis of the proposal of the Public Health Institute of the Federation of Bosnia and Herzegovina, stipulates the Immunization Program (determines the schedule of immunization, contraindications, the method of immunization provision, as well as the authorities of health institutions).

The Law on Health Protection assigns authority over the management of the immunization program to the Public Health Institute of the Federation of Bosnia and Herzegovina. The implementation of the Immunization Program is an obligation of the cantons (10), and responsible pediatricians and medical staff of all municipalities in FBiH.

The basic tasks of the National Immunization Program are as follows: • Achieving and maintaining a high level of coverage with vaccines from the program

(focused on children under five years of age, i.e. children under one year of age) • Reduction of morbidity and mortality caused by vaccine preventable diseases (VPD) • Eradication of measles • Control of whooping cough, severe cases of childhood tuberculosis, rubella including

Congenital Rubella Syndrome (CRS), mumps, hepatitis B and invasive diseases caused by Haemophilus influenzae type b (Hib)

• Ensuring safe injections • Reduction of wastage rates • Reliable functioning of the cold chain

During the post-war period the immunization program has been implemented without major interruptions until June 2002, when media in FBiH initiated a series of articles questioning the use of UNICEF vaccines, particularly questioning the quality of the EUVAX vaccine, produced in Korea, followed by concerns about the unusual packaging of a DTP vaccine from CSL, Australia, and a case of encephalitis following the immunization with that vaccine. The authorities withdraw the CSL vaccine and procured limited quantities of acellular DTP vaccines and mono-dose acellular DTP vaccines were introduced for


17

revaccination. Although it was found that case of encephalitis was coincidental or at least not linked to any inferior quality of the CSL vaccine, the anti-immunization campaign in the media continued for a prolonged period, and that resulted in a significant disturbance in the operations of the immunization services in the Federation. Due to this crisis in the immunization program the Minister of Health, in April 2003 invited the WHO Office for Europe to coordinate a management review of the immunization program (IPMR).

The management review of the immunization program for children in FBiH was executed between June 2nd and 10th 2003 by experts from the Federation, from the Ministry of Health and cantonal institutes for public health, together with the representatives of WHO, UNICEF, the World Bank and CDC. The commission observed both weaknesses and advantages in program management and coordination and provided conclusions and recommendations.

In relation to management and coordination, key issues were • the introduction of new antigens in the immunization program, without prior analysis of

financial sustainability, • difficulties in the assessment of the target population, • large variation of vaccination coverage in different Cantons • individuals responsible for the program tend to be overburdened, etc.

Pursuant to the recommendations of the management review of the immunization program, positive steps were made: such as, preparatory measures for the introduction of the neonatal Hep B vaccine, appointment of a contact person for immunization at the Federal Ministry of Health, establishment of an Independent Advisory board for Immunization to the Federal Ministry of Health, appointment of– cantonal and municipal EPI coordinators, appointment of persons responsible for immunization in hospitals and maternity wards. On the federal level, a person responsible for the cold chain was appointed. Scientific and technical debates on the introduction of the neonatal Hep B vaccine were resolved, and the Decree on mandatory Immunizations was reviewed, the list of contraindications was revised. A new schedule for immunization was recommended, according to which one dose of Hib vaccine and one dose of DTPa vaccine were reduced. The immunization schedule for 2004 is shown in Figure 2 (below). Figure 2: FBiH – Immunization calendar 2004 Upon birth Hep B dose 1 + BCG at birth (Hep B in the first 12-24 hours)

1 month Hep B dose 2

2 month DTP1 OPV1 Hib1

3-4 month DTP2 OPV2 Hib2

6 months DTP3 OPV3 Hep B 3

12 months MMR

18 months OPV + Hib 3

5 years DTPa OPV

6 years MMR

7 years Hep B 3 doses (0,1,6)

14 years Td OPV + Ru (girls)

18 years T


18

Furthermore, based on recommendations from the review, the Federation Solidarity Insurance Fund (FHIF) is now responsible for financing procurement of vaccines for whole Federation starting January 1 2005.

In 2005 the seven year Hep B vaccination will be discontinued since the successful introduction of the neonatal Hep B vaccination has made the pre-adolescent progra superfluous, and efforts to establish and retain high coverage in this age cohort is judged to be not cost-effective. The immunization schedule (see Figure 3) should not be amended in the coming five years, and there are no planned introductions of new antigens according to the Federal EPI manger. Figure 3: FBiH - Immunization Calendar 2005 BCG Hep B DPT Polio MMR DT T Rubella Hib

Upon birth

1 month

2 months

3-4 months

6 months

X12 months

18 months

5 years 3 6 years

14 years 4

18 years

In the course of the previous year a lot has been done on improving the quality of reporting, a set of educational seminars were held, a new form of reporting has been proposed, in accordance with the immunization schedule and target age groups. Introduction of new reporting system in FM clinics, as part of contracts monitoring, is expected to further enhance reporting.

Provision of vaccines is executed in compliance with the recommendations of WHO consultants – supply of vaccines for six months on the Federal level with reserves sufficient for three months, supply of vaccines for three months on the cantonal level with reserves sufficient for 1.5 months, supply of vaccines for one month on the municipal level with reserves sufficient for 15 days. A new form has been introduced in order to facilitate the management of inventories and analysis on all levels. Namely, standard factors of distribution have been used: 1.25 for multi-dose packages and 1.05 for mono-dose packages. New forms have been introduced for reporting on consumption, distribution and inventories of vaccines in the field. The objective is to establish actual distribution factors in the coming years and to permit analysis of the reason for stock-outs and surplus stocks.

Adjustments of the cold room on the federal level were made, and another cold room has been opened facilitated in Mostar. A freezer for OPV has been procured in the Public Health Institute of FBiH. Some cantons still lack freezers for storage of OPV, otherwise the capacity 3 DTPa 4 Girls


19

of the cold chain on the cantonal level is satisfactory. Training courses on the management of inventories and the cold chain were held on the Federal level and in all cantons in FBiH.

Waste disposal has not been resolved.

The procurement of vaccines is executed by the procurement Commission of the Federal Ministry of Health through tenders. The Ministry of Health purchases most vaccines used in the program, while UNICEF only have provided the basic vaccines BCG, DTP and OPV. Syringes and needles for immunization are provided by cantonal funds. In the course of 2004, GAVI provided a share of AD syringes and safety boxes. GAVI has been providing the second and the third doses of the infant Hep B vaccine since May 2004. The procurement of vaccines is executed in compliance with the plan of the Public Health Institute of the Federation of Bosnia and Herzegovina, with the aid of a calculation tool provided by WHO, in 2004 including the building of a 25% vaccine stock reserve, based on official statistical data.

1.1 Immunization coverage Reports are prepared in immunization centers. The annual report on mandatory immunizations in the Federation of Bosnia and Herzegovina is based on evaluated reports provided by cantonal public health institutes.The planned number of immunization doses has been inexact due to the lack of any census of the population since 1991. Therefore the target group for immunization is a mere estimate.

The immunization program in FBiH in 2003 was implemented in accordance with the Decree on Mandatory Immunization with certain amendments in comparison with the preceding year. According to the decision of the Commission for Contagious Diseases of the federal Ministry of Health, immunization against the Haemophilus influenzae type b has been introduced and one revaccination against polio was phased out.

Reported vaccination coverage for 2003 is given in Figure 4 below. Figure 4: FBiH - Coverage rates of the immunization program for 2003 Type of vaccine Planned Vaccinated Coverage BCG 23078 21078 91.3% DTP/OPV /Hib 24085

DTP 1 22476 93.3% DTP 2 21883 90.9% DTP 3 19977 82.9% OPV 1 22333 92.7% OPV 2 21868 90.8% OPV 3 20418 84.8%

MMR 24534 20486 83.5% HEP B 1 34186 27591 80.7% HEP B 2 26972 78.9% HEP B 3 22181 64.9% Hib 1 21332 88.6% Hib 2 17089 71.0% Hib 3 7688 31.9%

Several facts have had an adverse influence on the implementation of the immunization program in 2003:


20

• In the course of the year, the field has not been provided with necessary vaccines continuously.

• The delivery of UNICEF’s vaccines was delayed by months. • The procurement of vaccines by the FBiH Ministry of Health met with certain difficulties. • In Sarajevo Canton, an unusually high number of post-vaccination parotitis was reported

after the second dose of MMR vaccine.

Because of the aforementioned difficulties, the target coverage with EPI vaccines has not been achieved. The average coverage with the BCG vaccine is below 95% (91.2%).

The coverage with three doses of the DTP vaccine in the area of the Federation amounted to 82.9%. The lowest coverage rate of that vaccine was registered in the area of Posavina Canton (63%).

The average coverage with all three doses of oral polio vaccine in FBiH amounted to 85%, which is also significantly below the target set by the WHO.

The average coverage with the vaccine against measles, rubella and parotitis in 2003 amounted to 84%. The highest percentage of immunized persons was achieved in West-Herzegovina Canton (95%), while the lowest percentage was registered in the area of Sarajevo canton – 68%.

There were also difficulties in the implementation of vaccination against hepatitis B in grade one of primary school, related to timely delivery, so that the coverage with three doses of Hep B vaccine amounted to 72%.

The vaccination of children against Haemophilus influenzae type b started relatively late, so that an entire annual cohort of children of under one year of age was unable to receive the third dosage of the vaccine therefore it was administered to only 33% of the cohort.

