Khyber Pakhtunkhwa Immunization Support Project (KPISP

Khyber Pakhtunkhwa Immunization

Support Project (KPISP) (GAVI

Assistance in kind)

2015-16 to 2019-20

ADP No. 497, Code 150525 (2015-16)

Total Cost Rs. 24,242.4 Million

Expanded Program on Immunization

Provincial Department of Health

Government of Khyber Pakhtunkhwa

http://www.google.com.pk/imgres?sa=X&biw=1078&bih=509&tbm=isch&tbnid=F_y-Ku4MJfZjLM:&imgrefurl=http://apps.who.int/immunization_delivery/en/&docid=RFQ_N1UosI6fxM&imgurl=http://apps.who.int/entity/immunization_delivery/EPI_logo.JPG&w=70&h=70&ei=jGcHU67mA-qs0QXbiYD4Bg&zoom=1&ved=0CKUBEIQcMBk&iact=rc&dur=1100&page=3&start=25&ndsp=15

Expanded Program on Immunization, Khyber Pakhtunkhwa (EPIKP) (GAVI Assistance in kind) 2015/16 to 2019/20

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KPISP PC1 2015/16 to 2019/20

Khyber Pakhtunkhwa Immunization Support Program

KPISP Planning Commission Form 1 ....................................................................................... 6 1. Name of the Project ............................................................................................................................ 6

2. Location ............................................................................................................................................. 6

3. Authorities Responsible for: ............................................................................................................... 6

4. Plan Provision .................................................................................................................................... 6

5. Project objectives and its relationship with Sectoral objectives ............................................................ 6

6. Description, Justification and Technical Parameters ............................................................................ 7

6.1 Description ................................................................................................................................... 7

6.2 Justification .................................................................................................................................. 8

6.3 Technical Parameters .................................................................................................................. 10

6.3.1 Program Goal ........................................................................................................................... 10

6.3.2 Program Milestones ................................................................................................................. 10

6.3.3 Specific Objectives and Implementation Strategies ................................................................... 10

6.3.4 Institutional/ Implementation Arrangements ............................................................................. 18

6.3.5 Performance-Based Payment Mechanism ................................................................................. 18

6.3.6 Disbursement Linked Indicators .............................................................................................. 20

7. Capital Cost Estimates ...................................................................................................................... 21

9. Demand and Supply Analysis ........................................................................................................... 22

10. Financial Plan and Mode of Financing .............................................................................................. 23

10.1 Funding Sources ....................................................................................................................... 23

10.2 Fund Flow Mechanism .............................................................................................................. 24

11. Project Benefits and Analysis ........................................................................................................... 24

11.1 Financial Benefits ..................................................................................................................... 24

11.2 Social Benefits with Indicators .................................................................................................. 24

11.3 Constrains to Women’s Participation ......................................................................................... 25

11.4 Beneficiary Population .............................................................................................................. 25

11.5 Employment Generation (direct and indirect)............................................................................. 25

11.6 Environmental Impact ............................................................................................................... 26

11.7 Impact of Delays on Project Cost and Viability .......................................................................... 26

12. Implementation Schedule ................................................................................................................. 26

13. Management Structure and Manpower Requirements ........................................................................ 26

14. Additional Decisions Required to Maximize Socio-economic Benefits from the Project .................... 26

15. Certificate ........................................................................................................................................ 28

Annexes ........................................................................................................................... 29 Annex 1: Situational Analysis of Expanded Program on Immunization ...................................................... 29

Annex-2: Organogram at Provincial Level under Integrated PC-1 .............................................................. 36

Annex-3: Organogram at District Level under Integrated PC-1 .................................................................. 37

Annex-4: Fund Flow Mechanism .............................................................................................................. 38

Annex-5: Program Description ................................................................................................................. 39

Annex-6: Governance, Management Reforms and Provincial Coordination ............................................... 40


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Annex-7: Environmental and Social Management Guideline (ESMG) ....................................................... 44

Annex-8: Budget Requirement for KPISP (detailed) .................................................................................. 53

Annex-9: Cost of Vaccines: Shares of GAVI Financing & Govt. Co-Financing ......................................... 87

Annex-10: Results Based Framework KPISP ............................................................................................ 88

Annex-11: Scaling-Up of Vaccine Logistics Management Information System (vLMIS) ......................... 108

Annex-12: Aide-Mémoire: NISP Appraisal Mission (March 30 – April 10, 2015) .................................... 109

Annex-13: GAVI Partnership Agreement by the provinces with commitment on Co-financing ................ 122

Annex-14: Endorsement of GAVI Partnership by Government of Khyber Pakhtunkhwa .......................... 124

Annex-15: Implementation Schedule and Activity Timelines................................................................... 125


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Acronyms

AD Auto-destruct

ADP Annual Development Program

AEFI Adverse Events Following Immunization

AFP Acute Flaccid Paralysis

AusAID Australian Assistance for International development

BCG Bacillus Calmette-Guerin

BHU Basic Health Unit

BPS Basic Pay Scale

CDS Comprehensive Development Strategy

CHC Community Health Center

cMYP Comprehensive Multi-year Plan

DFID Department of International Development

DGHS Director General Health Services

DHS Director Health Services

DLI Disbursement Linked Indicator

DPT Diphtheria Tetanus Pertussis

DQS Data Quality Self-Assessment

DSV District Superintendent Vaccination

EPI Expanded Program on Immunization

EVM Effective Vaccine Management

FAP First-Aid Post

FATA Federally Administered Tribal Areas

FMT Female Medical Technician

GAVI Global Alliance for Vaccines and Immunization

GAVI HSS GAVI Health System Strengthening

GDP Gross Domestic Product

GGE General Government Expenditure

GGHE General Government Health Expenditure

GHE Government Health Expenditure

GoKP Government of Khyber Pakhtunkhwa

GVAP Global Vaccine Action Plan

HMIS Health Management Information System


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HR Human Resources

ICC Inter-agency Coordinating Committee

ICS Immunization-system-component-specific

IEC Information, Education and Communication

ILR Ice-Lined Refrigerator

IP Immunization Practices

IPV Inactivated Polio Vaccine

KAP Knowledge, Attitude and Practice

KPISP Khyber Pakhtunkhwa Immunization Support Project

KP Khyber Pakhtunkhwa

LHS Lady Health Supervisor

LHV Lady Health Visitor

LHW Lady Health Worker

M&E Monitoring and Evaluation

MCHC Maternal and Child Health Center

MDGs Millennium Development Goals

MICS Multiple Indicator Cluster Survey

MIS Management Information System

MLM Mid-Level Manager

MNCH Maternal Neonatal and Child Health

MNT Maternal and Neonatal Tetanus

MONHSRC Ministry of National Health Services Regulation and Coordination

MT Medical Technician

OPV Oral Polio Vaccine

P&D Planning and Development

PC-1 Planning Commission Form No.1

PCV-10 Pneumococcal Conjugate Vaccine - 10

PDHS Pakistan Demographic and Health Survey

PEI Polio Eradication Initiative

Rs. Pakistani Rupee

PoA Plan of Action

POL Patrol Oil Lubricants

RBM Results-Based Monitoring

RED Reaching Every District


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RHC Rural Health Center

SIA Supplementary Immunization Activity

SIS Skilled Immunization Staff

SOPs Standard Operating Procedures

THQH Tehsil Headquarters Hospital

TPV Third Party Vendor

TT Tetanus Toxoid

UC Union Council

UNICEF United Nations Children's Fund

vLMIS Vaccines Logistics Management Information System

VPD Vaccine Preventable Disease

WHO World Health Organization


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KPISP Planning Commission Form 1

5. Project objectives and its relationship with Sectoral objectives

The specific objectives of the project are to fulfill the development agenda of the Government

of Khyber Pakhtunkhwa outlined in Comprehensive Development Strategy (CDS) 2010-17:

‘Attainment of a secure, just and prosperous society through socioeconomic and human

1. Name of the Project

Khyber Pakhtunkhwa Immunization Support Project, (KPISP) (GAVI Assistance in kind), ADP

No. 497, Code 150525 (2015-16) (as per ADP)

2. Location

All 25 districts of Khyber Pakhtunkhwa province

3. Authorities Responsible for:

Sponsoring Agency

Government of Khyber Pakhtunkhwa Health Department and GAVI

Execution Agency

Health Department, Government of Khyber Pakhtunkhwa through

Director General Health Services Office and Deputy Director EPI

Operation and

maintenance

Health Department, Government of Khyber Pakhtunkhwa through

Directorate General Health Services Office and Deputy Director EPI

Financing Source

Government of Khyber Pakhtunkhwa, NISP (GAVI, World Bank,

BMGF, etc.)

4. Plan Provision

Provision in the current

year PSDP and ADP

The project is included in the Health Sector, Khyber Pakhtunkhwa

ADP 2015-16 at Serial No.497 and Code No. 150525. Rs. 1800 million

(Khyber Pakhtunkhwa allocation, Rs. 150 million, Donors allocation

Rs. 1650 million) have been allocated to the project for 2015-16.


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resource development, creation of equal opportunities, good governance and optimal

utilization of resources in a sustainable manner’.1

Under its recently promulgated Integrated Development Strategy 2014-18, the Government of

Khyber Pakhtunkhwa explicitly acknowledges the serious challenges that the health sector is

facing today. These include: ongoing conflict and extremist propaganda against immunization

inhibiting public health activities, poor governance and weak regulatory framework leading to

inefficient service delivery, limited availability of skilled workforce and weak monitoring and

internal control systems. This project provides the platform to further aims of the Government

of Khyber Pakhtunkhwa to addressing deficiencies in the health care system, improve

management at the facility and supervisory levels through an integrated approach.

The priority outcomes delineated in the Khyber Pakhtunkhwa Health Sector Strategy2 2010-17

have been used as foundation for designing the strategies3 and interventions and setting

programmatic objectives as follows:

• 90% of the children receive vaccination according to EPI schedule

• Polio transmission is reduced to zero

• Measles and Neonatal Tetanus are eliminated

Through its implementation, project will augment the immunization specific outcomes and

targets laid down in Integrated PC-1 by increasing immunization coverages among children

and women and reducing burden of vaccine preventable diseases.

6. Description, Justification and Technical Parameters

6.1 Description

Immunization is one of the most fundamental competencies of public health programs.

Therefore, EPI aims to contribute in economic development of the province through improved

human workforce and decrease morbidity and mortality owing to vaccine preventable

diseases.4

Expanded Program on Immunization (EPI) in Pakistan including Khyber Pakhtunkhwa

province was initiated in 1979-80 with the ultimate similar objectives of reduction in morbidity

and mortality caused by six diseases known to be killer diseases for children as to be

Diphtheria, Pertussis, Tuberculosis, Whooping Cough, Tetanus and Polio. In addition to this,

the program also worked to immunize pregnant ladies with Tetanus Toxoid vaccine to

gradually eliminate Neonatal Tetanus. In due course immunization against Hepatitis B in 2006,

Hemophilia Influenza Type B (Hib) in 2008 and Pneumococcal Pneumonia in 2012 were

added.

Routine immunization is the basis of the EPI activities. Vaccinations are done in static EPI

centers, and throughout-reach and mobile vaccination teams. The immunization schedule

1 Comprehensive Development Strategy 2010-17, Government of Khyber Pakhtunkhwa Available at: http://lgkp.gov.pk/wp-content/uploads/2014/03/11.-Report-on-Khyber-Pakhtunkhwa-

Comprehensive-Development-Strategy-2010-2017.pdf

2 Khyber Pakhtunkhwa Health Sector Strategy 2010-17, Government of Khyber Pakhtunkhwa Available at: http://www.healthkp.gov.pk/downloads/HSS-KP.pdf 3 (1) Enhancing coverage and access to essential health services especially for the poor and vulnerable, (2) A

measureable reduction in morbidity and mortality due to common diseases especially among vulnerable segments of the population, (3) Improved human resource management, and (4) Improved governance and accountability and improved regulation and quality assurance.

4 Childhood Tuberculosis, Poliomyelitis, Hepatitis-B, Diphtheria, Pertussis, Tetanus, Measles, Haemophilus Influenza Type b, Pneumonia, Rotavirus and Neonatal Tetanus

http://lgkp.gov.pk/wp-content/uploads/2014/03/11.-Report-on-Khyber-Pakhtunkhwa-Comprehensive-Development-Strategy-2010-2017.pdf

http://lgkp.gov.pk/wp-content/uploads/2014/03/11.-Report-on-Khyber-Pakhtunkhwa-Comprehensive-Development-Strategy-2010-2017.pdf

http://www.healthkp.gov.pk/downloads/HSS-KP.pdf


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including the above vaccines stretches over the child’s first year and tetanus vaccination is

given to women of childbearing age. The involvement of Maternal Neonatal and Child Health

services, trained Dais, community health workers like Lady Health Workers (LHWs) &

Community Midwives together with Health Education forms part of an integrated program

approach within the sector. Priority interventions include: capacity building, enhancing

community participation, effective vaccine and logistics management, case-based surveillance,

ensuring sufficient and sustainable funding, and strengthening partnerships for immunization.

6.2 Justification

Although EPI is being implemented for nearly thirty five years in Pakistan, the outcomes of

the immunization system remain dismal in Pakistan in general and Khyber Pakhtunkhwa in

particular. Pakistan is the one of the three remaining countries where Poliomyelitis is endemic

and yet to be eradicated. In 2014, 306 Polio cases were reported in Pakistan, with 68 in Khyber

Pakhtunkhwa province. The routine immunization coverages for other vaccines also remain

much below the required standards which have also resulted in recurrent outbreaks of

transmissible diseases such as measles. According to Pakistan Demographic and Health Survey

2012, nearly 47% children of age 12-23 months had not received all the required doses of

vaccines. The Government of Khyber Pakhtunkhwa is fully committed to achieve this strategic

aim. Provision of immunization services to children and their mothers has been a priority of

Government of Khyber Pakhtunkhwa already reflected in all the provincial health policies and

plans. However, there are numerous chronic systemic problems and bottlenecks that have

plagued the overall functioning of EPI. This critical analysis, described under seven

immunization program components, is presented in Annex 1.

In order to address these systemic problems and bottleneck, in 2014, the Government of Khyber

Pakhtunkhwa developed its Comprehensive Multi-year Plan (cMYP) for Immunization

through which year-wise resource requirement for the period 2014-18 were projected and also,

potential funding gaps were analyzed.

The present project provides a financing mechanism for the cMYP by aligning support through

a single financing platform for Routine Immunization not only from the existing government

resources but also from the donors and development partners (GAVI, UNICEF, JICA, World

Bank, Gates Foundation etc.)

Expanded Program on Immunization (EPI) is one of the major health programs that require

substantial proportion of the total budget allocation every year. However, now it has been

realized that like other provinces, the Government of Khyber Pakhtunkhwa has to finance its

immunization program from its own resources after the end of 7th National Finance

Commission (NFC) Award in June 2015. In addition, new vaccines are to be introduced in

2015 and 2016. Therefore, the existing Integrated Project does not fulfil the entire resource

requirement for EPI without which it is not possible for the Government of Khyber

Pakhtunkhwa to continue with provision of immunization services and to reduce burden of

vaccine preventable diseases (VPD)5.