The objective of the program is to achieve high coverage for traditional antigens as shown in Figure 5: Figure 5: FBiH - Coverage targets by antigens Type of Vaccine 2005 2006 2007 2008 2009 2010 2011

BCG 95% 97% 98% 98% 98% 98% 99% DTP(1) 92% 95% 96% 97% 97% 97% 98% DTP(3) 92% 95% 96% 97% 97% 97% 98% TT 92% 95% 95% 95% 95% 95% 95% OPV(1) 95% 97% 98% 98% 98% 98% 99% Td 92% 95% 96% 97% 97% 97% 98% DTPa 92% 95% 95% 95% 95% 95% 95% Rubella 40% 40% 40% 40% 40% 40% 40% Hep B Mono 92% 95% 96% 97% 97% 97% 98% Hep B 95% 95% 95% 95% 95% 95% 95% Hib 92% 95% 96% 97% 97% 97% 98% MMR 92% 95% 95% 98% 98% 99% 99%

1.2 Reporting of vaccine preventable diseases The monitoring of diseases that can be prevented through immunization is part of the mandatory reporting of contagious diseases, except for congenital rubella and Hib invasive disease. Standard forms, recommended by the WHO, are used for reporting on AFP and


21

measles. Cantonal public health institutes use data based on reported cases of VPD from the level of hospital centers, in order to prepare weekly bulletins that are then submitted to the Federal Public Health Institute. The Federal Public Health Institute analyses the data and publishes weekly, monthly and annual reports on contagious diseases. However, laboratory certification of VPD cases is limited. The country lacks a referral virological laboratory, and therefore most often the disease is not confirmed by laboratory testing. The rate of detection of AFP cases is low < 1/100.000 of children under 15 years of age. Stool samples for AFP monitoring are sent to Rome, while hepatitis B diagnostics are available in large clinical centers only. A relatively low incidence of measles, rubella and whooping cough is registered in FBiH. In the previous period (1997-2002) epidemics of measles and mumps had been registered only in the part of the country where there was lack of MMR vaccines occurred during the war and in the post war period.

1.3 Recommended actions As identified in the IPMR most of the problems in immunization are due to system problems that have required some immediate actions to improve the program in the short term. However, the major structural problems are to be addressed through the reform of the health sector.

The strategies shall require: • Facilitation on daily provision of services to the envisaged population, as well as the

provision of vaccination services to the population that has immigrated or that comes from the other entity. Also, immunization in areas with low coverage of EPI antigens. Monitoring of occurrences of diseases that can be prevented through immunization enables the discovery, notification, examination and documentation of any and all potential cases presented on any level.

• The plan for information and communication based on positions and practice of the population and of the health workers in regards to the vaccination, with the usage of educational materials and social engagement, communication ad mobilization of the society.

• Guaranteed annual budgets of required funds for vaccines (continual supply of high quality vaccines – timely procurement, inventories on all levels) - strengthening of procurement procedures for vaccines.

• Implementation of safe vaccination practices and provision of necessary materials. • Improvement of staff capacities on all levels through training.

2 Republika Srpska The Strategy of vaccine-preventable disease (VPD) control has a long tradition in BiH. Mandatory immunization has beee carried out for the following diseases: tetanus from 1946, diphtheria from 1948, perttusis and polio from 1961, measles from 1971, mumps and rubella from 1980. Two-dose MMR vaccination program has been implemented since 1989. It was interrupted during the war anf for a period of 3 years thereafter, when measles (M) and MMR vaccines were used in the immunization program. In order to protect children better, MMR vaccination and revaccination were reintroduced in 1999. Hepatitis B vaccine for infants was introduced in 2001.

The Ministry of Health of Republic of Srpska has appointed the National PHI of RS, by the Decree on mandatory immunization, as the institution responsible for purchase, storage, and distribution of vaccines, as well as for the implementation of immunization program. The PHI has an obligation to report all activities to Ministry of Health on a regular basis.


22

Main tasks of immunization program are as follows: • Achieving and maintaining high coverage of program vaccines (focus on children under 5

years of age), • Reduction of morbidity and mortality of VPD • Elimination of measles and Congenital Rubella Syndrome • Control of pertussis, severe cases of TB in children, rubella, mumps, hepatitis B , • Enabling safe injections • Reduction of vaccine waste • Reliable functioning of cold chain.

From 2005, vaccine supplies are distributed in accordance with WHO Consultant’s reccommendations – biannual supplies on entity level, with 3-months stock, quarterly supplies on regional level, with 1,5-months stock, monthly supplies on municipality level, with 2-weeks stock. A software system of vaccine distribution will be introduced.

Figure 6 , below, shows the current vaccination schedule in Republik Srpska. Figure 6: Vaccination schedule – RS BCG Hep B DPT Polio MMR DT T Pertusis

Upon birth

1 month

3 months

4 months

6 months

12 months

18 months

4 years

6 years

7 years

14 years

18 years

On September 20th 2002, the RS National Assembly adopted the Program of Health Policy and Strategy for health in the Republic of Srpska until 2010.

Objective No. 5 within the main strategy is the Prevention and control of contagious diseases, in relation to VPD specifically:

Elimination of measles and CRS as well as Hepatitis B in children.

The institution responsible for the task: the Ministry of Health and Social Protection, the RS Public Health Institute and the Health Insurance Fund. .


23

2.1 Immunization coverage Reports are prepared in the immunzation centres. Planning of the number of children to be immunized is difficult due to lack of census since 1991. Therefore, target population figures for imunization are only an estimation. Population displacement after the war contributes to lack of reliability of the estimated figures. Most of people that moved into certain areas are not included into the denominators. In areas bordering SCG, children who are born in SCG are not included in denominator figure for neonatal BCG and Hepatitis B vaccines, but are included into figures for following doses.

Annual report on mandatory immunization in RS is based on evaluation of reports submitted by regional PHIs.


24

Section 3: Current Expenditures and Financing

1 Summary The total cost of the NIP increased by 28.4% in 2003 compared to the previous year – from 1.61 in 2002 to 2.06 million US$ in 2003 as shown in Figure 7 below. Figure 7: BiH – past and current expenditures by entities5

$1.01$1.36 $1.46

$0.59

$0.70$0.87

$-

$0.50

$1.00

$1.50

$2.00

$2.50

2002 2003 2004

Mill

ions

RS

FBiH

The overall increase was due primarily to higher costs of vaccines in the FBiH offset by the decrease in cost of NIP (regardless GAVI support). Table 1: BiH – share of expenditures on vaccines in total NIP costs by type of entities, type of

vaccines and years Vaccines 2002 2003 2004

FbiH Traditional $ 36,925 $ 70,591 $ 80,940

New $ 630,387 $ 781,724 $ 819,287

Subtotal FbiH $ 667,312 $ 852,315 $ 900,227

% of NIP FBiH 66% 63% 61%

NIP costs $1,011,491 $1,363,186 $1,463,796

RS Traditional $ 22,613 $ 28,892 $ 79,394

New $ 103,951 $ 94,561 $ 199,794

Subtotal RS $ 126,564 $ 123,453 $ 279,188

% of NIP of RS 21% 18% 32%

NIP costs $ 593,896 $ 697,862 $873,782

BiH Traditional $ 59,538 $ 99,483 $ 160,334

New $ 734,338 $ 876,285 $1,019,081

Total Vaccines BiH $ 793,876 $ 975,768 $1,179,415

% of NIP BiH 49% 47% 50%

Grand total – NIP BiH $1,605,387 $2,061,048 $2,337,578

5 The cost of the NIP of Republika Srpska in 2004 is estimated (projected)


25

The expenditures on vaccines constituted a half of the total cost in the BiH, as shown in Table 1 (on page 24) although the share of traditional antigens was 5% in 2003 and 7% in 2004.

Vaccines were the main cost category in FBiH (approximately two third) in distinction from the RS where shared personnel costs dominated.

2 The Federation of Bosnia and Herzegovina

2.1 Introduction This part contains an analysis of initial information pertaining to total costs of the NIP, and relate to the main components (vaccines, wages, transport etc.), as well as financial resources (the FBiH Government, international donors etc). The analysis concerns 2002, the year prior to the beginning of GAVI support, and to 2004, the year in which GAVI support started.

Again it should be stressed: the FBiH started using GAVI financial support in May 2004 although the GAVI made its commitment in 2002. Even in 2004 the share of GAVI contribution in the total cost of vaccines was very small – only 0.6%. So it was impossible to make any sound conclusions comparing costs and financing structures in years 2002 and 2004. The differences observed between these to years are mostly due to other factors than GAVI financial support.

Secondly, it was very difficult to define pre-VF year and the year following the first support receiving from the VF. According to guidelines the year 2005 qualified for the year following first support from GAVI. Even the recognition of the year 2004 as the first VF-year required modification of the tool. Correspondingly, it was not easy to define the last year of VF support. The year of 2008 is assumed to be the last year of VF support considering that the usage of GAVI support started in 2004.

Therefore, the presented analysis of current expenditures and financing is valuable more in terms of understanding

a) a cost structure and drivers as well financing set up in the period of 2002-2004;

b) the major trends observed during this period rather than to evaluate an impact of GAVI support on expenditures and financing of the NIP.

The total cost of the NIP increased from 1,01 million US$ in 2002 to $1.46 million US$ in 2004 (by 46%) as shown in Figure 7 (on page 24).

The cost of the NIP was 1.42 million US$ in 2003 constituting:

a) 0.03% of the total GDP, amounting to US$ 4,838 million

b) 0.31% of the total public health expenditure amounting to US$ 458 million

c) 12.36% of overall resources allocated to health protection/public health amountint go US$ 12 million

2.2 Cost structure The cost of vaccines have been a main cost driver in the FBiH since 2002 as shown in Figure 8 (on page 26) ranging from 61% (in 2004) to 66% (in 2002) of the total cost of the NIP.


26

Figure 8: FBiH - Cost Profile (Shares in %)

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

2002 2003 2004

Other optional informationOther SIAsMeasles CampaignsPolio CampaignsOther capital costsCold chain equipmentVehiclesOther routine recurrent costsTransportationPersonnelInjection suppliesNew and underused vaccinesTraditional Vaccines

‘Shared personnel costs’ is the next most important cost category being approximately a quarter of the NIP. Therefore vaccines and shared personnel accounted together for more than four fifth of the total cost.

Each of major cost categories will be described below in details.

2.2.1 Vaccines Expenditures on traditional vaccines never exceeded one tenth of the total vaccine cost (as shown in Figure 8 above) and even much less if the cost of Td antigen is excluded (<6%) as shown in Table 2 (below). Table 2: FBiH – costs of traditional vaccines by antigens and years

2002 2003 2004 2002 2003 2004 Traditional vaccines

Absolute value Share in %

BCG $ 2,836 $ 3,005 $ 18,424 7.7% 4.3% 22.8%

DTP $ 7,341 $ 7,941 $ 10,596 19.9% 11.2% 13.1%

Tetanus (TT) $ 4,125 $ 5,687 $ 5,517 11.2% 8.1% 6.8%

Polio (OPV) $ 19,310 $ 16,769 $ 17,432 52.3% 23.8% 21.5%

Td $ 3,313 $ 37,189 $ 28,971 9.0% 52.7% 35.8%

Total traditional vaccines $ 36,925 $ 70,591 $ 80,940 100.0% 100.0% 100.0%

Share in the total vaccine cost 5.5% 8.3% 9.0%

The same as above excluding Td 5.0% 3.9% 5.8%

Switching to DTPa antigen absorbed almost a half of the cost of new vaccines (and 42% of total expenditures on vaccines) in 2002 as shown in Table 3 on page 27. MMR absorbed


27

approximately a third of total vaccines costs. Vaccination with Hib and Hep B were almost equal in 2004 and each of them accounted for a quarter of expenditures on new vaccines. Table 3: FBiH – costs of most expensive vaccines by antigen and years

2002 2003 2004 2002 2003 2004Most expensive vaccines

Absolute value Share in %

DTPa $ 286,125 $ 263,100 $ 139,710 47.3% 35.7% 17.3%

Hep B Mono $ 81,907 0.0% 0.0% 10.2%

Hep B (10 doses) $ 5,115 0.0% 0.0% 0.6%

Hep B 7Y $ 114,032 $ 128,811 $ 114,648 18.9% 17.5% 14.2%

Subtotal Hep B $ 114,032 $ 128,811 $ 201,670 18.9% 17.5% 25.0%

MMR $ 204,303 $ 134,540 $ 273,108 33.8% 18.2% 33.9%

Hib $ - $ 210,791 $ 191,123 0.0% 28.6% 23.7%

Total $604,460 $737,242 $805,612 100.0% 100.0% 100.0%

It has to be stressed that the share of Heb B (in 10 dose vials) supplied by the VF was only 0.6% of the total expenditures on vaccines in 2004.

2.2.2 Personnel The staff responsible for the implementation of the NIP in the Federation of Bosnia and Herzegovina operates at three levels. At the level of the Federation, the staff includes the EPI manager, two health officers and four nurses. At the cantonal level, the NIP implementation is a joint responsibility of 11 health officers (cantonal EPI coordinators) and 14 nurses, while there are 138 medical doctors, the majority of whom are specialized pediatricians, and 144 nurses a the municipal (the lowest) level.

It has to be stressed that the NIP teams at all three levels are not involved in immunization activities full time. Even the EPI program manager (coordinator) and two health officers in the capital are involved part time. Therefore, the personnel cost is reflected in shared costs and not in direct recurrent costs.

2.3 Major trends The NIP became 46% more expensive in 2004 compared with the cost in 2002 due to the raise in expenditures mainly on vaccines by 45% and to less extend on personnel by 43% as shown in Figure 9 (on page 28). The increase in total costs in US$ was to a large extent due to the decrease in the exchange rate from 2.1 BAM for 1 US$ in 2002 to 1.5 BAM in 2004.

It has to be stressed that the major rise in cost of vaccines happened in 2003 – from 1.01 to1.36 million US$ (by 35%). The expenditures on vaccines increased only by 7% in 2004.

The analyses of trends in expenditures on the most expensive (new) antigens (see Table 3 above) reveal that the raise of cost of some antigens was offset by decrease of others. For instance the spending on DTPa in 2004 was the half of cost in 2002 ($139,710 vs. $286,125 respectively). At the same time the cost of vaccination against Hep B raised by 77% in 2004 compared with the year 2002.

The decrease in the cost of DTPa can be attributed mainly to the change in the vaccination schedule: One of two doses of DTPa was removed. That resulted in the reduction of the number of doses given. The full impact of this reduction is not seen in 2004 since the old schedule was used during 4 of 12 months in 2004. There was also 23% drop in price.


28

The cost of Hib vaccine decreased by 9.3% in 2004 though not as significantly as in case of DTPa. The decrease was caused again by the removal of 1 dose in 2004. However its effect was more difficult to observe because of the late introduction of Hib in 2003 – the fourth dose for the 2003 cohort was due in 2004. The removal of the 2nd dose in 2004 will have a full impact in 2005. At the same time creating a 25% buffer stock offset the decrease in the doses administered.

However the rise in the cost of vaccination against Hep B was due to the introduction of a neonatal mono dose vaccine in 2004 – it accounted for 41% of the total spending on Hep B considering also Heb B vaccination at the age of 7 years, and 94% of the spending on 3 doses during the first year of life. The share of GAVI contribution in the infant vaccination against Hep B (2 doses) was 6%. Figure 9: FBiH - Trend in Past Cost by Category (US$ Millions)

$-

$0.2

$0.4

$0.6

$0.8

$1.0

$1.2

$1.4

$1.6

2002 2003 2004


In 2004, due to an allegation of a high number of post-vaccination reactions to the MMR vaccine produced by the Institute of Immunology in Zagreb, a more expensive mono-dose vaccine was procured from another producer, which resulted in an additional burden for the Government budget (34% increase in the expenditures on the MMR vaccines).

It has to be stressed that the raise in cost for Hep B and MMR was also attributed to the establishment of a 25% buffer stock (similar to Hib).

Increase in the personnel cost (in US$) was due to the change in the exchange rate from 2.1 BAM for 1 US$ in 2002 to 1.5 BAM in 2004. The number of personnel and wages (in a national currency) were the same in 2002 and 2004.


29

Figure 10: FBiH - Trend in Past Financing by Source (US$ Millions)

$-

$0.2

$0.4

$0.6

$0.8

$1.0

$1.2

$1.4

$1.6

2002 2003 2004

HIF-Canton

FBiH Solidarity Fund

UNICEFGAVI - Vaccine Fund

Sub-national Gov.National Government

As to the trends in the financing of the NIP there were three sources: the state (federal) budget, sub-national (cantonal) governments and UNICEF. The share of UNICEF funding decreased from 9% in 2002 to 5 in 2004 due to the increase of the government’s purchase of new vaccines (MMR, Hep B, Hib).

The cantonal governments were financing a major portion of the cold chain equipment, its maintenance and shared personnel cost and the full cost of injection supplies.

The federal budget financed the procurement of vaccines, other capital costs and a small portion of maintenance and shared personnel costs (accounting for approximately 60% of the total financing).

3 Republika Srpska There was no data to calculate the cost of the national immunization program for the year 2001.

GAVI financial support was received and used in 2003, therefore it is considered as the first Vaccine Fund year and the year 2002 – as pre VF-year.

The total cost of the immunization program was 593 thousand US$ in 2002 and 697 thousand US$ in 2003 (17.5% increase).

The increase in the total cost of the program is mainly due to the change in the exchange rate (from 2.1 to 1.7) as shown in Figure 12 (on page 30): the personnel cost (both the direct and shared costs) constituting 63.4% of the total cost in 2002 was entered/calculated in the local currency. Therefore, its share increased to 69% in 2003 when the total cost was calculated in US$.

Correspondingly, the share of vaccine costs decreased 21.3% in 2002 to 17.7% in 2003 although there was insignificant decrease in real terms from 125 to 123 thousand US$. Moreover, the expenditures on new vaccines decreased from 103 to 94 thousands US$ despite of the 50% increase in the administration of Heb B. The decrease was due to the


30

reduction in the number of doses of MMR administered in 2003 (27 thousands vs. 31 thousands in 2002). Figure 11: RS - Cost Profile (Shares in %)

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

2001 2002 2003


Therefore, the main cost driver in the past and current (VF) year was the personnel cost increasing in the value when expressed in US$ (because of the change in the currency exchange rate).

It has to be stressed that shared costs constituted more than a half of the total cost in both years compared. Figure 12: RS - Trend in Past Cost by Category (US$ Millions)

$-

$0.1

$0.2

$0.3

$0.4

$0.5

$0.6

$0.7

$0.8

2001 2002 2003



31

The NIP was financed from 3 sources in 2002: the general budget (“National government”) managed by the MoF, municipal budgets (“sub-national governments”) and UNICEF as shown in Figure 13 below.

The general budget covered all routine recurrent costs except of vaccines in 2002. UNICEF paid for all traditional vaccines and for Hep B in 2002 as well as for the cold chain equipment (accounting for 7% of the total financing).

The municipals, i.e. local governments, were in charge of financing all shared costs and therefore contributed to the financing of more than a half of the NIP costs. Figure 13: RS - Trend in Past Financing by Source (US$ Millions)

$-

$0.1

$0.2

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WHO

UNICEFGAVI - Vaccine Fund

Sub-national Gov.National Government

GAVI share in the financing of the NIP was 14% in 2003 and together with the UNICEF’s provision of traditional vaccines constituted one fifth of the total expenditures on vaccines. (as shown in Figure 14 on page 32). The municipal (sub-national) governments continued financing of the shared costs amounting 59% of the total NIP expenditures.


32

Figure 14: RS – Financing of the NIP by sources in 2003

National government

21%

Sub-national governments

59%

UNICEF14%

GAVI6%


33

Section 4: Future Resource Requirements and Program Financing / Gap Analysis

1 Summary There is a 24% increase in the resource requirements in BiH from 2,338 in 2004 to 2,930 thousand US$ in 2010 as shown in Table 4 below. Table 4: BiH – future resource requirements (in thousand US$)

2004 2005 2006 2007 2008 2009 2010 FbiH

Vaccines 990*1,040 1,066 1,100 1,122 1,147

Total resource requirement 1,464 1,558 1,595 1,627 1,675 1,720 1,934 RS

Vaccines 279 282 285 288 291 294 297 Total resource requirement 874 871 886 901 921 947 995

Total BiH Vaccines 1,272 1,325 1,354 1,391 1,416 1,445 Total resource requirement (TRS) 2,338 2,429 2,480 2,528 2,596 2,668 2,930 Share of vaccines in TRS 52% 53% 54% 54% 53% 49%

* Note that 3 doses of Hep B at 7 years are not included in the costs of vaccines for 2005 and thereafter since the decision in December 2004 to discontinue Hep B vaccination at 7 years of age Resource requirements increase by one third in the FBiH and only 14% in RS . The vaccine cost increases only by 14% over the same period.

There is no funding gap in BiH if

a) existing approaches and factors remain the same (a basic scenario) and

b) b) both secure and probable financing is considered.