5 Childhood Tuberculosis, Poliomyelitis, Diphtheria, Pertussis, Neonatal tetanus, Hepatitis B, Haemophilus influenza type b (Hib), Pneumococcal pneumonia and Measles


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Under the Provincial Health Sector Strategy 2010-17, the Government of Khyber Pakhtunkhwa

(GoKP) has approved integration of health service delivery with special focus on maternal,

child and neonatal health, immunization and nutrition. Four federal vertical health programs

have been integrated at provincial and district levels, namely: Maternal, Neonatal and Child

Health (MNCH) Program, Lady Health Workers (LHWs) Program, Expanded Program on

Immunization (EPI) and Nutrition Program. However, the following essential technical

components of EPI have either not been financed or partially financed under the Integrated

Project:

• Procurement of vaccines and injection supplies

• Developing accountability mechanisms by introduction of online monitoring through

GPRS tracking of supervisory and immunization staff

• Availability of skilled field monitoring staff at district level

• Capacity building of immunization staff on introduction of new vaccines

• Replacement of outdated cold chain equipment, maintenance of cold chain equipment

and expansion in vaccine storage space on account of introduction of new vaccines

• Strengthening of vaccine management system through scaling up of Vaccine Logistic

Management Information System (vLMIS) or online EPI MIS

• Surveillance of VPD and computerization and online data reporting system

• Development and implementation of union-council level EPI micro-plans

• Adequate logistics for EPI service delivery, monitoring and supervision

Financial sustainability of EPI is the primary responsibility of the Government of Khyber

Pakhtunkhwa. This aspect is critical for the attainment of immunization outcomes. If the

immunization system in Pakhtunkhwa is not adequately financed and efficiently managed, the

immunization gains made so far will not be sustained. Consequently, the Government of

Khyber Pakhtunkhwa will not only fail in meeting its moral obligations to its populace but also

in realizing its commitments for achieving national and global immunization targets, including:

eradication of Poliomyelitis and elimination of Measles and Neonatal Tetanus.6’7

In this context, the present project, Khyber Pakhtunkhwa Immunization Support Project

(KPISP), is specifically tailored to meet the essential needs of immunization system. It builds

upon the strengths of the existing Integrated Project and provides the opportunity to supplement

effectiveness of Integrated Project by not only focusing on availability of vaccines, injection

6 Despite being a signatory to Global Vaccine Action Plan (GVAP), Pakistan has repeatedly missed on the targets

of eradicating Polio and eliminating Measles and Maternal and Neonatal Tetanus which has brought bad name to the country among the global community

7 At the current rate of progress, it is highly unlikely that Pakistan will meet the Millennium Development Goals (MDG) targets on health by 2015 (ref. Integrated Development Strategy 2014-18, Government of Khyber Pakhtunkhwa)

Available at: http://lgkp.gov.pk/wp-content/uploads/2014/08/Integrated-Development-Strategy.pdf

http://lgkp.gov.pk/wp-content/uploads/2014/08/Integrated-Development-Strategy.pdf


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supplies, cold chain, and other logistics but also to reform and strengthen the existing EPI

management structures and business processes through establishing performance-based

practices and ensuring accountability in management practices.

6.3 Technical Parameters

6.3.1 Program Goal

The overarching goal of Khyber Pakhtunkhwa Immunization Support Project is to increase the

equitable coverage of services for immunization against vaccine preventable diseases (VPD),

including poliomyelitis, for children between 0 and 23 months across the province.

6.3.2 Program Milestones

The following program milestones are set to assess the progress towards accomplishing the

overarching goal:

Program Milestones 2012 2015/16 2016/17 2017/18 2018/19 2019/20

Increase % of Penta3 coverage 70 73 78 80 85 90

Increase % of Measles 1 coverage 58 60 65 70 75 80

Increase % of population protected at birth

from neonatal tetanus 66 60 65 70 75 80

Increase % of OPV3 coverage 76 78 82 86 90 95

Increase % of PCV-10 coverage NA 73 78 80 85 90

Increase % of children (12-23 months) fully

immunized 53 60 65 70 75 80

Increase % of districts that have at or above

80% Penta3 coverage 52 60 65 75 85 90

Decrease Penta3 coverage in the lowest wealth

quintile less than % points of coverage in the

highest wealth quintile

43 35 30 25 20 15

Reduce % point difference between Penta-1

and Penta-3 coverage 10 9 9 8 8 7

Increase % of children whose mothers intend

to vaccinate children NA 10 20 25 30 35

6.3.3 Specific Objectives and Implementation Strategies

The above mentioned program milestones will be reached by achieving the following specific

objectives and the respective implementation strategies:

Objective 1: Availability of qualified human resources

Implementation Strategies:

1.1 Availability of skilled immunization staff

Once EPI starts operating the under the umbrella of Integrated Project, its requirement

for technical and managerial staff at the provincial level will be met from the new

management structure under the integrated setup (Annex 2 & 3). However, EPI will

require recruitment of new vaccinators at the district level because the existing

vaccinators are overburdened by Polio Eradication Initiative activities and also an

estimated population of 2.5 million is not covered by Lady Health Workers (LHWs).


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In order to ensure 100% coverage of routine immunization for children 0-23 months,

500 vaccinators will be recruited to provide outreach services in the LHW uncovered

area. The provision of recruitment of 500 vaccinators has already been under the

Integrated Project PC-I and the Government of Khyber Pakhtunkhwa has already

allocated Rs. 417 million for their remunerations.

In LHW-covered areas, the number of skilled immunization staff will be increased by

training 5000 existing Lady Health Workers (LHWs) in injection giving technique

under supervision of the vaccinators of the concerned union councils. In addition, EPI

trainings will be imparted to medical technicians and Lady Health Visitors (LHVs) to

increase the number of skilled immunization staff within the health care facilities.

1.2 Capacity building and skill development

The existing managerial staff will be trained in planning and management through Mid-

Level Managers (MLM) Training Program and 3 trainings will be imparted every two

years. In addition all other technical staff be trained based on their job requirements.

One hundred and fifty district trainers will be trained at provincial level for conducting

further trainings at the district level.

Overall, the training activities will be guided through development of annual training

and capacity building plan. These include trainings for: new vaccinators, refresher

courses for the existing vaccinators, introduction of new vaccines (IPV and Rotavirus

vaccine), surveillance, communication and advocacy. As per the guidelines from the

World Health Organization, refreshers will be conducted every two years.

The effectiveness of trainings of EPI managerial and technical staff will be enhanced

by conducting training need assessment and introducing a system of pre and post

trainings assessments. A provision of Rs. 131 million has already been allocated under

Integrated PC-1 and in addition, Rs. 11 million will be provided by Japanese

International Cooperation Agency (JICA) (Annex 8).

1.3 Staff motivation for improved performance

The staff motivation will be enhanced through a multiple pronged strategy comprising

non-monetary and monetary incentives: encouragement, capacity building, supportive

supervision and introduction of P4P scheme.

Performance based incentives inculcate a health competition in achieving desired goals

and objectives. The Government of Khyber Pakhtunkhwa plans to introduce Pay for

Performance (P4P) Scheme for technical and managerial staff at provincial, district and

union council levels. Service agreement will be signed through technical assistance for

designing P4P scheme.

Objective 2: Uninterrupted supply of vaccines, cold chain equipment and other logistics


2.1 Uninterrupted supply of vaccines and injection equipment

Uninterrupted supply of vaccines is a fundamental requirement of a functional

immunization program. Procurement of vaccines and injections supplies is the most

expensive component of EPI. During the next five years (2015/16 to 2019/20), it is

expected that EPI in Khyber Pakhtunkhwa will require Rs. 21,416 million for procuring

vaccines and injection supplies which amounts to 89% of the total budgetary

requirement for the entire program. Out of this requirement, GAVI will provide Rs.


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17,857 million under its grant for vaccines. The Government of Khyber Pakhtunkhwa

will provide Rs. 3,559 million for this purpose. This mechanism applies only to selected

vaccines, namely: Pentavalent, PCV-10 and Rotavirus vaccine. The Government of

Khyber Pakhtunkhwa has already agreed for providing its share for co-financing of

GAVI vaccines (Annex 9 & 14)

2.2 Expansion in storage capacity of vaccines and logistics

The current storage capacity is far below the required because, firstly, majority of the

cold chain equipment is outdated and secondly, new vaccines, IPV and Rotavirus, will

be introduced in 2015 and 2016 respectively. The outdated cold chain equipment

including cold rooms will be replaced in phased manner. In addition, new cold chain

equipment will be required establishing new Fixed EPI centers. Five new cold rooms

will be installed. Six hundred electricity operated Ice-liner Refrigerators (ILRs) will be

purchased in two years to replace the outdated ILRs and also to increase the storage

capacity for new vaccines. For areas where electricity is not available, 340 new solar

operated ILRs will be supplied.

In addition to procurement of cold rooms and ILRs, other cold chain equipment and

related supplies including cold boxes, vaccine carriers, electricity generators etc. will

be procured and supplied (Annex 8). A complete inventory will be maintained for cold

chain equipment with regular updating. Almost 15% of the total cost for procurement

of cold chain has been allocated for procurement of supplies and spare parts in the next

five years. All the cold chain equipment will be procured from WHO prequalified

venders.

Similar to storage capacity of vaccines, the current capacity of EPI warehouse is well

below par and cannot meet the future requirements. A new warehouse will be

constructed at the provincial level for EPI logistics comprising injection supplies,

stationary, buffer cold chain equipment and other non-vaccine consumables. In

addition, with support from UNICEF, three new warehouses will be constructed at

divisional/district level whereas three existing warehouses/stores will be renovated.

2.3 Innovative technologies for improving cold chain temperature management

Vaccines form the major bulk of the budget requirement; therefore, a fully functional

cold chain system is the lifeline for any immunization program because it ensures that

effectiveness and efficacy of the vaccines are maintained at all levels by keeping

vaccines at an appropriate temperature. Keeping in view the frequent power

breakdowns and harsh weather conditions, it is imperative that not only enough storage

capacity is available at provincial, district and health facility level but also the

maintenance of appropriate temperature is monitored vigilantly to avoid wastage of

precious resources.

State of the art technologies will be installed to strengthen monitoring of cold chain

temperature records at provincial, district and health care facility levels. It includes

installation of Smart-view Cold Room Temperature Monitoring systems for cold rooms

and 30-day temperature loggers for ILRs at district and health care facility levels.

Service agreements will be signed for technical support for Cold Room Temperature

Monitoring systems including: repair and maintenance, updating of software etc.

2.4 Effective vaccine management through improved planning

Effective vaccine management is a continuous process and requires active involvement

of workforce ranging from provincial EPI managers to vaccinators and drivers of the


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vaccine distributing vehicles. According to the recently completed, Effective Vaccine

Management (EVM) assessment report, Government of Khyber Pakhtunkhwa is

committed to pay special attention to this critical component because the scores

achieved are well below par. The current budget allocation is estimated on the basis of

EVM improvement plan. It includes developing a detailed program of activities to

implement the EVM improvement plan with defined milestones, oversights of the

implementation of the EVM improvement plan, training of vaccinators on EVM

criteria, training of store keeper on stock management and waste management, trainings

on new Smart-view System, Fridge tag training, vehicle drivers training, cold chain

technicians training on preventive measures, injury hazards and repair and maintenance

of cold chain.

2.5. Contracting out repair and maintenance of cold chain equipment

The EPI also plans to contract out repair and maintenance of cold chain equipment at

provincial and district levels. This will allow the government sector to benefit from the

private sector for timely and quality services. Service contracts will be signed after

selection of the successful firms through a transparent competitive bidding process. The

overall process will be carried out under the existing government rules and regulations

for procuring technical services.

Objective 3: Strengthening and optimization of immunization service delivery


3.1 Expansion in geographical coverage of static, outreach and mobile EPI services

The existing capacity of immunization service delivery will be strengthened and

optimized by implementing three strategies: Firstly, geographical coverage of fixed-

site immunization services will be increased by establishing new fixed EPI centers in

454 health facilities (Basic Health Units/ Rural Health Centers/ other PHC facilities)

that are not offering immunization services. Preference will be given to those union

councils which do not have a Fixed EPI Center. These new facilities will be equipped

with cold chain equipment and trained immunization staff. In addition, outdated cold

chain equipment will be replaced in the existing fixed EPI centers.

Outreach and mobile immunization services cover those hard to reach areas from where

it is difficult for the general population to come to EPI Fixed-centers for vaccination.

As a result, a large majority of children and women do not receive vaccines as per

schedule. All efforts will be made to integrate routine immunization and polio

eradication initiative activities to avoid duplication of efforts and developing synergies.

Vaccinators will be provided fixed Travelling Allowance on monthly basis for outreach

and mobile vaccination activities. They will also be responsible for providing vaccine

to the LHWs.

3.2 Contracting-out immunization services in urban slums and hard to reach areas

The Government of Khyber Pakhtunkhwa plans to improve the geographical coverage

of immunization services by involving private sector and civil society organizations in

selected 110 councils, mainly in urban slums and hard to reach areas. This will allow

the public sector to benefit from the existing network and coverage of private health

sector for timely and quality services. Service contracts will be signed after selection of

the successful firms through a transparent competitive bidding process. The overall

process will be carried out under the existing government rules and regulations for

procuring technical services.


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Objective 4: Improved oversight, coordination and program management performance


4.1 Improving oversight and management through development of

implementation guidelines and reporting instruments

Strengthening of planning and management and introduction of new interventions

demand developing of new guidelines, protocols and monitoring and reporting

instruments. Technical assistance will be provided to the existing EPI management staff

for developing new implementation guidelines and protocols.

4.2 Performance improvement through development of comprehensive annual

work plans

Governance and program management will be strengthened through building staff

capacities in policy and planning, by aligning PC-1s with the provincial cMYP for EPI,

and institutionalizing accountability mechanisms through regular progress assessment

and performance-based financing.

EPI specific annual work plans will be developed for service delivery, vaccine and cold

chain management, human resource management, supervision and monitoring and

communication and advocacy both at provincial and district levels. For this purpose, 6

planning workshops are planned every year: one for developing provincial annual work

plan and 5 for developing district annual work plans. In addition, the Federal EPI Cell

will provide technical assistance for organizing five District Immunization Waste

Action Planning (DIWAP) workshops followed by implementation of DIWAP.

The Government of Khyber Pakhtunkhwa also plans to update the existing cMYP

targets and activities on annual basis whereas a comprehensive review of cMYP is

planned for 2018.