The funding gap can occur if the state (either general budget or HIFs) fails to provide necessary resources (recognized as “probable”) timely for the procurement of vaccines and injection supplies. Moreover, if the health authorities in BiH opt for cheaper scenarios (no change of immunization schedules but purchasing vaccines more efficiently) the current level of state financing will be enough to cover the needs in vaccines and injection supplies.

The future resource requirements, program financing and the financial gap analysis by different scenarios will be done in detail separately for each entity.

2 The Federation of Bosnia and Herzegovina Several scenarios were developed for the calculation of future resource requirements. The scenarios differ by two factors – the vaccination schedule and price of vaccines as shown in Figure 15 below. Figure 15: FBiH – description of scenarios by

Vaccination schedule Scenarios

DTPa Heb B Mono MMR Hib Basic Market Market Market Market Alternative 1 Market Market UNICEF UNICEF Alternative 2 DTP

UNICEF UNICEF UNICEF UNICEF

Alternative 3 - - - -


34

The basic scenario will be described in details below covering main cost factors and the analysis of the financial gap. The alternative scenarios will be presented in terms of their impact on the financial gap.

2.1 Basic scenario

2.1.1 Resource requirements The analysis of future resource requirements covers the period from 2005 to 2011. It is assumed that GAVI supports ends in 2009 therefore the year 2008 was considered as the last VF year.

The resource requirements increases from 1.56 million US$ in 2005 to 1.67 million US$ in 2008 (by 7%) and to 1.79 million US$ in 2008 (by 15%).

Two cost categories: vaccines and injection supplies and shared personnel account for almost nine tenth of the total resource requirement as shown in Figure 16 (below). Figure 16: Projection of Future Resource Needs (US$ Millions)

$-

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Measles Campaigns

Polio Campaigns

Other capital costs

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Transportation

Personnel

Injection supplies

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Traditional Vaccines

The basic scenario is based on the assumption that no changes in the immunization schedule are expected – namely the most expensive new vaccines such as DTPa, Heb B mono (1st dose), MMR and Hib and the procurement will be made directly on the market

Therefore the increase in vaccine costs (including injection supplies) from 989 thousand US$ in 2005 to 1,076 thousand US$ in 2011 (by 19%) is attributed to the raise in cohort size and increase in coverage rates for some antigens (until 2008).

Inflation explains the gradual increase of resources requirements for the rest of cost categories except of cold chain equipment as shown Figure 16 (above) – the replacement of a part of cold chain equipment is envisaged in 2010 at the cost of 197 thousands.


35

2.1.2 Funding gap As it was mentioned earlier in section 2 (Major trends on page 27) the share of external sources in the financing of the NIP was less than one tenth. The main financial burden was and expected to be on the state.

A key point in the projection of financing from the state sources is not the lack of resources but guarantees that they will be correctly estimated and timely allocated by an agent responsible for the financing of the NIP (as described in details in section 1, sub-section 4.1 on page 8).

It has to be stressed that the Federation Solidarity Insurance Fund is expected to become a major source of financing in 2006 replacing the state budget. As far as this decision is not confirmed by a corresponding legal act all financing from the Federation Solidarity Insurance Fund is considered probable. Therefore, if we consider only the secure financing we get a quite prominent funding gap as shown in Figure 17 below – around 60% of the total resource requirements over the period of 2006-2011. Figure 17: FBiH – Future Secure Financing and Gaps (US$ Millions)

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FBiH Solidarity Fund

UNICEF

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National Government

Correspondingly no funding gap is expected if both secure and probable funding is considered provided that the Federation Solidarity Insurance Fund allocates fully required resources to the NIP as shown in Figure 18 on page 36.


36

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

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Funding Gap000000HIF-CantonFBiH Solidarity FundUNICEFGAVI - Vaccine FundSub-national Gov.National Government

It would have been more fair if we had considered part of the probable funding from the Federation Solidarity Insurance Fund – it is very likely that the Fund allocates the same amount of money (600-800 thousand US$) to the NIP as it was done by the state budget in 2002-4 after the financing responsibility is handed over. But it was not possible (because of the tool limitation) to split the future financing from one source in two categories: secure and probable. If it had been possible the funding gap with secure financing would have been around 5-6% instead of 60%.

2.2 Alternative scenarios Out of three alternative scenarios presented in Figure 15 (on page 33) the third one (no new/underused vaccines except of Heb B in 10 dose vials for all 3 doses) is less feasible because it is very unlikely the entity to opt for it (unless there is sever shortage of local money and there is no external support). Therefore it seems more hypothetical (but can be considered as the last resort in the strategy).

Alternative scenario #2 seems more feasible both from immunization and financial point of views. It is assumed that DTPa is replaced by 4th dose of DTP and Hep B mono – by 3rd dose of Hep B in 10ds vials.

If the FBiH opts for the alternative scenario #1 the effect will be counteracted by the high expenditures on DTPa procured directly from private suppliers (when the rest of new vaccines will be purchased at UNICEF prices). However , if GAVI provides support for the introduction of Hib in 2006-2008, this alternative becomes most realistic. In this scenario the F BiH Government seriously considers the possibility to use UNICEF procurement also for the new vaccines (DTPa, and Hep B Mono) presently not in the UNICEF Catalog).

.


37

Table 5: FBiH – comparison of alternative scenarios by future resource requirements by years*

Scenarios 2005 2006 2007 2008 2009 2010 2011 Basic Scenario

Vaccines $989,861 $1,040,218 $1,066,224 $1,099,826 $1,121,822 $1,147,494 $1,176,067 Total res req.-s $1,558,274 $1,594,857 $1,627,062 $1,674,886 $1,720,062 $1,934,358 $1,788,389

Alternative Scenarios Scenario 1

Vaccines $606,354 $636,285 $652,139 $668,419 $681,787 $696,257 $713,560 Total res. req.-s $1,174,767 $1,190,924 $1,212,977 $1,243,479 $1,280,027 $1,483,121 $1,325,882 Difference $383,507 $403,933 $414,085 $431,407 $440,035 $451,237 $462,507 Diff as % of basic 25% 25% 25% 26% 26% 23% 26%

Scenario 2 Vaccines $404,192 $423,080 $434,587 $445,622 $454,535 $464,458 $477,033 Total res. req.-s $971,395 $976,381 $994,061 $1,019,290 $1,051,355 $1,249,874 $1,087,878 Difference $586,879 $618,476 $633,001 $655,596 $668,707 $684,484 $700,511 Diff as % of basic 38% 39% 39% 39% 39% 35% 39%

* Note that 3 doses of Hep B at 7 years are not included in the costs of vaccines for 2005 and thereafter since the decision in December 2004 to discontinue Hep B vaccination at 7 years of age The scenario 2 (no DTPa and Heb B mono) yields in average 38% reduction of total resource requirements due to more than 50% decrease in the vaccine costs, Table 5 above.

Only the switching from private suppliers to UNICEF without changing the vaccinations schedule saves approximately one fourth of the total costs (scenario 1) due to 39% decrease in the vaccines costs.

What is most important that the vaccine costs in both scenarios are much less than of the amount presently spent by the FBiH: • if the funding from the state resources stay at the level of 2002 when approximately 570

thousand was allocated from the state budget, there is no need in any external financial support in case of the alternative scenario #2;

• The level of public spending on vaccines in 2003 and 2004 was higher than will be needed in case of the alternative scenario #1.

3 Republika Srpska The projection of resources requirements and funding gaps covers the period from 2004 to 2010 considering that the GAVI supports ends in 2007.

Only two scenarios will be considered for the projection of resources requirements and analysis of funding gaps.

A basic scenario implies that RS continues the procurement of MMR directly from the market while Heb B vaccines will be procured at UNICEF rates after GAVI support ends in 2007.

The alternative scenario implies that the immunization schedule remains the same but MMR will be procured at UNICEF rates.

Finally, the possibility of adding Hib vaccine to the immunization schedule (at UNICEF rates) is considered in two more alternative scenarios: #2 if nothing changes just Hib is added (basic scenario + Hib) and #3 if MMR is purchased at UNICEF prices and Hib is added (alternative scenario #1 + Hib) as shown in Figure 19.


38

Figure 19 RS – description of scenarios6

Vaccines Scenarios

Hep B MMR Hib Basic U M - Alternative 1 U U - Alternative 2 U M U Alternative 3 U U U

3.1 Basic scenario

3.1.1 Resource requirements Total resource requirements for the NIP is expected to increase by 14% from 873 thousand US$ in 2004 to 995 thousand US$ in 2010 as shown in Figure 20 (below).

The cost of vaccines increases slightly (by 6%) if Hib is not introduced. The 14% raise in total resources requirements is mainly attributed to the following cost categories: • personnel and shared personnel costs increase by 13% due to inflation • cold chain equipment replacement in 2009 and 2010. Figure 20: RS - Projection of Future Resource Needs (US$ Millions)

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Measles Campaigns

Polio Campaigns

Other capital costs

Cold chain equipment

Vehicles

Other routine recurrent costs

Transportation

Personnel

Injection supplies

New and underused vaccines

Traditional Vaccines

3.1.2 Funding gap The Health Insurance Fund of the RS becomes the main source of financing of the NIP as in the FBiH, however there is no assurance (policy decision) that it will happen and the fund will be obliged by law to allocate adequate resources to the NIP.

6 “U” stands for UNICEF prices and “M” for market prices


39

The projection of future financing is based on the assumption that the Health Insurance Fund will provide money for: • vaccines and injection supplies • Shared personnel costs.

The rest of costs have to be covered from the state budget.

The financing of new vaccines from the Health Insurance Fund was considered as probable due to aforementioned reason.

No funding gap is envisaged till 2010 considering both secure and probable financing as shown in Figure 21 (below).

The funding gap varies from 21% to 26% if only secure financing is considered as shown in Figure 22 (on page 40) Figure 21: RS - Secure and Probable Funding and Gaps (US$ Millions)

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Figure 22: RS - Future Secure Financing and Gaps (US$ Millions)

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3.2 Alternative scenarios The future resource requirements for each scenario are shown in Table 6 below. Table 6 RS - comparison of alternative scenarios by future resource requirements by years Scenarios 2004 2005 2006 2007 2008 2009 2010 Basic Scenario Vaccines $279,188 $282,141 $284,962 $287,812 $290,856 $294,209 $297,151 Total res. req.-s $873,782 $871,204 $885,601 $900,677 $921,278 $947,466 $995,425 Alternative 1

Vaccines $154,492 $156,198 $157,759 $159,337 $161,096 $163,151 $164,783 Difference from basic -$124,696 -$125,943 -$127,203 -$128,475 -$129,760 -$131,058 -$132,368 Difference in % from basic -44.7% -44.6% -44.6% -44.6% -44.6% -44.5% -44.5%

Total res. req.-s $749,086 $745,261 $758,398 $772,202 $791,518 $816,408 $863,057 Difference from basic -$124,696 -$125,943 -$127,203 -$128,475 -$129,760 -$131,058 -$132,368 Difference in % from basic -14.3% -14.5% -14.4% -14.3% -14.1% -13.8% -13.3%

Alternative 2 Vaccines $279,188 $419,609 $441,160 $453,695 $454,150 $459,136 $463,727

Difference from basic $0 $137,468 $156,198 $165,883 $163,294 $164,927 $166,576 Difference in % from basic 0.0% 48.7% 54.8% 57.6% 56.1% 56.1% 56.1%

Total res. req.-s $873,782 $1,012,123 $1,045,721 $1,070,821 $1,088,911 $1,116,775 $1,166,427 Difference from basic $0 $140,919 $160,120 $170,144 $167,633 $169,309 $171,002 Difference in % from basic 0.0% 16.2% 18.1% 18.9% 18.2% 17.9% 17.2%

Alternative 3 Vaccines $154,492 $256,826 $272,098 $283,802 $288,101 $291,427 $294,341

Difference from basic -$124,696 -$25,315 -$12,864 -$4,010 -$2,755 -$2,782 -$2,810 Difference in % from basic -44.7% -9.0% -4.5% -1.4% -0.9% -0.9% -0.9%

Total res. req.-s $749,086 $849,294 $876,606 $900,878 $922,821 $949,025 $996,999 Difference from basic $124,696 $21,910 $8,995 -$201 -$1,543 -$1,559 -$1,574 Difference in % from basic 14.3% 2.5% 1.0% 0.0% -0.2% -0.2% -0.2%


41

The procurement of MMR vaccine at UNICEF prices instead of getting directly from the private providers (alternative scenario #1) saves in average 14% of the total resource requirements on the NIP and decreases the expenditures on the vaccines almost by half.

If Hib vaccine is added in 2005 to the immunization schedule (without any other changes – as in basic scenario) then it increases the total financial requirements in average by 18% and the expenditures on vaccines by more than half (alternative scenario #2).

The introduction of Hib will not result in any significant changes in the resource requirements if combined with the procurement of MMR at UNICEF rates (alternative scenario #3), even the cost of vaccines will be slightly less (~1-2%).

Therefore, the alternative scenario #1 can be considered as the best solution to the shortage in funding if the probable financing described above can not be secured (from the Health Insurance Fund) completely. It also can serve as a prerequisite for the painless introduction of Hib (alternative scenario #3). The alternative scenario #2 is the most undesirable (expensive) because it increases the funding gap (a need in probable funding) unless GAVI provides support for the introduction of Hib in 2006-2008.


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Section 5: Sustainable Financing Strategy, Actions and Indicators

1 The Federation of Bosnia and Herzegovina

1.1 Review of major findings – SWOT analysis The description and analysis of the country and health care system context, national immunization program features, the past and future resources requirements, financing and the financial gap structure leads to the following conclusion structured by the strength and weaknesses of the national immunization program and the opportunities and threats existing beyond the program. The summary of conclusions is given separately for RS and FBiH. Figure 23: FBiH – summary of findings (SWOT)

POSITIVE NEGATIVE

Strength Weaknesses

INTE

RN

AL

• High level of coverage • Highly motivated and skilled staff at all levels • A robust system of disease surveillance and

reporting in place • Past weaknesses have forcefully been countered

after the Immunization Management Program Review in 2003

• The Ministry of Health has taken a stronger grip on development and monitoring of the program

• With important adjustments of the vaccination schedule, reducing the no, of doses of new expensive vaccines and discontinuation of unnecessary vaccinations

• Lack of integration of communication messages and strategies into the management of the immunization program either for health workers or the public

• Unstable vaccine supplies to cantonal Institutes of Public Health

• Limitations in monitoring vaccine coverage for program strengthening.

• Lack of coordinated vaccine stock management resulting in overages and shortages.

• Inadequate cold chain management • Responsibilities of financing agents are not

clearly defined in the legislation (at all levels)

Opportunities Threats

EXTE

RN

AL

• In general, population accepts vaccination easily • Introduction of effective mechanisms of the

reimbursement of PHC to create incentives favorable for vaccination

• High level of public spending (both in absolute and relative terms) on health care

• Possibility to purchase vaccines at lower price without sacrificing quality

• Destructive media statements creating negative public attitude and demanding costly revisions of the immunization program and/or resulting in lower coverage

• Introduction of family medicine (with the replacement of the specialized immunization services) without due consideration of the needs of immunization

• Uninsured residents may face problems in access to immunization services

As it was outlined in section 1 and 4 there is no funding gap in the literal sense of the word: there are enough resources allocated to health care in public domain. Therefore the reliability of financing and the efficiency of the NIP implementation are key issues for the sustainability of the financing of immunization. Consequently the proposed strategy options are built around two categories: Resource mobilization & reliability and efficiency7.

7 The terms “efficiency” in this particular context (of the financial sustainability of the NIP) has more narrow meaning than the efficiency of entire health care system; therefore, issues which address inefficiencies in health care system (for instance related to “allocative inefficiency”) are placed under the category of “Resource mobilization & reliability”


43

1.2 Strategy Options Two preliminary strategy options were developed: • one emphasize advocacy - to make the NIP high priority on political agenda and secure

resources in public domain • the second emphasize efficiency – to assure minimum spending on vaccines with

maximum benefit for the prevention of communicable diseases

Strategy option 1 – “advocacy”: 1. Resource mobilization & reliability:

1.1. Ensure that all cost categories (direct routine costs, capital costs and shared costs) of the NIP are shared among and recognized by opinion makers in the governments at different levels

1.2. Ensure that the responsibilities of different financial agents (the state budget, the canton budgets, the Federation Solidarity Insurance Fund and the cantonal Health Insurance Funds) for the financing of the NIP are clearly defined in the legislation

1.3. Ensure that the needs of the NIP in terms of resource requirements and organizational arrangements are well recognized and integrated in short and medium-term planning and institutional reforms of the primary health care system

2. Efficiency: 2.1. Ensure that coordination of the vaccine stock management improved (minimizing

shortages and overages) 2.2. Ensure that vaccines are procured at the lowest cost (close to UNICEF prices)

without sacrificing quality

Strategy option 2 – “efficiency”: 1. Resource mobilization & reliability:

1.1. Ensure that all cost categories (direct routine costs, capital costs and shared costs) of the NIP are shared among and recognized by opinion makers in the governments at different levels


2. Efficiency: 2.1. Ensure that coordination of the vaccine stock management improved (minimizing

shortages and overages) 2.2. Improve cold chain management 2.3. Ensure that vaccines are procured at the lowest cost (close to UNICEF prices)

without sacrificing quality 2.4. Consider to revise the vaccination schedule based on sound cost-benefit analysis 2.5. Increase public awareness of the benefits of immunization (regarding both

traditional and new vaccines), quality of the vaccines used and possibility of side effects to prevent interruption of the immunization)

2.6. Increase the knowledge and change the attitude of health care providers toward to rationale vaccination (and/.or side effects of and contradictions of vaccines)

The preliminary strategy options were assessed and prioritized against criteria in accordance with the guidelines.


44

Figure 24: FBiH – assessment of the strategy option 1 – “advocacy”

Criteria Strategy elements Financial

importance Programmatic Importance

Implementation cost

Feasibility

1. Mobilization & Reliability 1.1 Costs are shared

and recognized Medium Low Time of financial

specialists and NIP coordinator Publications, workshops

High possibility of success by using FSP tool to produce messages to share

1.2 Responsibilities for financing are enforced

High Medium Time of MoH to draft legal acts

High probability to draft the law and pass it

1.3 The needs of the NIP are integrated in financial planning and reforms of PHC system

High High Time of MoH & NIP to prepare specialists for changes health policy, primary health care Round tables, workshops

Moderate probability to influence the reform design, development of effective payment schemes

2. Efficiency 2.1 Stock management

coordination improved

Low High Cost of technical assistance, cost MIS, training of staff

High probability, but technical assistance/ external support will be needed

2.2 Vaccines procured at the lowest cost

High Medium Cost/time for changes in legislation, cost of capacity development

Moderate – resistance from market agents has to be overcome

Three elements of the strategy have the highest impact on financing (and financial sustainability). None of them are too costly to be rejected because of the inputs required. The strategy element # 1.2 “Responsibilities for financing are enforced” should be a top priority considering high probability of success and medium programmatic importance. Strategy element 2.1 “Stock management coordination improved” can be on the bottom of the priority list for this strategy option despite its high programmatic importance and feasibility (offset by low financial importance and relatively high cost).

The strategy element 1.3 “The needs of the NIP are integrated in financial planning and reforms of PHC system” deserves special attention. It is linked to the opportunity describing in details in section 1 and is related to ongoing health care reforms (supported by SITAP and HSEP projects). It covers several critical issues for the sustainability of the NIP such as integration of the needs of immunization in primary health care facility setup (e.g. cold chain equipment), special focus on immunization in the education of family physicians (considering that specialized immunization services will be replaced by family medicine services), factoring incentives in the reimbursement models (e.g. additional payment for each immunized child on top of per capita payment, penalties (payment withdrawals) or rewards (flat or variable bonuses) for meeting immunization targets, etc.). These issues are solved in a policy-making arena beyond the scope of immunization program. Therefore it requires advocacy as well as policy advice activities to put pressure on technical and political decision makers in charge of the primary health care reform.