4.3 Strengthening monitoring system through computerization of Union Council

micro plans

Planning processes will be strengthened down to the service delivery level. According

to the Reaching Every District (RED) Strategy, computerized micro plans for

implementation of immunization service delivery will be prepared in every union

council. The micro-plan will have a very precise coverage estimate for each Union

Council. As a policy, LHWs and Vaccinators will prepare joint micro-plans for

immunization in each UC. An online database will be created to enable data entry of

the micro-plans in the agreed format by union council. These plans will be consolidated

for submission upwards and will be used by the higher level supervisors and monitors

for assessing field activities.

4.4 Institutionalizing regular performance reviews

Performance of EPI will be assessed and tracked against mutually agreed Disbursement

Linked Indicators (DLIs) and targets set under a Results-Based Monitoring (RBM)

Framework (Annex 10). The DLI results will be verified by third-party independent

audit firm contracted by MONHSRC.


15

There will be biannual review meetings at the provincial level formalized as a

provincial monitoring/ technical committee chaired by the Secretary of Health to

evaluate performance of the routine program and polio/measles eradication activities.

The oversight by provincial committees will be supplemented by monthly review

meetings held at the district level. Internal monitoring of the routine immunization

activities will be complemented and validated annually by independent 3rd party

monitoring to be conducted by firms hired on competitive basis by the federal EPI cell.

4.5 Strengthening field monitoring and supervisory systems

Inadequate field monitoring and supervisory staff is an important aspect of weak

program management. The root causes include lack of workforce, unavailability of

means of transportation and lack of resources for operational costs of the field activities

at all levels in general and at district level in particular.

This project is highly focused on strengthening the monitoring and supervisory system

at the service delivery level. For this purpose, a total number of 25 District

Superintendent Vaccination (one per district) and 125 Tehsil/ Town Superintendent

Vaccination (5 per district on average) will be recruited for district and sub-district

levels respectively. This work force will bridge the gap for field monitoring and monitor

and supervise field staff not only for EPI but also other health programs.

New vehicles and motor cycles will be procured for strengthening field monitoring and

supervision by provincial, district and sub-district staff. Five Suzuki Jimny Jeeps will

be procured for the provincial EPI Team and 25 as a shared vehicle for District EPI

Coordinators and District Surveillance Officer. Similarly, 150 motor cycles will be

procured for 25 District Field Supervisors and 125 Multipurpose Field Supervisors. All

procurement will be authorized as per the procurement procedures laid down under

Integrated PC-1. The Government of Khyber Pakhtunkhwa is committed to provide

adequate resources for the operational costs of field visits.

4.6 Innovative technologies for oversight and robust monitoring

It has been a long standing concern that the EPI field staff often do not go to the field

and consequently, monitoring systems has been crippling over years. In order to

overcome this long standing issue, the Government of Khyber Pakhtunkhwa plans to

launch a web-based GPRS Tracking System (eVaccs) for supervisors and vaccinators.

This innovative technology will enable the district and provincial managerial staff to

analyze and verify whether field supervisors and vaccinators are visiting their assigned

areas for vaccination, monitoring and supervision.

4.7 Adequately financed management support systems and program operations

The historical analysis indicates that substantial expenditures on the basis of one-time

budget allocation for capital items do not produce the desired results because these are

not supported by budget allocation for on-going operations. Therefore, provision of

adequate budget for operating expenses is important for continuity and sustainability of

immunization related activities.

In order to meet the requirements of new staff structure reporting guidelines and

maintenance of management operations, adequate budget has been allocated for POL

for supervisory vehicles and motor cycles, fuel for electricity generators for cold rooms,

printing and stationery, office expenses (electricity, gas, telephone, fax, couriers etc.),

repair and maintenance of vehicles, operating expenses for vLMIS/ online EPI MIS,


16

and transportation of vaccines, injection supplies and other non-vaccines items from

provincial to district to health facility levels.

Objective 5: Improved performance of surveillance system, data quality and routine

monitoring/reporting


5.1 Strengthening of surveillance system and epidemiological response to disease-

outbreaks

Despite being the backbone of a responsive EPI, surveillance remains a neglected entity

and is primarily limited to surveillance of suspected Polio cases. The critical capacity

of surveillance will be greatly enhanced. The main aims is to establish a well-

functioning and sustained EPI and vaccine preventable disease reporting system in 3

years encompassing surveillance, online reporting and response. The strengthening will

build on the capacities and experience of the system for surveillance of acute flaccid

paralysis (AFP) supported by WHO, which rapidly and comprehensively assembles

data from the basic health facility to provincial and national levels.

The overall performance of surveillance monitoring/reporting will be enhanced by

recruiting one surveillance officer per district for increasing reliability, accuracy,

completeness and timeliness of reporting data both from active and passive surveillance

sites. Technical and health facility staff will be sensitized and trained in VPD

surveillance. Surveillance reporting and monitoring tools will be reviewed and new

tools, where required, to meet the program requirements. Existing network of

surveillance system will be expanded through integration with other disease control

initiatives.

District teams will be trained and supervised in launching epidemiological response in

case of disease-outbreaks. It includes: case detection and notification, case and outbreak

verification and investigation, data management, data quality audit, laboratory

equipment, transportation of laboratory samples, and data quality audit.

5.2 Innovative IT solutions for improving quality of surveillance data

The Government of Khyber Pakhtunkhwa plans to install introduce Android-based

online Surveillance Reporting System for improving reporting and quality of

surveillance data. Android cell phones will provided to the surveillance centers for

online reporting system. This innovative system will help in reducing delays in

reporting system and facilitate timely decision making.

5.3 Strengthening of routine immunization data reporting and feedback systems

At present there is a discrepancy in program reported data and the survey data due to

lack of a functional management information system (MIS), with limited monitoring

and oversight.

The performance of routine EPI monitoring/reporting will be enhanced by increasing

reliability and accuracy of administrative data increase through reduction in

discrepancy ratio (between administrative and survey data). Regular assessment of the

data quality will be used to identify the gaps in the routine immunization data

monitoring and reporting system. Technical and health facility staff will be sensitized

and trained on the importance of validity and verification of data. Data Quality Self-


17

assessment (DQS) system will be developed and implemented to improve data quality

and reliability. Reporting and monitoring tools will be reviewed and new tools, where

required, to meet the program requirements. Technical assistance will be provided to

develop new reporting and monitoring guidelines and instruments to meet the

requirement of this project (Annex 8).

Data collection and reporting practices will be streamlined by introducing regular

feedback mechanism from provincial and district administrative setups to their

subordinate offices. Online reporting system will be established in every district.

5.4 Scaling-up of vLMIS or Online EPI MIS

It is essential that the EPI achievements, VPD surveillance and stock levels of vaccines

are monitored at all levels for regular monitoring, VPD surveillance and avoiding stock

outs and maintaining continuous supply of vaccines. Online MIS system across all

districts of Khyber Pakhtunkhwa will play an instrumental role in this regards because

it requires real time data entry of daily vaccination, VPD cases, vaccine stocks and

quarterly data updating of cold chain equipment (Annex 11). An effective and

sustainable online MIS system will ensure adequate data flow, quality and quantities of

vaccines are available at the service delivery point and will give access to demand

forecasting, capacity planning, analysis and modeling based on valid data and

consumption, stock status and real-time supply chain management capabilities.

This information is monitored through web-based technology both at district and

provincial levels. Effectiveness of reporting and monitoring about availability of

vaccines and functionality of cold chain will be strengthened by institutionalizing

online reporting system.

The existing management staff do not have the technical capacity to take up this

challenge. Therefore, service agreement will be signed with any entity/ organization

having a rich experience in implementation and management of online MIS. Service

contracts will be signed after selection of the successful firms through a transparent

competitive bidding process. The overall process will be carried out under the existing

government rules and regulations for procuring technical services. Capacity of the

government staff will be built to gradually take over this initiative over a period of two

years. Health care facility staff will be trained on online MIS. Computers, accessories

and online software will be provided for data recording and on-line reporting.

Objective 6: Demand generation through effective communication and advocacy


6.1 Advocacy and partnership building

Advocacy seminars will be organized for parliamentarians, bureaucratic leadership,

religious leaders, media persons, philanthropists and donor community. Periodic

financial projections will be used for advocacy for resource mobilization and

sustainability by giving presentations and briefings. In addition, efforts will be made

for so that funding for EPI activities is gradually transferred from the development

budget to recurrent/regular budget in order to maximize financial sustainability of the

program.

Besides effort for increasing financial sustainability of EPI, political bodies and senior

religious figures will be sensitized on the benefits of routine immunization. A sustained

communication presence will be ensured at all levels to achieve the program objectives.


18

Advocacy activities will be coordinated with the social mobilization messaging – and

raise political awareness to support these activities designed to enhance awareness of

parents regarding the importance of immunization, increase the involvement of

community and political leadership in immunization and improve the motivation and

interpersonal skills of vaccination staff.

Provincial education department will be approached and convinced on awareness of

immunization and its importance to improve child health outcomes will be added as a

component of the standard school curriculum.

6.2 Behaviour change communication and creating awareness

Standardization of immunization related information and content materials will ensured

and efforts will be made to improve look of IEC/BCC materials and increasing visibility

of immunization sites. Promotion of positive attitude towards immunization will be

enforced through creating synergies between multiple channels of communication.

These activities will include: awareness creation through electronic and print media

along with radio broadcasts highlighting the importance and benefits of immunization

will be utilized across the province. Key government officials and community figures

at provincial and district level will be mobilized by involving them in immunization

activities in the form of launching and making public statements in support of the

program.

Knowledge and attitude of the target population toward immunization will be improved

by focused community mobilization and communication interventions. Staff including

LHWs will be trained on behaviors change communication. Civil society will be

engaged in generating demand for immunization services. Mother and child health

weeks and special immunization days will be arranged. In addition, effective awareness

campaign will be launched through print and electronic media.

6.3 Research, evidence generation and dissemination

Operations research and other studies will be conducted for formative research and

assessing the effectiveness of the communication strategies. In addition, EPI policy

briefs will be developed and EPI annual progress report will be published and

disseminated every year. Case studies based on already identified human interest stories

will also be developed for sensitization decisions makers and target communities.

6.3.4 Institutional/ Implementation Arrangements

As envisaged under the Integrated PC-1, provincial EPI activities will be implemented by the

provincial health department under the leadership of Director Health Services (DHS). The

project will use the existing institutional arrangements both at provincial and district levels

(Annex 2 & 3).

The Director Health Services and Deputy Director EPI will coordinate with finance

department, planning and development department, accountant general office, concerned audit

offices and also with other branches of the provincial health department.

6.3.5 Performance-Based Payment Mechanism

The project will be financed both from the government budget and external donor funding. A

single financing agreement will govern all flow of funds under this project (Annex 4).

In order to access the donor-funded financing, the project will employ Disbursement Linked

Indicators (DLIs) to finance project results, which will serve as an incentive to achieve these

results by disbursing a portion of the total project financing only once key results have been


19

met under each component. Progress of the province will be monitored through assessment

against the agreed upon province-specific targets for each indicator (Annex 10). The DLI

results will be verified by third-party independent audit firm contracted by MONHSRC. The

reports of these audits will be reviewed by the National Immunization Coordination Committee

(ICC), before forming the basis of the disbursement request made by the Federal EPI cell to

the donors including World Bank and GAVI.

The description and timing of measurement of the DLIs is given below:


20

6.3.6 Disbursement Linked Indicators

Disbursement Linked Indicator (DLI)

Year-wise Dates of Assessment

Responsibility for Verification 2015-

16

2016-

17

2017-

18

2018-

19

2019-

20

Y1 Y2 Y3 Y4 Y5

1. Percent of children aged between 12-23

months who are fully immunized 70% 80%

(1) PDHS, (2) if PDHS is not

available, then TPV contracted by

Federal EPI cell and Joint Review

Team (WB, GAVI, GF)

2. Percent of Union Councils (UCs) for

which revised computerized UC level micro

plans are in functional use at district and

provincial levels

60%

TPV contracted by Federal EPI cell

and Joint Review Team (WB,

GAVI, GF)

3. Percent of UCs reporting at least 80%

coverage of full immunization in children

between 12-23 months, which have these

reports validated by independent TPV

40% 60%



GAVI, GF)

4. Percentage of districts with at least 80%

timeliness & completeness reporting on

vLMIS (BLS 25% 5/25)

40%

(10/25)



GAVI, GF)

5. Percent of districts with recognized

surveillance sites having functional online

surveillance for Vaccine Preventable

Diseases (VPD) & Adverse Events Following

Immunization (AEFI)

40%



GAVI, GF)

6. At least 80% score achieved in all

components in EVM assessment at provincial

level

Yes



GAVI, GF)

7. Percent of detailed UC supervisory plans

available for all district supervisors to all

provincial supervisor officers (BLS 0%)

50%



GAVI, GF)

8. Level of expenditures incurred by the

provincial health department spent on public

awareness campaigns for immunization

through print and electronic media (Rs. in

Millions)

50



GAVI, GF)

9. Percent of children under two years of age

with vaccination card available (BLS 40%) 55%



GAVI, GF)

10. Budget allocations for EPI are

continuous, adequate and can be easily

tracked within the government financial

management information system

Yes Yes



GAVI, GF)

TPV – Third Party Vendor, WB – World Bank, GAVI – Global Alliance for Vaccines and Immunization, GF – Bill &

Melinda Gates Foundation, EVM – Effective Vaccine Management


21

7. Capital Cost Estimates

The estimates of the project cost have been prepared in May 2015. The basis of capital cost

estimates is market survey, schedule rates, rates estimated under Integrated Project PC-I and

national pay scales. The year-wise estimation of physical activities are given as under:

A INVESTMENT COST

1 Procurement of computers, office

equipment, furniture 33.3 - - - - 33.3 0.1%

2 Technical Assistance for E-

reporting system, P4P & vLMIS 45.0 45.1 - - - 90.1 0.4%

3 Trainings of Managers, LHWs,

Vaccinators, etc. 62.6 44.2 58.4 67.2 62.6 295.0 1.2%

4 Procurement of Vehicles 85.5 - - - - 85.5 0.3%

5 Program Reviews and Meetings 3.0 3.3 3.6 4.0 4.4 18.3 0.1%

6 Printing - 10.6 18.2 20.0 22.0 70.6 0.3%

7 Third Party Evaluation 2.0 2.0 2.0 2.0 2.0 10.0 0.0%

8 Research, Studies, Reports etc. 5.0 - 6.1 - 7.3 18.4 0.1%

9 Construction of warehouses/

stores 68.5 27.5 - - - 96.0 0.4%

10 Procurement of IT equipment for

E-reporting & monitoring 8.9 12.5 20.6 24.7 9.2 75.9 0.3%

TOTAL 313.7 145.2 108.8 117.8 107.5 793.0 3%

B RECURRENT COST

1 Workforce

Remunerations/Incentives 59.0 68.1 74.9 82.4 90.7 375.2 1.5%

2 Demand Generation, Advocacy &

Communication - 31.9 35.1 38.6 42.5 148.0 0.6%

3 Procurement of Vaccines 1,972.9 3,996.2 4,570.9 5,126.5 5,749.6 21,416.0 87.1%

4 Procurement of Syringes & Safety

Boxes 59.2 69.1 77.8 64.4 76.1 346.5 1.4%

5 Annual Development Plans 7.4 2.6 11.3 10.4 10.7 42.3 0.2%

6 Cold Chain & Logistics 234.8 69.2 9.1 10.0 11.0 334.1 1.4%

7

Operating office expenses

(POL/CNG , transportation of

medicines/supplies, utilities,

communications etc)

5.5 6.1 6.7 7.3 8.1 33.6 0.1%

8 Immunization service delivery

through private sector/CSOs 12.0 39.6 79.9 87.8 96.6 315.9 1.3%

9 Operations, repair & maintenance

of cold chain 26.0 28.6 31.4 34.6 38.0 158.6 0.6%

10 Repair & maintenance of vehicles 7.9 8.6 9.5 10.5 11.5 48.0 0.2%

11 Operating Expenses for Field

Monitoring (POL etc.) 89.9 98.9 108.8 119.6 131.6 548.7 2.2%

12 Operating expenses for vLMIS

and E-reporting/ monitoring 0.8 1.1 1.5 2.0 2.2 7.6 0.0%

13 Procurement of Surveillance

materials and activities 3.5 3.9 4.2 4.7 5.1 21.4 0.1%

TOTAL 2,478.7 4,423.9 5,020.9 5,598.7 6,273.6 23,795.9 97%


22

8. Annual Operating and Maintenance cost after completion of the Project

After completion of the project, the Government of Khyber Pakhtunkhwa will be required to

provide Rs. 4,785.7 million per year as annual operating and maintenance costs.