The preliminary strategy option 2 was assessed against the same criteria as shown in Figure 25 below:


45

Figure 25: FBiH – assessment of the strategy option 2 – “efficiency”


importance Programmatic importance

Implementation cost

Feasibility

1. Mobilization & Reliability 1.1 Costs are shared

and recognized Medium Low Time of financial

specialists and NIP coordinator Publications, workshops

High possibility of success by using FSP tool to produce messages to share


High Medium Time of MOH to draft legal acts






2.2 Cold chain management

Medium Medium Time of NIP director, trainers, cost of trainings, tools to be developed & installed

High probability unless the upgrade of equipment is needed (conditional upon the availability of money)



Moderate – resistance from market agents has to be overcome

2.4 Revision of the vaccination schedule

High High Cost of conducting cost-benefit analysis, time of policy makers to endorse changes

low main reductions made – expert opinion geared to use US & EU programs, resistance from market agents less important

2.5 Increase public awareness (social mobilization)

Medium Medium High costs for the development and implementation PR strategy

High probability of success if authorities are convinced in cost-effectiveness, external support from ICC members might be needed in the beginning

2.6 Increase knowledge & change attitude of health care providers towards the rationale of vaccination, side effects and contra-indications

High High Medium – cost of continuous education of health care providers (workshops, conferences, production of materials)

High probability of success but takes long time to be accomplished.

The strategy elements under the category 1 “Mobilization & Reliability” were borrowed from the strategy option 1 and assessed. The strategy option 2 has higher programmatic importance compared with the option 1 because of its elements 2.4 “Revision of the vaccination


46

schedule” and 2.5 “Increase public awareness (social mobilization)”. These two elements deserve to receive priority – both demonstrate high financial and programmatic importance but are costly. However, the revision of vaccination schedule toward elimination of costly vaccines can yield significant savings. However, important reductions were made during the last year – the F-BiH expert opinion is already geared to the use US & EU programs. These trends are difficult to revert particularly when the country is striving for EU membership. Resistance from market agents is less important. Another argument explaining the low feasibility of the element 2.4 is that there is no uniform understanding of the need in revision of the immunization schedule among opinion makers and policy makers. Therefore, it won’t be easy to initiate this issue and put it on agenda.

The strategy element 2.5 “Increase public awareness (social mobilization)” seems to be most expensive relatively to other elements. In distinction from the strategy element # 2.4 it will be more difficult to prove its cost-effectiveness. If the FBiH authorities want to prevent delay in the introduction of new vaccines and several times higher expenditures on more expensive vaccines (substitutes), this component becomes critical. However, the positive experience of the successful introduction of neonatal Hep B vaccination that reached very high coverage figures for both BCG and hep B in the maternity wards suggests that # 2.5 will be achieved primarily with the next element 2.6.

The strategy element 2.6 “Increase knowledge & change attitude of health care providers towards the rationale of vaccination, side effects and contra-indications” serves the same purpose as the previous one but from other end: if one needs to change public opinion the support of medical professionals becomes critical. Secondly this element is necessary to achieve sustainability of the implementation of the NIP especially in terms of compliance to the schedule. This factor becomes more important with the introduction of family medicine assuming that the role of previous medical personnel well trained and experienced in immunization will decrease. The feasibility of this element is high in long run assuming that different forms of education takes years and should be maintained to upgrade the knowledge of medical professionals. No doubt it has to be integrated in the human resource development strategy in health sector.

As to priority setting the following three elements of the strategy option #2 were setting as top priorities: • 1.2 “Responsibilities for financing are enforced” • 2.3 “Vaccines procured at the lowest cost”, • 2.6 “Increase knowledge & change attitude of health care providers towards the rationale

of vaccination, side effects and contra-indications”

If we compare the two strategy options the first one seems more “light” – less costly with immediate effect on financial sustainability. The second option is more “heavy” – more costly (because of social mobilization/public awareness approach) with relatively delayed effect.

The two strategy options can be considered as complementary: the government will start with the strategy option 1 and will opt for the second option if: a) the first option is implemented successfully and b) funds for the certain elements of the second option are available (mobilized). The synthesis of these two options (considering priorities identified above) broken down in short and medium-term strategy interventions will look as shown in Figure 26 on page 46.


47

Figure 26: FBiH – optimal strategy Strategy elements Short-term Medium-term

1. Resource Mobilization & Reliability:

1.1 Ensure that the responsibilities of different financial agents (the state budget, the canton budgets, the Federation Solidarity Insurance Fund and the cantonal Health Insurance Funds) for the financing of the NIP are clearly defined in the legislation

1.2 Ensure that the needs of the NIP in terms of resource requirements and organizational arrangements are well recognized and integrated in short and medium-term planning and institutional reforms of the primary health care system

2. Efficiency

2.1 Ensure that coordination of the vaccine stock management improved (minimizing shortages and overages)

2.2 Ensure that vaccines are procured at the lowest cost (close to UNICEF prices) without sacrificing quality

2.3 Consider to revise the vaccination schedule based on sound cost-benefit analysis

2.4 Increase public awareness of the benefits of immunization (regarding both traditional and new vaccines), quality of the vaccines used and possibility of side effects to prevent interruption of the immunization)

2.5 Increase the knowledge and change the attitude of health care providers toward to rationale vaccination (and/.or side effects of and contradictions of vaccines)

1.3 Action plan and indicators The action necessary to implement the financial sustainability strategy with the corresponding output

indicators, time frame and responsible agents is shown in

Figure 30 (on page 53).


48

Figure 27 FBiH – action plan and indicators Strategy element Output indicators Actions Responsible

agency Time frame Estimated costs

1. Resource Mobilization & Reliability: • Share of actual domestic expenditures on recurrent costs of immunization program/amount budgeted for recurrent costs within the last fiscal year

• Well established Financial Planning process involving all financiers


• Roles of state agencies in the financing (allocation of public funds) to the NIP defined in legislation

• Existence of laws, statutes, regulations and/or official decrees specifying amounts or allocations to be dedicated to immunization programs

-1. To develop a policy options with the roles of financial agents in the mobilization, management and allocation of funds to the different cost categories of the NIP

-2. To discuss the policy options with policy makers and to arrive at final decision

-3. To draft and endorse the corresponding legal acts

• MoH of the BiH • Public Health

Institute

by the end of 2005 ~0$


• Cold chain equipment at PHC level is incorporated in the standards of the primary health care facilities

• PHC medical personnel responsibilities are defined in the payment contracts and enforced

• The roles of sub-national and local

-1. To participate in the design of PHC facility standards (enforced by licensing or contractingmechanisms) and integrate the needs of the NIP

• Public Health

Institute

-2. To participate in the design of the functional plans and the scope of work of medical professionals of PHC institutions to integrate the needs of the NIP

-3. To develop clear mechanisms of the vaccine distributions and update the legislation to implement

• MoH of the FBiH

• Cantonal health authorities

• The Federation Solidarity Insurance Fund

• Cantonal Health Insurance Funds

• International partners involved



49

Strategy element Output indicators Actions Responsible agency

Time frame Estimated costs

health authorities in the supply of vaccines are defined and financed

• Reimbursement schemes of PHC providers consider appropriate incentives for immunization services

them -4. To include incentives favorable for

the immunization services in the health care financing policy options

in health care reforms (e.g. the World Bank)

2. Efficiency 2.1 Ensure that coordination of the

vaccine stock management improved (minimizing shortages and overages)

• Cases of shortages and overagesdecreased by XX %

-1. To develop and introduce the stock

management procedure(guidelines)

• Trends of vaccine stock-outs, by cantons

• Public Health

Institute

-2. To install (stock) management information system

-3. To train personnel

by the end of 2005 30-50,000 US$ to develop system 30-40,000 US$ to install system (including hardware)


• Purchase of quality vaccines with use of international procurement mechanism or direct procurement with price differential of less than ten percent from UNICEF prices

-1. To revise the legislation to enable state procurements directly from UNICEF

-2. To conduct market assessment to identify suppliers with the lowest prices (meeting quality standards)

• MoH of the FBiH • Public Health

Institute



• The vaccination schedule revised with sound justification

-1. To conduct cost-benefit analysis of the introduction of costly antigens

-2. To develop proposal on changes in the vaccination schedule

-3. To approve revised schedule


Institute

by the end of 2007 ~50,000 per antigen

2.4 Increase public awareness of the benefits of immunization (regarding both traditional and new vaccines), quality of the vaccines used and possibility of side effects to prevent interruption of the immunization)

• The public (positive) attitude toward: o vaccination in

general remains high (above 95%)

o specific antigens (e.g. DTP, Hep B) increased by 15%

-1. To conduct baseline assessment of public attitudes (e.g. KAP survey)

-2. To develop the social mobilization (information campaign) strategy

-3. To implement the strategy -4. To evaluate changes in public

attitude

• Public Health Institute

by the end of 2010 100,000 US$ for surveys 0.5-1.0 mln US$ for the implementation


50

Strategy element Output indicators Actions Responsible agency


2.5 Increase the knowledge and change the attitude of health care providers toward to rationale vaccination (and/.or side effects of and contradictions of vaccines)

• 100% of family doctors (PHC medicalpersonnel) trained and demonstrating support to the NIP – requirement

-2. To develop training master plan -1. To conduct baseline assessment

-3. To integrate relevant issues in the human development strategy in health care sector

-4. To evaluate results periodically


Institute

by the end of 2010 60,000 US$ for assessments 40-60,000 US$ for developing the training master plan

Bosnia and Herzegovina THE FINANCIAL SUSTAINABILITY PLAN

NEGATIVE

v 1.23 ICC

51

2 Republika Srpska

2.1 Review of major findings – SWOT analysis The analysis of future resource requirements and funding gaps in RS as well as the overall context (section 1) and the NIP main parameters (section 2) lead to the conclusion that similar to the FBiH the financial sustainability of the NIP in RS is not linked to or determined by the availability of money. Summary of findings is given in Figure 28 below. Figure 28: RS – summary of findings (SWOT analysis)

POSITIVE

Strength Weaknesses

INTE

RN

AL • High level of coverage

• Highly motivated and skilled staff at all levels • A robust system of disease surveillance and

reporting in place

• Limitations in monitoring vaccine coverage for program strengthening.

• Lack of coordinated vaccine stock management resulting in overages and shortages.

• Inadequate cold chain management • Responsibilities of financing agents are not

clearly defined in the legislation (at all levels)

Opportunities Threats

EXTE

RN

AL • In general, population accepts vaccination easily

• Introduction of effective mechanisms of the reimbursement of PHC to create incentives favorable for vaccination

• High level of public spending (both in absolute and relative terms) on health care

• Possibility to purchase vaccines at lower price without sacrificing quality

• Introduction of family medicine (replacement of the existing practice of delivery primary health services by specialists) without due consideration of the needs of immunization

• Uninsured residents may face problems in access to immunization services

2.2 Strategy options The finding of the SWOT analysis lead to the development of one strategy option with emphasis on the resource mobilization & reliability and efficiency as shown below: 1. Resource mobilization

1.1. Ensure that the needs of the NIP in terms of resource requirements and organizational arrangements are well recognized and integrated in short and medium-term planning and institutional reforms of the primary health care system


2. Efficiency 2.1. Ensure that coordination of the vaccine stock management improved (minimizing

shortages and overages) 2.2. Improve cold chain management 2.3. Ensure that vaccines are procured at the lowest cost (close to UNICEF prices) without

sacrificing quality 2.4. Revise the vaccination schedule based on sound cost-benefit analysis

The preliminary strategy components were assessed and prioritized against criteria in accordance with the guidelines as shown in Figure 24 (on page 44).


52

Figure 29: RS - assessment of the preliminary strategy elements


importance Programmatic importance

Implementation cost

Feasibility

1. Mobilization & Reliability 1.1 The needs of the

NIP are integrated in financial planning and reforms of PHC system

High High Time of NIP coordinator to lobby within the government, specialists in health policy, primary health care Round tables, workshops

Moderate probability to influence the reform design, development of effective payment schemes


High Medium Time of NIP coordinator to lobby within the government, specialist to draft legal acts






2.2 Cold chain management

Medium Medium Time of NIP director, trainers, cost of trainings, tools to be developed & installed

High probability unless the upgrade of equipment is needed (conditional upon the availability of money)



High – policy makers are interested to save resources

2.4 Revision of the vaccination schedule

High High Cost of conducting cost-benefit analysis, time of policy makers to endorse changes

High – the key stakeholders are to carry out sound analysis before introduction of Hib vaccine

The strategy component 2.3 “Vaccines procured at the lowest cost” is of a top priority considering the overall context it RS (therefore was ranked higher against “feasibility” criteria in distinction from the FBiH). The second priority is the strategy component 1.2 “Responsibilities for financing are enforced” – it has quite high probability to be accomplished considering commitment of policy makers and has very high financial importance at almost no implementation cost. The next (by priority) component will be 2.4 “Revision of the vaccination schedule” – there is no need to revise the schedule in terms of dropping out an expensive antigen. However, the strategy component ensures that new expensive antigens such as Hib are not introduced without sound cost-benefit analysis and the assessment of its impact on the financial sustainability of the NIP.


53

2.3 Action plan and indicators The action necessary to implement the financial sustainability strategy with the corresponding output indicators,

time frame and responsible agents is shown in

Figure 30 (below).

Figure 30 RS – action plan and indicators Strategy element Output

indicators Actions Responsible

agency Time frame Estimated

costs 1. Resource

Mobilization & Reliability:

• Share of actual domestic expenditures on recurrent costs of immunization program/amount budgeted for recurrent costs within the last fiscal year

• Well established Financial Planning process involving all financiers


• Roles of state agencies in the financing (allocation of public funds) to the NIP defined in legislation

• Existence of laws, statutes, regulations and/or official decrees specifying amounts or allocations to be dedicated to immunization programs

-1. To develop a policy options with the roles of financial agents in the mobilization, management and allocation of funds to the different cost categories of the NIP

-2. To discuss the policy options with policy makers and to arrive at final decision

-3. To draft and endorse the corresponding legal acts

• MoH of the BiH


by the end of 2005

~0$


• Cold chain equipment at PHC level is incorporated in the standards of the primary health care facilities

• PHC medical personnel responsibilities are defined in the payment contracts and enforced

• The roles of sub-national

-1. To participate in the design of PHC facility standards (enforced by licensing or contracting mechanisms) and integrate the needs of the NIP

-2. To participate in the design of the functional plans and the scope of work of medical professionals of PHC institutions to integrate the needs of the NIP

• MoH of the FBiH


• Health Insurance Fund

by the end of 2007

~0$


54

Strategy element Output indicators

Actions Responsible agency


and local health authorities in the supply of vaccines are defined and financed

• Reimbursement schemes of PHC providers consider appropriate incentives for immunization services

-3. To develop clear mechanisms of the vaccine distributions and update the legislation to implement them

-4. To include incentives favorable for the immunization services in the health care financing policy options

2. Efficiency 2.1 Ensure that

coordination of the vaccine stock management improved (minimizing shortages and overages)

• Cases of shortages and overages decreased by %

• Trends of vaccine stock-outs, by cantons

-1. To develop and introduce the stock management procedure (guidelines)

-2. To install (stock) management information system

-3. To train personnel


by the end of 2005

30-50,000 US$ to develop system 30-40,000 US$ to install system (including hardware)


• Purchase of quality vaccines with use of international procurement mechanism or direct procurement with price differential of less than ten percent from UNICEF prices

-1. To revise the legislation to enable state procurements directly from UNICEF

-2. To conduct market assessment to identify suppliers with the lowest prices (meeting quality standards)

• MoH of the FBiH


by the end of 2005

~0$


• The vaccination schedule revised with sound justification

-1. To conduct cost-benefit analysis of the introduction of costly antigens

-2. To develop proposal on changes in the vaccination schedule

-3. To approve revised schedule

• MoH of the FBiH


by the end of 2007

~50,000 per antigen


55

Section 6: Signatures and Stakeholder Comments

For the Government of Bosnia and Herzegovina Signature: ……………………………………………...……………... Signature: ……………………………………………...……………... Title: Minister of Civil Affairs Minister of Finance Date: ………………………………………….…………………. Signature: ……………………………………………...……………... Signature: ……………………………………………...……………... Title: Minister of Health in Federation Bosnia and Herzegovina Minister of Health in Republik Srpska We, the undersigned members of the Inter-Agency Coordinating Committee endorse this report. Signature of endorsement of this document does not imply any financial (or legal) commitment on the part of the partner agency or individual.

Agency/Organisation Name/Title Date Signature Agency/Organisation Name/Title Date Signature


56

1.1 Stakeholders comments At the ICC meeting 26 January 2005 the Minister of Health in the Federation of Bosnia and Herzegovina expressed his satisfaction with the Financial Sustainability Plan as a significant novel instrument in the long term planning and financing of the immunization program. He noted that since the document has been produced within a short period of time it should be carefully evaluated by all Governmental Agencies involved. The ICC meeting agreed in consensus that the FSP is a working document open to appropriate revisions as new data are available and the action plans are reviewed for implementation. The first revision is planned to be prepared together with the GAVI Annual Report for 2004, and with the application for GAVI support for the introduction of Hib vaccination and injection safety supplies by 22 April 2005.


57

A n n e x e s Figure 31: FBiH - past and current costs Cost Category 2002 2003 2004

Routine Recurrent Cost US$ (%) US$ (%) US$ (%)Vaccines (routine vaccines only) 667,312$ 66.0% 852,315$ 62.5% 900,227$ 61.5%

Traditional Vaccines 36,925$ 70,591$ 80,940$ New and underused vaccines 630,387$ 781,724$ 819,287$

Injection supplies 25,241$ 2.5% 30,596$ 2.2% 33,518$ 2.3%Personnel -$ 0.0% -$ 0.0% -$ 0.0%

Salaries of full-time NIP health workers (immunization specific) -$ -$ -$ Per-diems for outreach vaccinators/mobile teams -$ -$ -$

Transportation -$ 0.0% -$ 0.0% -$ 0.0%Fixed site and vaccine delivery -$ -$ -$ Outreach activities -$ -$ -$

Maintenance and overhead 1,524$ 0.2% 88,714$ 6.5% 91,076$ 6.2%Short-term training -$ -$ 0.0% -$ 0.0%IEC/social mobilization -$ 0.0% -$ 0.0% -$ 0.0%Supervision, Monitoring and Disease Surveillance 1,563$ 0.2% 1,917$ 0.1% 2,146$ 0.1%Other Outreach costs (excluding per-diems, transport and ice) -$ 0.0% -$ 0.0% -$ 0.0%Other routine recurrent costs -$ 0.0% -$ -$

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

Subtotal Recurrent Costs 695,640$ 973,542$ 1,026,967$ Routine Capital Cost

Vehicles -$ 0.0% -$ 0.0% -$ 0.0%Cold chain equipment 31,337$ 3.1% 35,865$ 2.6% 37,976$ 2.6%Other capital costs 864$ 0.1% 882$ 0.1% 900$ 0.1%

Subtotal Capital Costs 32,201$ 36,747$ 38,876$ Supplemental Immunization Activities

Polio Campaigns -$ 0.0% -$ 0.0% -$ 0.0%Vaccines -$ -$ -$ Other operational costs -$ -$ -$

Measles Campaigns -$ 0.0% -$ 0.0% -$ 0.0%Vaccines -$ -$ -$ Injection supplies -$ -$ -$ Other operational costs -$ -$ -$

Yellow Fever Campaigns -$ 0.0% -$ 0.0% -$ 0.0%Vaccines -$ -$ -$ Injection supplies -$ -$ -$ Other operational costs -$ -$ -$

MNT Campaigns (CBAW) -$ 0.0% -$ 0.0% -$ 0.0%Vaccines -$ -$ -$ Injection supplies -$ -$ -$ Other operational costs -$ -$ -$

Enter other Campaigns -$ 0.0% -$ 0.0% -$ 0.0%Vaccines -$ -$ -$ Injection supplies -$ -$ -$ Other operational costs -$ -$ -$

Enter other Campaigns -$ 0.0% -$ 0.0% -$ 0.0%Vaccines -$ -$ -$ Injection supplies -$ -$ -$ Other operational costs -$ -$ -$