9. Demand and Supply Analysis

Existing Capacity of Services

EPI services are provided most exclusively by the public health delivery network8 through

fixed EPI centers and outreach immunization services. EPI fixed centers manned by

vaccinators are established in health facilities supported by facility staff; vaccinators with lady

health workers (LHWs) undertake outreach services. There are 1616 health facilities in the

province with 994 functional EPI centers.9 About 9 percent of the union councils out of the

total 1040 do not have any EPI center established. In total, 588 government health facilities are

operating without a functional EPI center. These areas are covered through the EPI staff

working in the adjacent union councils but the overall satisfaction level remains well under par.

Projected Demand for Ten Years

After successful 5-year implementation of this project, the Government of Khyber

Pakhtunkhwa will be required to provide funds for recurrent expenditures only at the rate of

Rs.4, 785.7 million per year. The projected cost for next 5 years after completion of the project

is estimated at Rs. 23,928 million.

Capacity of Project being implemented both in public and private sectors

This project will mainly be implemented through public sector. However, this project also

envisages to benefit from strengths of private sector in areas already mentioned under the

project technical parameters. Service contracts will be signed after selection of the successful

firms through a transparent competitive bidding process. The overall process will be carried

out under the existing government rules and regulations for procuring technical services.

Supply – Demand gap

As already mentioned under section ‘6.2 Justification’, in order to address the systemic

problems and bottleneck, in 2014, Government of Khyber Pakhtunkhwa has already developed

its Comprehensive Multi-year Plan (cMYP) for Immunization through which year-wise

resource requirement for the period of 5 years were projected and also, potential funding gaps

were analyzed.

The present project provides a financing mechanism for the cMYP by aligning support through

a single financing platform for Routine Immunization not only from the existing government

resources but also from the donors and development partners (GAVI, UNICEF, JICA, World

Bank, Gates Foundation etc.)

Designed capacity and output of the proposed project

This project is specifically tailored to meet the essential needs of immunization system. It

builds upon the strengths of the existing Integrated Project and provides the opportunity to

8 District Headquarters Hospitals, Tehsil Headquarters Hospitals, Rural Health Centers, Basic Health Units and other PHC Centers

9 Provincial Comprehensive Multi-year Plan (cMYP) for Immunization 2014-18


23

supplement effectiveness of Integrated Project by not only focusing on availability of vaccines,

injection supplies, cold chain, and other logistics but also to reform and strengthen the existing

EPI management structures and business processes through establishing performance-based

practices and ensuring accountability in management practices.

10. Financial Plan and Mode of Financing

10.1 Funding Sources

The project will be financed both from the government budget and external donor

funding. It covers the entire resource requirement of Routine Immunization. Out of the

total requirement, 72% of the total resource requirement is available from the donor

funding (GAVI, JICA and UNICEF). In order to meet the remaining cost of this project,

the Government of Khyber Pakhtunkhwa is required to provide Rs. 6,172.3 million (Rs.

3,559.1 for vaccines and injection equipment and Rs. 2,613.3 for operations) for the

next five years which amounts to 25% of the total cost. Further details are presented in

the table below:

Rs. in million

Financial Year Total for 5

years 2015-16 2016-17 2017-18 2018-19 2019-20

a) GAVI 1,687.8 3,412.8 3,795.1 4,231.6 4,729.7 17,857.0

b) JICA 40.5 - - - 40.5

c) UNICEF 115.0 15.0 2.0 2.0 2.0 136.0

Total Donor Funds

Available (a+b+c) 1,843.3 3,427.8 3,797.1 4,233.6 4,731.7 18,033.5

d) Federal EPI, Local

Funds Available 7.00 2.00 9.20 9.20 9.20 36.6

Total Donor and

Local Funds

Available (a+b+c+d)

1,850.3 3,429.8 3,806.3 4,242.8 4,740.9 18,070.1

e) Funding Required

from GoKP 883.0 1,070.2 1,245.7 1,409.4 1,564.1 6,172.3

Total Cost of KPISP

(a+b+c+d+e) 2,733.3 4,500.0 5,052.0 5,652.2 6,305.0 24,242.4

GAVI will provide co-financing for vaccine costs as per the agreed commitments

(Annex 9).

The World Bank IDA Credit of US$50 million, focusing on results with well-defined

qualitative and quantitative targets for a five-year period, will be co-financed with the


24

multi-donor trust fund (MDTF) administered by the World Bank with contributions,

subject to their approval, from the GAVI Alliance, USAID, and potentially from other

development partners. The current proposed size of the MDTF is US$90 million,

however, depending on the project performance, more funding may become available

from development partners. In addition, US$20 million will be sought from the Health

Results Innovation Trust Fund (HRITF), administered by the World Bank, in the second

year of the project for national scale up of the demand-side interventions. Lastly, the

Bill & Melinda Gates Foundation will finance up to US$25 million for a partial,

conditional buy-down of the IDA credit. This contribution by the Gates Foundation,

made over the five-year life of the project, will be solely used to write-off interests and

service charges as well as a portion of principle of the credit upon successful project

completion (Annex 12).

The Government of Khyber Pakhtunkhwa is accordingly anticipated to receive an

estimated US$16 million from development partners under NISP, including IDA credit

$5 million, MDTF grant $9 million, and HRITF grant $2 million, subject to the

partner’s approval.

10.2 Fund Flow Mechanism

A single financing agreement will govern all flow of funds under this project. The

budget allocation from the provincial government and funds from the donors will be

transferred to Provincial Consolidated Account-1 of the Government of Khyber

Pakhtunkhwa (Annex 4). The funds under this project will be released to the

Assignment Account of Integrated Project for further release to Director Health

Services and Designated Assignment Accounts of District Health Officers (25 districts)

for provincial and district level activities respectively.

11. Project Benefits and Analysis

11.1 Financial Benefits

No direct revenue will be generated by this project; however, the benefits of a healthier

nation and less mortality through this program will be on the overall economic situation

of the country. This program will facilitate the Government of Khyber Pakhtunkhwa in

improving child health through strengthening of healthcare delivery system and

ensuring service availability. The potential benefits of this expenditure will include

increased utilization of healthcare especially by the poorer segments of population,

resulting into social and financial wellbeing of the households. This should lead to a

positive impact on the economy through availability of funds at the household level,

which should lead to an improved standard of living.

11.2 Social Benefits with Indicators

This program is critical to the health growth related goals, smallest amount intervention

which results in lowering the overall cost of morbidity directly borne by the government

and decreases the sequelae and complications due to vaccine preventable diseases.

Improved health status can increase utility of individuals directly as well as indirectly

through higher labor income and thus expanded consumption basket. At national level,

immunization is a cost effective way of improving health status of the contemporary

and future generations which results in increasing national stock of health capital.

Immunization helps save lives, prevents serious illnesses, and is recognized as one of

the most effective public health interventions. The enhanced human capital through this


25

sort of intervention improves welfare of the society (the ultimate goal of any public

intervention) through spending less time in bad health and increases labor productivity

through acquisition of more stock of health capital. All this, ultimately, results in better

living standard of the nation. Therefore, EPI forms the cornerstone for any reduction in

morbidity and mortality at the population level. The capacity of EPI to enhance the

equity in service delivery and its benefits compared to costs enhances the government’s

ability for poverty reduction by directly reducing the cost of health care for the

population.

The project will contribute to improvement of community access to child and maternal

health and PHC services. This will lead to the improvement of health related indicators

such as EPI coverage, health education and utilization of health care facilities. This, in

turn, will improve the impact indicators such as newborn, infant and child mortality,

nutrition of children etc. The estimated population covered and served by the project is

approximately 29.7 million.

• Reduce Infant Mortality Rate to 40 per 1000 live births by 2017

• Eradicate Poliomyelitis by 2015

• Eliminate Measles and Neonatal Tetanus

11.3 Constrains to Women’s Participation

The main issue regarding women is administering the TT injection; most of the

vaccinators are male. Women in some of the areas are more reluctant to get an injection

from male vaccinators.

The project will train the Lady Health Workers for administering TT injection to

women in the field. TT injection at static centers will be assigned to the Lady Health

Visitors and Female Medical Technicians.

11.4 Beneficiary Population

The project is targeted towards children, pregnant women and women in child bearing

age.10 The total beneficiaries over the five year period are as follows:

(Population in thousands)

Age Group 2015-16 2016-17 2017-18 2018-19 2019-20

Children under 1 year 984 1,012 1,039 1,068 1,097

Pregnant women 1,004 1,032 1,060 1,089 1,119

Women in Child Bearing Age

(15-49 yrs.) 6,188 6,358 6,533 6,713 6,898

11.5 Employment Generation (direct and indirect)

This project is aimed at increasing the overall quality of life, through decreasing infant

and child mortality, improving availability of services for maternal and child health,

and increasing awareness of the community for immunization and nutrition. The

10 Population profile is based on annual projections provided by Bureau of Statistics, Government of Khyber

Pakhtunkhwa and further projections generated under Comprehensive Multiyear Plan for Immunization


26

program aims to work in tandem with other primary health care initiatives and will

ultimately lead to poverty reduction.

Under this project, 201 staff members11 of essential categories will be employed at

district levels for effective implementation of the immunization system.

11.6 Environmental Impact

Under this project special emphasis will be given upon environmental protection. Sharp

waste management is an important component of EPI activities. The waste includes

syringes and empty vaccines vials. The project will follow the Environmental and

Social Management Guideline (ESMG) guidelines presented in Annex 7 to ensure that

the waste is burnt and buries in a proper manner with safety boxes under supervision of

in-charge of Fixed EPI Centers.

11.7 Impact of Delays on Project Cost and Viability

The project is designed to link into ongoing integration of health programs and

strengthen the health care delivery system. The project aims to fill in the gaps in the

health system to achieve the millennium development goals. In case of delay in project

approval the achievement of MDGs for Pakistan will become difficult. In addition, the

Government of Khyber Pakhtunkhwa will fail to honor its obligations and comments

towards achieving global milestones on eradication of poliomyelitis and elimination of

measles and neonatal tetanus.

Vaccines are one of the most expensive items under EPI. If these are not supported

through state of the art cold chain system and effective management, and monitoring

and supervision in the field, it will result in wastage of resources and ultimately poor

program outcomes.

12. Implementation Schedule

Project starting date: 01.07.2015

Project completion date: 30.06.2020

Implementation plan and activity timeline is attached as Annexure 15.

13. Management Structure and Manpower Requirements

The EPI services are provided through Static Centers, Outreach teams and mobile teams. These

centers are located at Hospitals, Rural Health Centers, Basic Health Units, Civil Dispensaries

and Maternal Child Health centers. The implementation EPI at the district level lies under

control of District Health Officer (DHO).

As envisaged under the Integrated PC-1, provincial EPI activities will be implemented by the

Deputy Director EPI under the leadership of Director Health Services (DHS). The project will

use the existing institutional arrangements both at provincial and district levels (Annex 2 & 3).

14. Additional Decisions Required to Maximize Socio-economic Benefits from the Project

This project is highly dependent upon the level of cooperation and facilitation with other health

programs that have been integrated under the Integrated Project. All these programs are

expected to use the available resources through sharing and mutual cooperation. Integration of

health services is a new initiative in Khyber Pakhtunkhwa. It will have its own teething

problems. Therefore, timely recruitment of staff (epidemiologist, surveillance officer etc.) and

11 25 District Surveillance Officers, 01 Communication & HE Officer, 25District Field Supervisors, 125 Field

Supervisors and 25 Drivers


27

their training in EPI activities is a must. It will be imperative to bring clarity in roles and

responsibilities through timely promulgation of policy and management

directives/notifications.

Procurement of vaccines, injection supplies and cold chain equipment are the major cost drivers

under this project. Establishing a centralized procurement system at the federal level with

effective participation from the provinces will help in taking benefits from the economies of

scale.

Timely release of funds by the Provincial Finance Department to the Health Department is

essential for effective implementation of project activities. Any delays or hindrances will

hamper implementation of project activities ultimately leading to revision of the PC-1 and

failure in meeting the targets under DLIs.


28

15. Certificate

Certified that the project proposal has been prepared on the basis of instructions provided by the

Planning Commission for the preparation of PC-I for Social Sector projects.

Prepared by

Signature: ___________________

(Dr. Ayub Rose), Program Manager/ DD EPI,

Khyber Pakhtunkhwa

Tel: 0919212418 Fax No: 0919213849

Checked by

Signature: ___________________

(Dr. Parvez Kamal Khan), Director General Health Services,

Khyber Pakhtunkhwa

Tel No: 091 9210269 Fax No: 0919210230

Signature: ___________________

(Mr. Abid Majeed),

Secretary Health, Khyber Pakhtunkhwa

Tel No: 091 9210342 Fax No: 0919210419

Forwarded for consideration of ECNEC by

Signature: ___________________

(Mr. Azam Khan), Additional Chief Secretary,

Planning and Development Department, Khyber Pakhtunkhwa

Tel No: 0919210344 Fax No: 091 9211369


29

Annexes

Annex 1: Situational Analysis of Expanded Program on Immunization

Situational Analysis of Expanded Program on Immunization

(1) Governance and Management

Governance and management of EPI has been complex both in terms of relationship between

provincial health department and Federal Ministry of Health, and also between various

departments within the provincial health department.