Subtotal Supplemental -$ -$ -$ Shared cost and other optional information

Shared Personnel Costs 263,040$ 26.0% 331,563$ 24.3% 375,922$ 25.7%Shared Transportation Costs 1,148$ 0.1% 1,475$ 0.1% 1,767$ 0.1%Building 19,462$ 1.9% 19,859$ 1.5% 20,264$ 1.4%Other optional information -$ 0.0% -$ 0.0% -$ 0.0%

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

Subtotal Optional 283,650$ 352,897$ 397,953$ GRAND TOTAL 1,011,491$ 1,363,186$ 1,463,796$

Routine (Fixed Delivery) 1,011,491$ 1,363,186$ 1,463,796$ Routine (Outreach Activities) -$ -$ -$ Supplemental Immunization Activities -$ -$ -$

Figure 32: RS – past and current costs

§


58

Figure 33: FBiH – future resource requirements Cost Category 2005 2006 2007 2008 2009 2010 2011Routine Recurrent Cost US$ US$ US$ US$ US$ US$ US$

Vaccines (routine vaccines only) 989,861$ 1,040,218$ 1,066,224$ 1,099,826$ 1,121,822$ 1,147,494$ 1,176,067$ Traditional Vaccines 67,196$ 70,270$ 72,419$ 73,364$ 74,831$ 76,328$ 78,652$ New and underused vaccines 922,665$ 969,948$ 993,805$ 1,026,462$ 1,046,991$ 1,071,166$ 1,097,415$

Injection supplies 32,638$ 34,188$ 35,109$ 36,151$ 36,874$ 37,656$ 38,667$ Personnel -$ -$ -$ -$ -$ -$ -$

Salaries of full-time NIP health workers (immunization specific) -$ -$ -$ -$ -$ -$ -$ Per-diems for outreach vaccinators/mobile teams -$ -$ -$ -$ -$ -$ -$

Transportation -$ -$ -$ -$ -$ -$ -$ Fixed site and vaccine delivery -$ -$ -$ -$ -$ -$ -$ Outreach activities -$ -$ -$ -$ -$ -$ -$

Maintenance and overhead 94,602$ 96,874$ 98,709$ 100,934$ 103,685$ 101,175$ 101,823$ Short-term training -$ -$ -$ -$ -$ -$ -$ IEC/social mobilization -$ -$ -$ -$ -$ -$ -$ Supervision, Monitoring and Disease Surveillance 1,913$ 1,951$ 1,990$ 2,030$ 2,071$ 2,112$ 2,154$ Other Outreach costs (excluding per-diems, transport and ice) -$ -$ -$ -$ -$ -$ -$ Other routine recurrent costs -$ -$ -$ -$ -$ -$ -$

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

Subtotal Recurrent Costs 1,119,014$ 1,173,231$ 1,202,032$ 1,238,941$ 1,264,452$ 1,288,437$ 1,318,711$ Routine Capital Cost

Vehicles -$ -$ -$ -$ -$ -$ -$ Cold chain equipment 33,348$ 6,138$ 1,233$ 5,188$ 16,238$ 197,761$ 12,555$ Other capital costs -$ 1,457$ 1,486$ -$ -$ -$ -$

Subtotal Capital Costs 33,348$ 7,595$ 2,719$ 5,188$ 16,238$ 197,761$ 12,555$ Supplemental Immunization Activities

Polio Campaigns -$ -$ -$ -$ -$ -$ -$ Vaccines -$ -$ -$ -$ -$ -$ -$ Other operational costs -$ -$ -$ -$ -$ -$ -$

Measles Campaigns -$ -$ -$ -$ -$ -$ -$ Vaccines -$ -$ -$ -$ -$ -$ -$ Injection supplies -$ -$ -$ -$ -$ -$ -$ Other operational costs -$ -$ -$ -$ -$ -$ -$

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

MNT Campaigns (CBAW) -$ -$ -$ -$ -$ -$ -$ Vaccines -$ -$ -$ -$ -$ -$ -$ Injection supplies -$ -$ -$ -$ -$ -$ -$ Other operational costs -$ -$ -$ -$ -$ -$ -$

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

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

Subtotal Supplemental -$ -$ -$ -$ -$ -$ -$ Shared cost and other optional information

Shared Personnel Costs 383,440$ 391,109$ 398,931$ 406,910$ 415,048$ 423,349$ 431,816$ Shared Transportation Costs 1,803$ 1,839$ 1,876$ 1,913$ 1,951$ 1,990$ 2,030$ Building 20,669$ 21,083$ 21,504$ 21,934$ 22,373$ 22,821$ 23,277$ Other optional information -$ -$ -$ -$ -$ -$ -$

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

Subtotal Optional 405,912$ 414,031$ 422,311$ 430,757$ 439,372$ 448,160$ 457,123$ GRAND TOTAL 1,558,274$ 1,594,857$ 1,627,062$ 1,674,886$ 1,720,062$ 1,934,358$ 1,788,389$

Routine (Fixed Delivery) 1,558,274$ 1,594,857$ 1,627,062$ 1,674,886$ 1,720,062$ 1,934,358$ 1,788,389$ Routine (Outreach Activities) -$ -$ -$ -$ -$ -$ -$ Supplemental Immunization Activities -$ -$ -$ -$ -$ -$ -$


59

Figure 34: RS – future resource requirements Cost Category 2004 2005 2006 2007 2008 2009 2010Routine Recurrent Cost US$ US$ US$ US$ US$ US$ US$

Vaccines (routine vaccines only) 279,188$ 282,141$ 284,962$ 287,812$ 290,856$ 294,209$ 297,151$ 85,065

212,086 21,663

127,464 127,464

- 3,346 3,346

- 22,795

- - - -

10,910 10,910

- - - -

483,329

- 49,883

- 49,883

- - - - - - - - - - - - - - - - - - - - - - - -

417,601 12,225 32,387

- - - - - -

462,213 995,425 995,425

- -

Traditional Vaccines 79,394$ 80,349$ 81,152$ 81,964$ 82,949$ 84,223$ $ New and underused vaccines 199,794$ 201,792$ 203,810$ 205,848$ 207,907$ 209,986$ $

Injection supplies 20,247$ 20,515$ 20,720$ 20,928$ 21,206$ 21,448$ $ Personnel 113,184$ 115,448$ 117,757$ 120,112$ 122,514$ 124,964$ $

Salaries of full-time NIP health workers (immunization specific) 113,184$ 115,448$ 117,757$ 120,112$ 122,514$ 124,964$ $ Per-diems for outreach vaccinators/mobile teams -$ -$ -$ -$ -$ -$ $

Transportation 2,971$ 3,030$ 3,091$ 3,153$ 3,216$ 3,280$ $ Fixed site and vaccine delivery 2,971$ 3,030$ 3,091$ 3,153$ 3,216$ 3,280$ $ Outreach activities -$ -$ -$ -$ -$ -$ $

Maintenance and overhead 21,125$ 21,548$ 21,979$ 22,418$ 23,091$ 24,267$ $ Short-term training -$ -$ -$ -$ -$ -$ $ IEC/social mobilization -$ -$ -$ -$ -$ -$ $ Supervision, Monitoring and Disease Surveillance -$ -$ -$ -$ -$ -$ $ Other Outreach costs (excluding per-diems, transport and ice) -$ -$ -$ -$ -$ -$ $ Other routine recurrent costs 9,688$ 9,882$ 10,079$ 10,281$ 10,487$ 10,696$ $

Testing vaccines 9,688$ 9,882$ 10,079$ 10,281$ 10,487$ 10,696$ $ Other (specify) -$ -$ -$ -$ -$ -$ $ Other (specify) -$ -$ -$ -$ -$ -$ $ Other (specify) -$ -$ -$ -$ -$ -$ $ Other (specify) -$ -$ -$ -$ -$ -$ $

Subtotal Recurrent Costs 446,403$ 452,564$ 458,588$ 464,704$ 471,370$ 478,864$ $ Routine Capital Cost

Vehicles 16,948$ -$ -$ -$ -$ -$ $ Cold chain equipment -$ -$ -$ 420$ 5,644$ 15,452$ $ Other capital costs -$ -$ -$ -$ -$ -$ $

Subtotal Capital Costs 16,948$ -$ -$ 420$ 5,644$ 15,452$ $ Supplemental Immunization Activities

Polio Campaigns -$ -$ -$ -$ -$ -$ $ Vaccines -$ -$ -$ -$ -$ -$ $ Other operational costs -$ -$ -$ -$ -$ -$ $

Measles Campaigns -$ -$ -$ -$ -$ -$ $ Vaccines -$ -$ -$ -$ -$ -$ $ Injection supplies -$ -$ -$ -$ -$ -$ $ Other operational costs -$ -$ -$ -$ -$ -$ $

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

MNT Campaigns (CBAW) -$ -$ -$ -$ -$ -$ $ Vaccines -$ -$ -$ -$ -$ -$ $ Injection supplies -$ -$ -$ -$ -$ -$ $ Other operational costs -$ -$ -$ -$ -$ -$ $

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

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

Subtotal Supplemental -$ -$ -$ -$ -$ -$ $ Shared cost and other optional information

Shared Personnel Costs 370,818$ 378,234$ 385,799$ 393,515$ 401,385$ 409,413$ $ Shared Transportation Costs 10,855$ 11,072$ 11,294$ 11,519$ 11,750$ 11,985$ $ Building 28,758$ 29,334$ 29,920$ 30,519$ 31,129$ 31,752$ $ Other optional information -$ -$ -$ -$ -$ -$ $

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

Subtotal Optional 410,431$ 418,640$ 427,013$ 435,553$ 444,264$ 453,150$ $ GRAND TOTAL 873,782$ 871,204$ 885,601$ 900,677$ 921,278$ 947,466$ $

Routine (Fixed Delivery) 873,782$ 871,204$ 885,601$ 900,677$ 921,278$ 947,466$ $ Routine (Outreach Activities) -$ -$ -$ -$ -$ -$ $ Supplemental Immunization Activities -$ -$ -$ -$ -$ -$ $

Documents

Bosnia and Herzegovina THE FINANCIAL …...Bosnia and Herzegovina THE FINANCIAL SUSTAINABILITY PLAN THE FINANCIAL SUSTAINABILITY PLAN v 1.23 ICC 1 Bosnia and Herzegovina version “FSP