Prior to devolution 2010, the National Immunization Technical Advisory Group at apex level

advised the federal EPI cell, Ministry of Health, and Inter-agency Coordination Committee by

providing evidence-based policy direction on various immunization-related issues – although

implementation was the responsibility of Khyber Pakhtunkhwa, like other three provinces.

After the constitutional amendment of 2010, the stewardship function for EPI at the federal

level has been moved to the Ministry of National Health Services, Regulation and Coordination

(MONHSRC) whereas other functions of have been functions of the federal Ministry of Health

have been devolved to the provinces with effect from July 2011 – including the management

of immunization services. The provinces were thereafter also expected to plan and manage

their own provincial budgets for EPI. After the devolution 2010, the extent to which federal

roles like policymaking, oversight, and monitoring and evaluation will be managed by

MONHSRC remains partially defined. It also includes the uncertainties related with the

responsibility of procuring vaccines and injection supplies

Prior to the approval of Integrated PC-1, at the provincial level, EPI was managed by the

Deputy Director EPI under the supervision of Director General Health Services. At the district

level, District Health Officer was responsible for the district level EPI management and

implementation. The organization structure of EPI has limited linkages with the other health

programs both at provincial and district levels. After paradigm shift from vertical approach to

integrated implementation, new horizontal linkages have been developed between EPI and

other programs where a large number of positions now share responsibilities which were

previously under the direct hierarchical control of EPI managers. In theory, this policy change

has provided an opportunity to achieve sums greater than the inputs by effective use of

resources by avoiding duplication in service provision. However, on the other hand, especially

in the short term, this change has made EPI more vulnerable to system breakdowns and teething

problems on account of modified roles and responsibilities because the EPI managers and

implementers are not fully trained in their new roles and responsibilities. Besides, they have no

former experience of working in an integrated manner by sharing resources and

responsibilities.

The major issues related with EPI governance and program management include lack of clarity

in roles and responsibility, inadequate preparation for the on-going health sector reform

process, absence of functional monitoring and accountability mechanisms, and lack of

oversight by the health authorities have resulted into poor performance.

(2) Immunization Service Delivery

The overall situation for EPI is not very encouraging in Khyber Pakhtunkhwa. The

immunization coverage rates are low. Poor law and order situation due to the ongoing militancy

has been claimed as a major contributor. The local militant groups have been active against


30

Polio vaccination and health workers involved in immunization campaigns have also been

killed. Consequently, the global push towards Polio eradication has been severely jeopardized.

EPI services are provided most exclusively by the public health delivery network12 through

fixed EPI centers and outreach immunization services. EPI fixed centers manned by

vaccinators are established in health facilities supported by facility staff; vaccinators with lady

health workers (LHWs) undertake outreach services. There are 1616 health facilities in the

province with 994 functional EPI centers.13 About 9 percent of the union councils out of the

total 1040 do not have any EPI center established. In total, 588 government health facilities are

operating without a functional EPI center. These areas are covered through the EPI staff

working in the adjacent union councils but the overall satisfaction level remains well under par.

(3) Human Resource Management

A total of 19,104 staff of various categories are available at the facility level including nurses,

LHVs, dispensers, midwives, technicians and LHWs. However, taking into account their

contribution towards immunization services, there is a deficit of 55% human resources that are

required to maintain the desired immunization coverage of more than 80%.13

As per government policy, the cadre of vaccinators/ EPI technicians has been declared as dying

cadre which means no further staff will be recruited once a position becomes vacant. This

policy has increased the deficit of availability of skilled immunization staff. The government

plans to complete this deficit by training the existing Lady Health Workers (LHWs) on EPI

service delivery and also recruiting additional LHWs.

Refresher training for vaccinators is not a regular feature and these trainings are largely limited

to introduction of new vaccines and also availability of funds from the external donors. In

addition, classroom trainings are primarily theoretical in nature with limited practical training

on injection giving technique. In the last couple of years, only 25 percent of vaccinators were

exposed to any refresher training.

EPI services cannot be effectively managed and supervised without availability of trained mid-

level program managers (MLM). However, a small proportion of the available District EPI

coordinators and District Health Officers were ever trained on MLM with no refresher

conducted in the last two years. Training need assessment and on-job training almost does not

exist.

(4) Vaccine, Cold Chain and Logistics

In absence of an efficient vaccine forecasting system, occasional stock-out of certain vaccines

and sometimes threat of expiry are key challenges faced by EPI. The federal EPI cell has been

responsible for vaccine procurement and also forecasting. The dependence on the coverage

data reported by the districts, which lacks validity, is high and no mechanism for data quality

assurance is in place. Without availability of trained staff, the present structure of provincial

EPI will face severe problems in forecasting and procuring vaccines.

The cold chain available in the province is more than a decade old and unreliable and need

replacement. Currently, there are 5 five cold rooms at the provincial level and 5 divisional

stores each of 10 cubic meters located in districts. The currently capacity of the stores is

inadequate for storage of vaccines presently and the situation will worsen when new vaccines

will be added in 2015 and 2016. There is no central warehouse for storage of other vaccine

12 District Headquarters Hospitals, Tehsil Headquarters Hospitals, Rural Health Centers, Basic Health Units and other PHC Centers

13 Provincial Comprehensive Multi-year Plan (cMYP) for Immunization 2014-18


31

related equipment. The performance levels and maintenance of cold chain remains falls below

when compared with the required standards as the recommended guidelines of the World health

Organization and UNICEF.14 On account of these deficiencies, it becomes very difficult to

ensure that quality and efficacy of vaccines is being ensured adequately.

The current transportation capacity is enough for the needs, however, with the introduction of

new vaccines and provinces maintaining their central stores themselves, further expansion is

required in transportation capacity.

(5) Costing and Financing

Lack of staff capacity in financial and procurement management is a weak area under EPI. In

addition, funding for EPI is channeled through different resources in a fragmented manner

which makes it difficult to track down the actual utilization and often results in duplication of

efforts and expenditures.

(6) Surveillance, Monitoring and Reporting

EPI has very weak monitoring and oversight mechanisms. There is lack of trained manpower

to undertake surveillance and monitoring functions. There is no practice of developing any

monitoring or supervision plans, hardly ever any visits are made to the field for data verification

and validation. Where ever such field visits are conducted, the objectivity is lost because formal

monitoring tools and supervisory checklists are not used.

In addition, other than AFP surveillance there is no active well developed VPD surveillance

system in place. The WHO introduced DEWS (Disease Early Warning System) was there but

it was inadequate for the EPI needs. The lack of a well-developed VPD surveillance system

with a comprehensive data quality assurance mechanism is an important reason for poor

immunization service outcomes.

(7) Demand Generation, Communication and Advocacy

There is no comprehensive advocacy and communication strategy and plan to create demand

for immunization services in the community. Further, the health communication area is the

most neglected both in terms of human resource as well as interventions focused on behavior

change communication. The UNICEF has conducted KAP surveys in the past the findings from

which can be utilized to address the key barriers to low utilization of immunization services.

In addition, lack of allocation of government resources for advocacy and communication is a

key concern. Over the last three years, no budget has been allocated for advocacy and

communication component.

14 Add reference from EVM Report 2014


32

SWOT ANALYSIS

Program

Component

Strength Weakness Opportunities Threats

Program

Management

• Immunization a

government

priority under

provincial

strategy and

development

strategy

• Strong

administrative

structures

• Strong

coordination

within the

program and with

health deptt

• Government

commitment/

coordination with

partners

• Complicated

administrative

reporting

hierarchy

• Highly

centralized

management with

limited mid-level

management

capacity

• Poor record

keeping

• Inadequate

monitoring and

supervision

• No control of

provincial

manager on staff

placement,

performance and

rotation at district

level

• Poor

coordination

within

stakeholder at

district level

• Routine EPI is

low priority for

district health

team

• DHO not under

EPI

administrative

structure

• Lack of

coordination with

KPH

• Devolution

• Partner support

for routine EPI

• Linkages with

KPH

• Plan to integrate

health services

• Political and

administrative

interference

• Natural and

manmade

disasters

• Economic crisis

Component Strengths Weaknesses Opportunities Threats

Human

resource

Management

-A functional and

experienced team

(technical and

management) at

provincial level

• No HR need

assessment ever

done

• No HR policy

• Lack of trained

secretarial staff

• Lack of staff and

skill mix at

district level

• Staff absenteeism

at field level

• HSRU in process

of developing HR

policy

• availability of

paramedics for

involvements in

EPI

• Ban on

recruitment by

the provincial

government

• Frequent

changing of

Programme

Manager

• Political

appointments


33

• Unrealistic ratio

of service

provider to

population

• No DDO power

with EPI

coordinator

• Lack of clearly

defined roles and

responsibilities

and service rules

Component Strengths Weaknesses opportunities Threats

Costing and

financing

• Government

financing for EPI

• District staff on

the recurrent

budget

•

• Low allocation

for EPI share in

current budget

• Weak financial

and procurement

management

capacities

• Weak financial

controls

• No Drawing and

Disbursement

Officer (DDO)

• Increased Fiscal

space

• Donor interest

and support

• Donor disinterest


Vaccine and

cold chain &

logistics

• Availability of

cold rooms at

provincial and

divisional levels

• adequate and

timely vaccine

availability for

routine

immunization

• Weak cold chain

system

• Inadequate

mobility support

• Available

resources are less

than the needed

• More than 10

year old

equipment

• Provincial

warehouse not as

per required

• Poor vaccine

stock

management at

facility level

• poor vaccine

reporting system

at UC and district

level,

• Low storage

capacity of

provincial,

divisional and

district stores,

• More than 10

years old CC

equipment,

• Donors and

partners support

for strengthening

cold chain

• poor law and

order

• old cold chain

may top

functioning


34

• Provincial ware

house not as per

standards,

Poor vaccine

stock

management at

facility and

district level,

Component Strengths weaknesses Opportunities Threats

Immunization

services

• Trained /

technical work

force for service

delivery

• Increasing

services

provision at

doorsteps

• Compromised

outreach services

• Difficult access

to for distance

community

• High population

to EPI provider

ratio

• No control over

outreach workers

by HF in-charge

• Difficulty in

access distant

communities in

security

compromised

areas

• LHWs

availability and

involvement in

RI

• Acceptance of

community of

EPI services

• Poor Law and

order situation

• Hilly terrain

• Large scale

migration


Surveillance

and reporting

• Management

structures

available at

programme and

district level

• -AFP

surveillance

system in place

• Functional DHIS

and VPD

reporting systems

Provincial Level

• Lack of training

in surveillance of

HR in provincial

EPI office

District Level

• Existing

monitoring

structures

nonfunctional

(low capacity, no

mobility, dying

cadre)

• Low capacity of

surveillance staff

• Weak reporting

record

maintenance,

• Poor data

management and

compliance

UC Level

• No VPD

monitoring,

• PEI monitoring

structures

availability

• PEI workload

overshadowing

routine

immunization

• use of

surveillance

transport by

DHO and local

influential


35

• Intermittent

reporting and

poor records at

facility levels,

Component Strengths Weaknesses Opportunities Threats

Demand

generation and

communication

• Strong

communication

network

• community

acceptability of

RI services

• No community

involvement in

planning and

implementation

levels

• Social taboos,

cultural barriers

&

misconceptions

about routine

immunization

among mothers

• limited staff

capacities in

counselling and

IPC skills

• PEI Outreach

workers for

community

mobilization

• Traditional norms

and practices

• illiteracy

• Religious

extremism


36

Annex-2: Organogram at Provincial Level under Integrated PC-1

Director General Health Services

(DGHS) BPS 20

Director Health Services (DHS)

BPS 20

Director Administration

BPS 20

Deputy Director

Public Health

Deputy Director

Reproductive Health

Dep. Dir. Knowledge

Management

Dep. Dir. Tech.

MNCH BPS 19

Dep. Dir. Tech.

FP BPS 19

Dep. Dir. Tech.

Nut. BPS 19

Dep. Dir. Tech.

EPI BPS 19

Health Promotion

& Education

Provincial

Epidemiologist

Deputy Director

Administration

Deputy Director

Personnel

Procurement Financial

Management

Drug Control

Asstt. Director

Personal

Deputy Director

Nursing

Asstt. Director

Personal

Asstt. Director

Personal

Logistic

Management

M&E

Officers Statician

IT

Programmer

Project

Director

DHIS

Research

Officers

Provincial

Surveillance Officers

Asstt. Data

Analyst


37

Annex-3: Organogram at District Level under Integrated PC-1

Deputy DHO

(Management

Support

Services &

Coordination)

BPS 18/19

Coordinator I

(Surveillance

and DHIS)

BPS 17

Coordinator II

(Communicable

& Non-

Communicable

Diseases)

BPS 17/18

Coordinator III

(Reproductive

& Child Health)

BPS 17

Coordinator IV

(Special

Interventions,

Nutrition &

Emergencies)

BPS 17

Coordinator V

(Quality

Management &

Oversight)

BPS 17

Financial

Management

and oversight

BPS 17

District Health Officer (DHO)

BPS 18/19

Communic

ation &

Health

Education

Officer

BPS 17

Assistant

Logistic

Officer

Food &

Sanitary

Inspector

Drug

Inspector


38

Annex-4: Fund Flow Mechanism

Provincial Consolidated

Account 1

Donor Funding

(Released on achievement

of DLIs)

Provincial Government

Own Funding

DGHS Integrated PC-1

Assignment Account

MONHSRC

(Procurement of Vaccines

& Injection Supplies)

Designated Assignment

Accounts of DHOs

District Health Office

25 Districts

(District level activities)

Director Health Service

(Provincial level activities)


39

Annex-5: Program Description

KPISP: PROGRAM DESCRIPTION

Background

EPI was initially launched as a pilot in major urban areas from 1976-78. In 1978 the program

was initiated across the country starting from all district headquarters using static centers with

gradual expansion into rural areas. An evaluation in 1982 exposed weaknesses in the static

center only approach and the program was redesigned and launched as a component of the

Accelerated Health Program (AHP) which included control of diarrheal diseases and training

of traditional birth attendants as the other two components. In AHP the service delivery model

was changed to outreach which is the same mode which persists today. The AHP was evaluated

in 1984 by an International commission and declared successful. EPI has since then continued

with essentially the same human resource and management structures.

The requirement for having a specific project to support the immunization program has been

established due several critical factors: firstly, the design of the project has not been reviewed

and new technologies have not been adopted over time, secondly the program has so far not

met its original objectives of achieving 80% plus immunization for all children (as evinced by

the recent outbreaks and consequent deaths of children due to measles) and thirdly, so far the

program has not been able to achieve polio eradication – a high priority goal for Pakistan. To

further complicate the situation the 18th constitutional amendment has increased the

responsibility of the provinces for the health sector and as such new capacities and potentially

new structures need to be created to enable the provinces to carry out these devolved

responsibilities.

The current Khyber Pakhtunkhwa Immunization Support Project (KPISP) is designed as a

one off management and structural reform of EPI particularly addressing its management and

accountability. It will revamp the infrastructure, review and reorganize the management

structures, review the human resource requirements and adjust accordingly and streamline the

reporting mechanisms to enable real-time reporting of data as well as enhance analytic

capacities to inform program management and policy.

Goal:

The overall goal of the project is to contribute “To reduce the morbidity and mortality due to

Vaccine Preventable Diseases (VPDs) in children under 5 years and pregnant women”.

Project Specific Objective

Objective 1: Availability of qualified human resources

Objective 2: Uninterrupted supply of vaccines, cold chain equipment and other logistics

Objective 3: Strengthening and optimization of immunization service delivery

Objective 4: Improved oversight, coordination and program management performance

Objective 5: Improved performance of surveillance system, data quality and routine


Objective 6: Demand generation through effective communication and advocacy


40

Annex-6: Governance, Management Reforms and Provincial Coordination

Governance and Management Reforms, Strengthening Management and Provincial

Coordination

The provincial EPI cell will ensure their presence and facilitate the holding of structured bi-

annual program review at district level. There will be notified Committees within the

departments of health. The Provincial EPI Cells will ensure that these committees are convened

on a regular basis (at least bi annually) and disseminate the minutes on their websites. These

committees will also review the physical and financial progress as well as annual work plans

including procurement and training plans. Bi-annual review meetings of provincial

coordination committee chaired by Secretary Health along with monthly review meetings at

district level for the purpose of monitoring, supervision, planning, reporting, data analysis, HR

management, trainings, coordination, data validation etc.

District Coordination

The provincial EPI Cells shall ensure that quarterly coordination meetings are held at the

district level with representation from all sections of the health department as well as relevant

officials from the line departments. The minutes of these meetings shall be made available on

the provincial websites. The responsibilities at the district level include: Monitoring,

Supervision, Planning, Reporting, data analysis, surveillance, Logistics, Financial

management, Vaccine management, HR management, Trainings, Review meetings, Health

Education, Social mobilization, Advocacy, Coordination, engagement of CSO and Private

sector and Data Validation

Program Review

A formal, iterative program review process will be instituted ensuring that EPI program data

will be reviewed at each level in a highly structured and focused manner. A template or format

will be designed for recording the discussions and decisions of the meeting so that performance

issues are highlighted in a very tangible and measurable manner. Subsequent review meetings

will quantify the status of implementation of the previous decision and recommendations, thus

turning the whole exercise into a spiral cycle model. The review must be conducted in such a

way that each Union Council (UC) is assessed against the standard of the expected program

targets and VPD surveillance data

Provincial Review

There will be quarterly review meetings at provincial level formalized as a provincial

monitoring and technical committee chaired by the Secretary Health to evaluate the routine and

eradication and elimination performance in the province. At the provincial level, monitoring of

the routine immunization activities will be carried out in a structured way at different levels i.e.

through analysis of the reports submitted from district and below tiers. For this purpose,

strengthening of the provincial EPI cells will be carried out through recruitment of additional

human resources (an EPI coordinator, a monitoring & evaluation specialist and a data analyst),

along with procurement and commissioning of the requisite hard and software. The monitoring

unit at the provincial EPI will have the primary responsibility to collate and analyze the data

generated from across the province, to a) give feedback to district and sub-district levels and

provide guidance for corrective action in response to any anomalies found, and b) these reports

would also be submitted for review by the regional review committees meetings, that will be

held periodically according to defined TORs


41

District Review

The oversight by provincial committees will be supplemented by monthly review meetings

held at the district level. Membership will be composed of the district task forces, which are

chaired by the district coordination officer, and the executive district officer (Health) who will

act as Secretary of each respective district. The composition can also be determined by the

competent authority at the district level.

Data Quality

Data quality is a major issue in the program with little or no credence given to the

administrative data reported by the program even by the program itself, thus there is a need to

substantially overhaul the data reporting systems and consolidation and analysis of the data to

ensure an acceptable level of quality within the reports.

Regular assessment of the data quality at different levels using the standard WHO Data Quality

Self-assessment (DQA) tool would be used to identify the gaps in the routine immunization

data monitoring and reporting system. Information would be generated through analysis of the

online reports submitted through the monitoring systems and surveys. This information would

be widely shared through feedback newsletters, web updates, press releases and news updates.

The feedback information would also importantly inform the provincial review meetings.

Collated data would also be disseminated locally and nationally for the purposes of advocacy

and to generate political attention and motivation for program improvement.

The feedback reports would highlight the achievements of the good performing districts and

UCs to improve staff motivation. The data generated through the monthly reports will also be

analyzed at the district level and the analysis report reviewed by the District Review

Committee.

For the provincial level analysis of data quality, the following surveys will be compared for

validation.

• Concurrence between LQAS

• LQAS and Third party (district and province)

• Administrative data and third party

• Administrative data, vLMIS and LQAS

Monitoring

Currently the monitoring of routine EPI services by the province and district is weak and almost

non-existent. No structured approach is followed to monitor the field activities, and feedback

is not very effective. The existing MIS of the EPI although timely is lacking in terms of

reliability and validity usually in the form of over reporting and lack of internal consistency.

At present the data is generated by the vaccinators in the course of fieldwork and is aggregated

at District level from where it is sent to the provincial EPI in the first week of the next month.

At the provincial directorate the data is aggregated for the whole province and cumulative

coverage figures are generated.

The feedback system is currently not functioning. The monitoring of the activities will consist

of desk based work and will be carried out primarily by the provinces and district. The activities

will mainly consist of: Vaccine utilization versus reported coverage, Trend of immunization in

the UC, Work performed compared to planned activities during campaign, Reported coverage

versus supervisory reports from a) district supervisors & b) provincial supervisors,

Administrative reports versus evaluated coverage, Third party reports and other national

regional surveys.


42

Reporting

In order to help in the monitoring and supervision of the field activities, the latest technological

approaches which have been successfully applied in some areas of the country, will be more

broadly introduced. This will help in better micro-planning and preparation of monitoring and

supervision plans. It will also help in keeping a track of the field staff to assess if they are

following their approved tour plans.

With the assistance of the technological advancements, (i.e. android solutions, GPRS Tracking

systems) there will be live data flow from the lower to the higher levels thus reducing the

margin of errors and helping in timely compliance of data reporting. The latest technological

advancements will also help in better area mapping of the catchment area for micro-planning

exercise as has been demonstrated with current polio eradication efforts.

On Line Reporting

The Union Council Level reports will be submitted electronically up to the provincial level

using the proposed revised micro plan format.

Cold Chain and Vaccines

At present there is inadequate capacity to manage vaccine logistics and cold chain effectively,

and data for decision making on vaccine supply management is very limited, resulting in

virtually no visibility into vaccine supply chain performance below the national level. With the

introduction of new vaccines into the country the costs have escalated significantly requiring

that there is an effective monitoring system at all levels. In recognition of the challenges with

vaccine management, the federal and provincial governments have identified the need for a

web-based Vaccine Logistics Management Information System as a priority for mitigating poor

data visibility challenges across the supply chain.

Third party evaluation

Federal EPI cell will be responsible to arrange for the independent 3rd party evaluation for the

program. However, it will engage the district in the process for selecting the firm for 3rd party

monitoring & evaluation and will define a transparent process and SOPs for the

accomplishment of this activity during the course of implementation of the project.

Surveillance (VPD and AEFI)

The goal of EPI surveillance activities is a well-functioning and sustained EPI and vaccine

preventable disease (VPD) reporting system in 3 years to ensure VPD surveillance, online

reporting and response. Currently, the detailed case information are arranged at higher level

compilation and reported by age group and immunization status for measles.

The capacity for surveillance is to be greatly enhanced, with the function taken up by province

and districts cell will providing technical and logistic support. Similarly the district would

report surveillance data to the provincial EPI cell who would collate such data on monthly basis

(zero report included). In order to strengthen disease surveillance in the country, the provincial

core capacities for surveillance and outbreak response, will be strengthened to implement all

surveillance systems.

Monthly AEFI (Adverse events following Immunization) surveillance system was introduced

as a separate system and needs to be strengthened. The EPI reporting system collects data from

basic health unit, rural health centers, tehsil (sub district) hospitals, district hospital and some

teaching hospitals. The Adverse Events Following Immunization (AEFI) data would be

monitored at district level and by the facility in-charge. At the provincial level it will be

reviewed by the epidemiologist. Initial training has been conducted and steps to integrate AEFI

and VPD reporting into the regular reporting system will be a mainstay of the assessment of


43

immunization service delivery. The online reporting will be available in 3 years of

implementation.


44

Annex-7: Environmental and Social Management Guideline (ESMG)

Environmental and Social Management Plan

(ESMP)

Government of Pakistan is planning to introduce the National Immunization Support Project

(NISP) in the country, to support newly devolved Expanded Program on Immunization (EPI) at

the provincial level. The World Bank will provide assistance for this purpose. In line with the

environmental legislation of Pakistan as well as the World Bank (WB) safeguard policies, the

present environmental and social management plan (ESMP) has been prepared, to address the

potentially negative environmental and social impacts associated with the proposed initiative. The

ESMP will also be broadly applicable to the vaccination to be carried out in connection with the

Emergency Response Project for Internally Displaced People (IDP-ERP) in the Federally

Administered Tribal Areas (FATA).

Background. Childhood immunization against vaccine preventable diseases is a highly cost

effective intervention, delivering significant reductions in morbidity and mortality from

inexpensive and standardized interventions. It remains one of the most fundamental competencies

of public health programmes. In line with international standards, the EPI in Pakistan aims to

immunize all children between 0 and 23 months against nine Vaccine Preventable Diseases

(VPDs), which include infant tuberculosis, poliomyelitis, diphtheria, pertussis, neonatal tetanus,

hepatitis B, Haemophilus Influenza type b (Hib), pneumonia and measles. From July 2015

onwards, one dose of the Inactivated Polio Vaccine (IPV) is planned to be introduced in the EPI

throughout the country at the age of 14 weeks of child.

Project Overview. The proposed project/initiative has been designed with the development

objective to increase the equitable coverage of services for immunization against the VPDs,

including poliomyelitis, for children between 0 and 23 months in Pakistan. These objectives will

be achieved with the help of four project/initiative’s components briefly described here:

Component 1: Strengthening Management, Governance and Stewardship Functions. This

component has the objective of addressing the fundamental systemic weaknesses that underlie the

poor performance and accountability of the EPI in Pakistan. The Component includes oversight,

coordination and stewardship functions; robust monitoring & evaluation mechanisms; and

surveillance systems. Component 2: Improving Service Delivery Performance. This component

will increase equitable access to the EPI services at the Union Council (UC) level through

improved planning, management of human resources and strengthened supply chain management

at the point of service delivery. The Component includes enhanced planning for performance;

availability and management of skilled human resources; effective supervisory systems for the

EPI; enhanced linkage to communities. Component 3: Demand Generation. The objective of this

component is to explore and expand innovative strategies to empower communities to access

immunization services and promote positive behaviors for acceptance and seeking of

immunization services. The key elements of this component include social mobilization and

community awareness, conditional cash transfer scheme, advocacy, and awareness raising through

standardized School Curriculum aimed at improving understanding of the pupils about VPDs and

their effective prevention through basic hygiene and immunization. Component 4: Improving

Capacity in Technical Areas for Increased Immunization Coverage. This component will finance

strengthening of the Federal EPI cell in national coordination, project management, research,


45

training and critical analytic capacities as well as health system strengthening elements. The component

will include capacity building of the Federal EPI Cell, support for national coordination, support for

strengthening of other health systems; training, research and evaluation.

The project will be implemented through five implementing agencies: The Federal EPI Cell with

responsibility for the federal territories, under Ministry of National Health Services, Regulations

and Coordination (NHSR&C) at Federal Government level, and four provincial EPI cells

established in the Director General Health Services (DGHS) in each province.

Key safeguards issues and their mitigation. The potential environmental, social and public

health impacts of the project include: decreased effectiveness of vaccine due to disruption in cold

chain; inappropriate handling of sharps and syringes and associated health hazards for the

vaccinators; and most importantly, inappropriate disposal of medical waste associated with

vaccinations (sharps, syringes, unused vaccines and gauzes) that may result in serious public health

issues. To mitigate these potential impacts and risks, the revised National EPI Policy and Strategic

Guidelines need to be effectively implemented; in particular, the cold chain management protocols

need to be strictly followed (Effective Vaccine Management Implementation Plan); only auto-

disable syringes need to be used; personal protective equipment (PPE) need to be used by the

vaccinators; Hospital Waste Management Rules of 2005, and guidelines need to be effectively

implemented to dispose immunization wastes; and finally appropriate trainings and capacity

building need to be carried out for all staff associated with vaccination.

In addition to the above-described mitigation measures, an action plan for immunization waste

management has also been proposed. Under this plan, during the year 1 of the project, current

immunization waste management practices will be documented and workable solutions will be

identified. During the year-2, immunization waste management action plans will be prepared at

the district level, and finally during the year-3, these plans will be implemented with the

immunization waste management systems being fully in place.

ESMP implementation arrangements. Overall coordination and implementation of ESMP will

be the responsibility of National Program Manager, EPI who will designate an ESM Focal Point

(FP) to coordinate on his/her behalf. Provincial EPI Managers will also designate similar ESM

Focal Points at each province level, who will provide support to the federal level ESM FP. Each

partner hospital/tertiary healthcare units will also nominate a focal person to ensure

implementation of ESMP. All these FPs need to be government officers to ensure government

ownership and accountability.

ESMP monitoring and reporting. In order to ensure effective implementation of ESMP during

the NISP initiative, a comprehensive monitoring mechanism has been proposed as part of this

document. Under this mechanism, key safeguard aspects of the initiative, namely; vaccine storage

and cold chain management, availability of auto-disable syringes, availability and usage of PPEs,

availability of safety boxes for disposal of sharps, disposal of immunization wastes in accordance

with the Hospital Waste Management Rules 2005 and Immunization Waste Management Action

Plans, and implementation of trainings will be monitored with regular monitoring reports prepared

as an output. In addition, environmental audits will be carried out on a six-monthly basis, and a

third party validation will be conducted on annual basis.


46

ESMP implementation cost. The ESMP implementation cost has been estimated to be around

Pak Rupees (Rs.) 36.6 million. This includes cost allocations for district immunization waste

management planning, implementation of district immunization waste management plans, and

annual third party validation.

Legal and Policy Framework

The present ESMP has been developed after reviewing the relevant promulgated environmental

legislation and guidelines of Pakistan and the World Bank’s safeguard policies. These legislations

and safeguard policies, and their relevance to the proposed project.

Stakeholder Consultation

Stakeholder consultation to identify perceived impacts and associated mitigation measures is an

integral component of an ESMP design and development process, and hence was carried out for

this project as well. Consultations were conducted with stakeholders identified in partnership with

the project team, and consisted of NGOs, federal government, and relevant Bank experts. The

consultations continued while preparing the present ESMP, and continuous review and comments

were sought from key professionals to add robustness to it.

Federal Environment Protection Agency

A meeting was held with the Director General, EPA on 28th January, 2014 to seek his advice on

identifying the environmental issues associated with the project, as well as suggestions for

mitigation measures. He identified immunization waste collection and disposal as the primary

issue associated with the project, along with limited capacity and knowledge towards associated

environmental hazards. He did not favor pit burial, since it can lead to groundwater contamination,

and suggested incineration as a better option. He offered Environment Protection Agency (EPA)

support in developing the training modules, and conducting the same keeping in line with the

Hospital Waste Management Rules, 2005. For remote areas, same trainings can be imparted using

a travelling training program, where dedicated staff and vehicles can be used for the purpose.

Federal EPI Cell

A meeting was held with the National Program Manager and his team, Federal EPI Cell on 6th

February, 2014. In addition to the immunization activities, he emphasized multiyear, multi-sectoral

programs that would target eradicating the sources of viruses. Municipal waste management for

improved hygiene and sanitary conditions, awareness about spread of communicable diseases,

baselines to measure impacts of immunization activities, and effects of physical environment on

immunization programs were the other issues raised by him.

Civil Society Organization

Comprehensive feedback from civil society was received through a workshop organized by WB

on the 5th of February, 2014. Representatives from eight national and regional NGOs and from

UNICEF, GAVI Alliance, and National EPI Program were present to discuss a range of issues

associated with vaccination service delivery, barriers to immunization, challenges associated with


47

gender, remoteness and marginalization of a community and environmental hazards associated

with such campaigns. In addition to the workshop, focused interviews were held with Civil Society

Human and Institutional Development Program (CHIP), National Rural Support Program (NRSP)

and LEAD Pakistan. Following is the summary of the discussions with the civil society:

Environmental Dimensions

• Use of sharp instruments and their improper disposal can lead into epidemics and

environmental hazards

• Pit burial is the usual practice being followed, but with varying degree of compliance

(relatively better at urban facilities than rural)

• Roles of private sector and NGO’s in waste collection and disposal needs to be considered

• Use of expired vaccines, or where vaccines become ineffective due to improper

temperature control, can cause epidemics as well as mistrust amongst the beneficiaries

• Recycling of hospital waste has been reported and is in practice. This must be discouraged

by all means

• Hospital waste associated with immunization campaigns need to be disposed off in a proper

manner

• Adverse events that might follow due to immunization need to be documented and

reported.

• General sanitary conditions play a vital role in the success of immunization campaigns.

Parallel investments need to be made into this sector

Social dimensions

• In many cases language barrier can be a major obstacle, where the care provider does not

speak the local language

• Limited number of vaccinators and how the gender of the vaccinator can be a major factor

in terms of access to women in the community. The teams need to have male and female

vaccinators

• Low literacy levels inhibit immunization

• Women's dependency for commuting and limitations on mobility of women to access the

service and existing power structures at the household level

• Access to remote areas with difficult geographic terrain and security issues

• Political interference incidence where the LHWs from different political parties were not

allowed in the community

• Communication discourse: It was shared that there are major gaps in communication and

sensitization of the community which is crucial for ownership.

• It was also shared that integrated health packages are received more in comparison to the

EPI as there was also trust build within the communities and that was one of the core factors

for bonding sustainable partnerships

Significant Environmental and Social Aspects and Mitigation Measures

This section describes the environmental and social aspects associated with the project activities,

as suggested by the stakeholders as well as the project team


48

Cold chain management for vaccine effectiveness

Vaccines need to be stored at recommended temperatures for them to remain effective. Also the

quantity to be administered is the key for it to work on a child or a mother. The campaign might

not achieve its targets of disease(s) elimination, as well as causing mistrust amongst the

communities (occurrence of disease despite vaccination), if the cold chain breaks. The project

activities involving administering vaccines using sharps and injections pose a high risk to the

health workers as well as the community at large. They can cause epidemics, as well as transfer

communicable diseases from a host population to another. Epidemics have an impact on virus

genetics, and mutations can be caused. Such mutations can cause imbalance within a particular

ecosystem, especially with symbiotic relationships, and can be detrimental to other

organisms/species survival. Hence, the issue is both environmental as well as a public health issue.

Mitigation

Cold chain management, in accordance to the National Expanded Program on Immunization (EPI)

Policy and Strategic Guidelines has to be ensured at all levels. Vaccines shall be stored at standard

temperatures in official EPI store only. They should not be stored for more than a period of six

months at federal level, three months at the provincial level, one month at the district and fifteen

days at the facility level. Standard stock ledger with name of the vaccine, quantity in doses, vial

size, manufacturer, expiry date, batch/lot number, date of receive and supply to be maintained at

all level and updated regularly. Reconstituted vaccine must be discarded six hours after

reconstitution or at the end of immunization session, whichever comes first.

Disposal of Sharps and Immunization Waste in general

Despite many efforts taken by the government and civil society organizations, medical waste and

sharp disposal remains a challenge for the hospital industry and environmental managers. Current

medical waste management practices shows that medical waste is not regulated and not always

disposed in an efficient manner. The hazards associated with improper waste disposal by any

healthcare facility operation are mostly caused by not following the infection control protocols,

not using proper personal protective equipment (PPE), and not employing proper procedures for

waste collection, transportation, storage, and final disposal. In addition, recycling of medical waste

also poses very serious health risks for the workers involved in recycling and also consumers using

the recycled products. Moreover, safety of staff handling sharps such as syringes and needles is at

risk if proper procedures are not followed. Air and water quality deterioration is another associated

potential impact if the waste is disposed by burning and/or burial.

Mitigation

Immunization waste is required to be managed in accordance to the legal framework of Pakistan,

specified under the Hospitals Waste Management Rules 2005. Auto disable (AD) syringes are

recommended by WHO to be used for immunization purposes. Safe disposal of these syringes is

absolutely necessary from a public health and environmental point of view. Once used, these

syringes must be disposed into customized Safety Boxes, as per National EPI Policy as well as

WHO recommendations. Current immunization activities are being carried out in accordance to


49

the WHO recommendations, and AD syringes and Safety Boxes are being used. Waste disposal

can be carried out by using pit burial method15.

Adverse Events Following Immunization (AEFI)

There is a possibility of reactions, allergies or any other side effects associated with immunization.

Such adverse events need to be reported and critically evaluated so as to ascertain their cause, as

well as to identify means to minimize their occurrence. Currently AEFI are reported diligently, but

there is a need to improve the information flow from UC level to provincial and national levels.

Mitigation

An effective and efficient AEFI recording and reporting needs to be in place, from the vaccinator

to the national program management levels.

Knowledge of Environmental and Social Risks associated with Immunization

Generally, there is limited capacity to address the environmental and social risks associated with

activities associated with immunization, especially with regards to the above mentioned aspects.

This limitation in itself poses a risk of project failure, and hence needs to be addressed effectively

at all project levels.

Mitigation

Appropriate training program needs to be devised for all stakeholders involved, congruent to their

roles and responsibilities.

Environment Enhancement

A vital aspect associated with the sustainability of immunization campaigns is the condition of the

surrounding physical environment, in terms of sanitation facilities, and levels of personal hygiene.

Many viruses breed in sewage, while others are transmitted due to touch and living conditions in

close confinement (communicable diseases). Epidemics and communicable diseases are common

in rural, relatively poorer areas of Pakistan, where the general literacy is low combined with

minimal sanitation infrastructure.

An immunization campaign will be more successful if there are parallel investments in sanitation

schemes, as well as in educating households about risks associated with communicable diseases.

This includes building infrastructure (covered drains, municipal waste treatment plants,) as well

as capacity building of communities into basic hygiene and that of sanitary staff into municipal

waste management.

KPISP will contribute towards building knowledge amongst communities on communal medicine

and hygiene through its training programs discussed later in the document.

Action Plan for Immunization Waste Management

Immunization waste management across Pakistan remains a challenge, especially at the Tehsil and

Union Council levels. As most of the primary level healthcare facilities do not have effective

systems and procedures in place, nor have infrastructure to manage and dispose-off infectious

waste. Hence immunization campaigns and/or other hospital treatments involving sharps and other

15 In the first phase of the project, Waste Disposal Site has to be a dedicated pit used for waste burial and burning

(designed and constructed in accordance to Hospital Waste Management Rules, 2005 and/or National EPI Policy and Strategic Guidelines). Recommendations for hospital waste management for EPIKP project duration will be a part of the District Level Action Plan for Immunization Waste


50

infectious wastes, can lead to public health risks, unless the waste is efficiently managed and taken

care of.

It is proposed under KPISP, to prepare a two to three years comprehensive action plan in order to

tackle this issue, and suggest workable and practical solutions. A year wise breakdown of activities

is proposed as under:

Year 1; Documentation of current practices and identification of workable solutions

Regional workshops on documenting current practices and systems currently in place for

infectious waste management; Identifying best practices from within the country as well as the

South Asian region. Documenting the results and dissemination to relevant stakeholders in the

government, academia and civil society

Year 2; District Action Plans prepared and notified

District Action Plans to be prepared on the basis of the above mentioned to Identification of short,

medium and long term milestones and action points from within the plans and notification of the

Plans by the respective provincial health departments and Appointment of provincial

immunization waste management coordinator in each province.

Year 3; Implementation of the District Action Plans and Immunization Waste

Management Systems in place

Provision of resources for the short term actions points of each provincial plan, execution of the

plans, especially of the short term actions that can be dealt with in the KPISP lifetime and

equipment, systems and procedures in place for immunization waste management, under the

monitoring and coordination of Federal EPI Program.

Social and Gender Aspects

According to research countries with the higher gender development index have greater coverage

of immunization According to Global Gender Gap Index Pakistan ranks 135/136, Gender

Inequality Index 123/148 and Social Institutions and Gender Index 55/86. This is also related to

the education levels of mothers and their socio economic status. As part of the ESMP there are

various social and gender related dimensions that need to be considered and mitigations to be

designed to expand vaccine coverage and make vaccination equitable in Pakistan.

The unique needs of the child care givers needs to be explored in the context of the country to

facilitate equitable access to services. There are inter-provincial disparities and even disparities

within the provinces. Research proves that poor education indicators in this case lower literacy

levels result in poor vaccine coverage. In case of Pakistan with relatively better education

indicators for males there is need for engagement of men with targeted advocacy to increase

coverage of vaccine.

Equal access is another key to improving equitable vaccine coverage (GAVI Alliance – Gender

and Immunization 2013). One of the major issues that need to be addressed is the access of the

beneficiaries to the provision of services, in this case the ease of access to the immunization and

access of the mothers and fathers to the health facilities. With the existing patriarchal structures

and gendered dynamics women have limited access to household financial resources and cannot

access healthcare. Although they are the caretakers in the house it is the men who are the decision

makers therefore inclusion of men and boys can increase the coverage of the immunization and

effect access.


51

In majority of the cases women are dependent on males for basic decisions including commute

and mobility. They are also usually escorted by male members of the household to travel outside

the house. Thus decision making ability including basic decisions that is, mobility, finances,

resource allocation and access to services are made by either the male of the household or elderly.

This dependency creates bottlenecks for women to access the services for their children. Mobile

vaccine services where the service provider reaches the doorstep can be one of the ways to mitigate

this implication. Female headed households usually fall in the last quintile and can be further

excluded due to their low socio economic status resulting in limited access to basic services.

Provider’s attitude towards the women beneficiaries is another crucial factor that results due to the

social stereotypes and gender related norms in the society. In the conservative societies due to

limited interaction of males and females there are taboos attached to women’s interaction with

male care givers thus creating limitations for females to access the services. This coupled with

gender discrimination and harassment further exasperates the issue.

Time poverty and feminization of poverty are some of the significant factors that need to be

considered and addressed in the context of the project. There are a large number of females in the

informal economy and during the crop sharing seasons etc. the opportunity cost of taking the

children to the health care units is very high for the female and male workers. Moreover with the

existing workloads including (caretaking, nurturing, reproductive and productive roles) women

face multiple challenges in equitable access to vaccination of children. Flexible schedules tailored

to the availability of the females can be one of the mitigations that can be proposed in the project

design and implementation.

Politicization of immunization and the various connotations attached with the Polio vaccination

result in fear and rumors that are attached to vaccine provision particularly in the northern and

conflict afflicted areas. There is resistance to immunization that is demanded by men but carried

out by women. In the communities with the various stereotypes attached the cost of getting

vaccinated can result in exclusion from the community. A gender sensitive behavior and

communication strategy can address such issues.

The existing power structures and the reinforcement of women’s care taking and nurturing roles is

another negative impact that needs mitigation. Through the engagement of females as the primary

care givers their nurturing roles is reinforced and with the existing workload this is additional

burden on the females, burden that can be shared by the male members of the household provided

there is social mobilization around engagement of men as care takers .

Gender based violence in form of domestic violence can hamper women’s access to the health

unit. In some cases the shame and taboos attached to disclosure of domestic violence results in the

segregation of women that in turn can affect the immunization of children.

Gender discrimination and harassment at workplace between the male and female workers can

also be negative externality that needs specific action. There is a code of conduct developed by the

government of Pakistan to address such issues: Harassment of Women at Workplace Act 2010.

Mitigations include ensuring that there should be separate bathrooms for females with prayer

facilities, protection of women against sexual harassment at workplace, separate waiting unit and

care units for women and children and equal access to health care service providers.


52

Inclusion of the disabled persons (parents) is another factor that needs affirmative action. The

disabled individuals might face greater difficulties in accessing the services and the same goes for

the minorities from the religious and ethnic backgrounds.

Consultations with the beneficiaries need to ensure that women’s participation and representation

is there and sex disaggregated data is collated when it comes to the beneficiaries. Moreover gender

inclusive grievance redress mechanisms need to be in place to ensure transparency and

accountability.

Institutional Arrangements for ESMP Implementation

Overall coordination and implementation of ESMP will be the responsibility of Provincial

Program Manager, EPI who will designate an ESM Focal Point (FP) to coordinate on his/her

behalf. District EPI Managers will also designate similar ESM Focal Points at each union council

level, who will provide support to the provincial level ESM FP. Each partner hospital/tertiary

healthcare units will also nominate a focal person to ensure implementation of ESMP. The primary

responsibilities of the provincial level ESM FP will be to conduct financial management of the

ESMP and effective implementation of ESMP, ensure that cold chain equipment, AD syringes,

safety boxes, waste management stuff and disinfectant equipment/chemicals are being made

available to the provinces, Coordinate with focal person of partner hospital/tertiary healthcare unit

to ensure implementation of ESMP, conduct the monitoring tasks and maintain all reports and

records, coordinate and ensure development of training material and implement of trainings

sessions, coordinate and ensure development of awareness material, conduct environmental

compliance audit for the program, commission annual third party validations of partner

hospital/tertiary healthcare unit, prepare Quarterly Progress Reports(QPR) for the entire project.

The responsibilities of the district level ESM FP

Coordinate with focal person of partner hospital/tertiary healthcare unit to ensure implementation

of ESMP, coordinate with focal person of partner hospital/tertiary healthcare unit to ensure

availability of cold chain equipment, AD syringes, safety boxes, waste management stuff and

disinfectant equipment/chemicals, conduct monitoring tasks in coordination with provincial level

FP and submit reports to National Program Manager, EPI, implement training sessions in

provinces, facilitate and coordinate third party validations in the province.

Prepare provincial QPRs.

The responsibilities of the partner hospital/tertiary healthcare unit

Identify a focal person to ensure implementation of ESMP, maintain the record of use of all

recommended equipment including AD syringes, safety boxes, waste management stuff and

disinfectant equipment/chemicals, prepare Monthly Immunization Waste Management Reports

(MIWMR), tally the records with the permanent registers maintained by the vaccinators, conduct

monitoring tasks and submit reports to relevant line authorities as per ESMP, ensure

implementation of training session in coordination with national and provincial EPI offices,

coordinate with relevant national and provincial managers for environmental monitoring and

reporting and prepare QPR and MIWMR for the facility.

| Khyber Pakhtunkhwa Immunization Support Program

53

Annex-8: Budget Requirement for KPISP (detailed)

S. No. Objectives, Strategies &

Activities

Physical Targets COST

TOTAL Year 1 Year 2 Year 3 Year 4 Year 5 Year 1 Year 2 Year 3 Year 4 Year 5

2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

Total Funding 2,733.3 4,500.0 5,052.0 5,652.2 6,305.0 24,242.4

GoKP Funding 883.0 1,070.2 1,245.7 1,409.4 1,564.1 6,172.3

Federal EPI Cell Funding 7.00 2.00 9.20 9.20 9.20 36.6

Donor Funding 1,843.3 3,427.8 3,797.1 4,233.6 4,731.7 18,033.5


54


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

1 Objective 1: Availability of qualified human resources 49.1 56.5 50.6 59.2 53.2 268.6

1.1 Availability of skilled immunization staff 40.4 32.5 35.7 39.3 43.2 191.2

GoKPK Funding

1.1.1

Health Education and

Communication Officer (provincial

office)

312,000 1 1 1 1 1 0.3 0.3 0.4 0.4 0.5 1.9

1.1.2 Recruitment of 25 District

Surveillance Officers (1 per district) 600,000 25 25 25 25 25 15.0 16.5 18.2 20.0 22.0 91.6

1.1.3 LHW's Training on EPI (batch of

20/training) 145,400 175 100 100 100 100 14.4 3.0 17.6 19.4 21.3 75.6

1.1.4 Skill building of Paramedics on EPI

(Batch of 25) - 37 37 37 37 37 - - - - - -

Sub-Total 29.4 19.5 35.7 39.3 43.2 167.2


55


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

1.2 Capacity building and skill development 8.7 19.8 11.3 16.0 5.7 61.5

GoKP Funding

1.2.1 Mid-Level-Managers (MLM)

Training on EPI (Batch of 20) 878,150 3 - 3 - 3 2.6 - 3.2 - 3.9 9.7

1.2.2 Training of District Master Trainers

(Batch of 25) 409,850 5 2 2 2 3 2.0 0.9 1.0 1.1 1.8 6.8

1.2.3 Trainings of Vaccinators (batch of

20/training) 160,450 25 - - - - 4.0 - - - - 4.0

1.2.4 Refresher trainings of Vaccinators

(batch of 20/training) 160,450 - 70 - 70 - - 12.4 - 14.9 - 27.3

1.2.5 Training on Introduction of New

vaccines (Batch of 20) 62,150 - 95 95 - - - 6.5 7.1 - - 13.6

Sub Total 8.7 19.8 11.3 16.0 5.7 61.5

Donor Funding

Sub Total - - - - - -


56


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

1.3 Staff motivation for improved

performance - 4.3 3.5 3.9 4.2 15.9

GoKP Funding

1.3.1 Technical Assistance for Developing

Pay for Performance Scheme 1,000,000 - 1 - - - - 1.1 - - - 1.1

1.3.2

Pay for Performance Bonuses for

Union Council Teams (3 per district

per Quarter)

60,000 - 25 25 25 25 - 1.7 1.8 2.0 2.2 7.7

1.3.3

Pay for Performance Bonuses for

District Teams (Biannual for 3

District)

450,000 - 2 2 2 2 - 1.0 1.1 1.2 1.3 4.6

1.3.4 Pay for Performance Bonuses for

Provincial Team (Annual) 500,000 - 1 1 1 1 - 0.6 0.6 0.7 0.7 2.6

Sub Total 4.3 3.5 3.9 4.2 15.9

Donor Funding

Sub Total - - - - - -


57


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

2 Objective 2: Uninterrupted supply of vaccines, cold chain

equipment and other logistics 3,129.7 4,042 3,974.0 4,150.0 4,383.0 19,678.8

2.1 Uninterrupted supply of vaccines

and injection equipment

1,944.4 3,926.6 4,481.6 5,026.3 5,637.2 21,016.1

GoKP Funding

2.1.1 Vaccines 256.6 513.8 686.5 794.7 907.5 3,159.1

2.1.1.1 Polio (OPV + OPV zero dose) 37.6 85.1 95.5 107.1 120.1 445.4

2.1.1.2 BCG

14.2 21.5 24.1 27.1 30.3 117.3

2.1.1.3 Pentavalent (DPT+HepB+Hib)

106.4 79.8 93.1 106.6 119.7 505.6

2.1.1.4 Pneumococal (PCV-10) Vaccine

66.5 159.8 186.3 213.0 239.6 865.1

2.1.1.5 Rotavirus Vaccine

0.0 39.9 66.5 93.2 119.7 319.4

2.1.1.6 Measles/ MR Vaccine 23.7 104.8 117.5 131.8 147.8 525.5


58


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

2.1.1.7 Inactivated polio vaccine (IPV) 0.0 0.0 77.9 87.3 98.0 263.2

2.1.1.8 Hepatitis-B (Birth dose) -

2.1.1.9 Tetanus Toxoid (TT) Vaccine 8.2 22.9 25.6 28.7 32.2 117.7

2.1.2 Injection Supplies 28.5 69.6 89.2 100.2 112.4 399.9

2.1.2.1 BCG Syringes 8.9 13.4 15.1 16.9 19.0 73.3

2.1.2.2 Syringes for Measles, Penta, IPV,

TT, MR, Hep-B, & PCV-10 15.0 44.5 59.5 66.9 75.0 260.9

2.1.2.3 Reconstitution Syringes 0.84 2.57 2.88 3.23 3.62 13.13

2.1.2.4 Safety Boxes 3.7 9.2 11.7 13.2 14.8 52.6

Sub Total 285.1 583.4 775.7 894.9 1,019.8 3,559.1


59


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

Donor Funding

2.1.1 Vaccines 1,687.8 3,412.8 3,795.1 4,231.6 4,729.7 17,857.0

2.1.1.3 Pentavalent (DPT+HepB+Hib) 673.9 795.3 888.4 994.2 1,114.9 4,466.7

2.1.1.4 Pneumococal (PCV-10) Vaccine 1,013.9 1,051.8 1,172.6 1,311.1 1,469.7 6,019.1

2.1.1.5 Rotavirus Vaccine 0.0 1,565.6 1,734.1 1,926.2 2,145.2 7,371.1

Sub Total 1,687.8 3,412.8 3,795.1 4,231.6 4,729.7 17,857.0


60


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

2.2 Expansion in storage capacity of

vaccines and logistics 303.3 96.7 9.1 10.0 11.0 430.1

GoKP Funding

2.2.1 Cold Chain 158.3 69.2 9.1 10.0 11.0 257.6

2.2.1.1

Walk in Cold Room (plus) 40 cubic

meter including procurement,

shipping and installation

6,000,000 3 2 - - - 18.0 13.2 - - - 31.2

2.2.1.2 ILR Dometic TCW2000 (Electrical) 204,000 400 200 - - - 5.1 44.9 - - - 50.0

2.2.1.3 ILR Dometic 40 SDD (Solar Direct

Drive) 714,000 135 - - - - 96.4 - - - - 96.4

2.2.1.4 RCW25 Cold Box 40,800 25 - - - - 1.0 - - - - 1.0

2.2.1.5 Vaccine Carriers 1,734 600 - - - - 1.0 - - - - 1.0


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Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

2.2.1.6 Generator 20 KVA for PHQ - - - - - - - - - - - -

2.2.1.7 Generator 5KVA for Districts 200,000 25 - - - - 5.0 - - - - 5.0

2.2.1.8 Voltage Stablizer I & III Phase 15,000 1,400 - - - - 21.0 - - - - 21.0

2.2.1.9 3 Phase Servo Stabiliers (15KVA).

Shipped and installed 204,000 5 2 - - - 1.0 0.4 - - - 1.5

2.2.1.10 200KVA Gensets and distribution

/switchover/auto-start panels 2,244,000 1 1 - - - 2.2 2.5 - - - 4.7

2.2.1.12 Spare parts of cold chain equipment

(10% of total cost) 7,500,000 1 1 1 1 1 7.5 8.3 9.1 10.0 11.0 45.8

2.2.2 Warehouses 25.0 27.5 - - - 52.5

2.2.2.1 Construction of 3 Divisional/district

EPI Warehouses 12,500,000 3 - - - - - - - - - -

2.2.2.1 Renovation of 3 Divisional/district

EPI Warehouses 2,000,000 3 - - - - - - - - - -


62


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

2.2.2.3 Construction of Provincial EPI

Warehouse 25,000,000 1 1 - - - 25.0 27.5 - - - 52.5

Sub Total 183.3 96.7 9.1 10.0 11.0 310.1

Donor Funding

2.2.1 Cold Chain 76.48 - - - - 76.48

2.2.1.2 ILR Dometic TCW2000 (Electrical) - 76.48 - - - - 76.48

2.2.1.3 ILR Dometic 40 SDD (Solar Direct

Drive) - - - - - - -

2.2.1.4 RCW25 Cold Box - - - - - - -

2.2.1.5 Vaccine Carriers - -


63


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

2.2.1.6 Generator 20 KVA for PHQ - -

2.2.1.7 Generator 5KVA for Districts - -

2.2.1.8 Voltage Stablizer I & III Phase - -

2.2.1.9 3 Phase Servo Stabiliers (15KVA).

Shipped and installed - -

2.2.1.8 Voltage Stabilizers I & III Phase - -

2.2.1.10 200KVA Gensets and distribution

/switchover/auto-start panels - -

2.2.1.11

Other Cold Chain Equipment

(Thermometers, fan motors, circuit

breakers etc)

- -

2.2.1.12 Spare parts of cold chain equipment

(10% of total cost) - -

2.2.2 Warehouses 43.5 - - - - 43.5


64


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

2.2.2.1 Construction of 3 Divisional/district

EPI Warehouses - 37.5 - - - - 37.5

2.2.2.1 Renovation of 3 Divisional/district

EPI Warehouses - 6.0 - - - - 6.0

2.2.2.3 Construction of Provincial EPI

Warehouse - - - - - -

Sub Total 120.0 - - - - 120.0

2.3 Innovative technologies for improving cold chain

temperature management 4.1 - 2.5 - 3.0 9.6

GoKP Funding

2.3.1 Smart-view Cold Room

Temperature Monitoring systems for

WIC/WIF) 4,080,000 1 - - - - 4.1 - - - - 4.1

2.3.2 3yr Smart-view service

support/communications/update

contract 2,040,000 - - 1 - 1 - - 2.5 - 3.0 5.5


65


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

2.3.3 30-DTR's with integrated Sim

(Fridge Tag-3) - - - - - - - - - - - -

Sub Total 4.1 - 2.5 - 3.0 9.6

Donor Funding

2.3.3 30-DTR's with integrated Sim

(Fridge Tag-3) 4.5 - - - - 4.5

Sub Total 4.5 - - - - 4.5

2.4 Effective vaccine management through

improved planning 5.4 5.0 5.4 6.0 6.6

GoKP Funding

2.4.1 Trainings on Vaccine Management 900,000 6 5 5 - 5 5.4 5.0 5.4 6.0 6.6 28.4

Sub Total 5.4 5.0 5.4 6.0 6.6 28.4

Donor Funding

Sub Total - - - - - -


66


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

2.5

Contracting out repair and

maintenance of cold chain

equipment 3.8 4.2 4.6 5.0 5.5 23.0

GoKP Funding

2.5.3 Contracting out repair and

maintenance of cold chain at

provincial level (4% of cold chain) 2,400,000 1 1 1 1 1 2.4 2.6 2.9 3.2 3.5 14.7

2.5.4 Contracting out repair and

maintenance of cold chain at district

level (8% of cold chain) 55,000 25 25 25 25 25 1.4 1.5 1.7 1.8 2.0 8.4

Sub Total 3.8 4.2 4.6 5.0 5.5 23.0

Donor Funding

Sub Total - - - - - -


67


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

3 Objective 3: Strengthening and optimization of

immunization service delivery 85.0 119.9 168.1 185.0 203.5 761.4

3.1 Expansion in geographical coverage of static, outreach

and mobile EPI services

73.0 80.3 88.3 97.1 106.8 445.4

GoKP Funding

3.1.1 Fixed Traveling Allowance for

Vaccinators (200 per person per day

for 16 days in one month) 200 364,800 364,800 364,800 364,800 364,800 88.3 97.1 106.8 445.4 106.8 445.4

Sub Total 88.3 97.1 106.8 445.4 106.8 445.4

Donor Funding

3.1.1 Fixed Traveling Allowance for

Vaccinators (200 per person per day

for 16 days in one month)

- - - - - -

Sub Total - - - - - - - - - - - -


68


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

3.2 Contracting-out immunization services in urban slums

and hard to reach areas 12.0 39.6 79.9 87.8 96.6 315.9

GoKP Funding

3.2.1

Contracting out immunization

service delivery to private

sector/CSOs in selected Union

Councils (110 UCs)

600,000 20 60 110 110 110 12.0 39.6 79.9 87.8 96.6 315.9

Sub Total 12.0 39.6 79.9 87.8 96.6 315.9

Donor Funding

3.2.1

Contracting out immunization

service delivery to private

sector/CSOs in selected Union

Councils (110 UCs)

-

Sub Total - - - - - -


69


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

4 Objective 4: Improved oversight, coordination and program

management performance 218.8 129.3 176.6 192.0 210.3 927.0

4.1 Improving oversight and management through development of implementation guidelines

and reporting instruments

GoKP Funding

4.1.1

Technical Assistance for developing

new reporting system for KPISP 5,000,000 1 - - - - 5.0 - - - - 5.0

Sub Total 5.0 - - - - 5.0

Donor Funding

4.1.1 Technical Assistance for developing

new reporting system for KPISP - - - - - -

Sub total - - - - - -


70


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

4.2 Performance improvement through development of

comprehensive annual work plans 7.4 2.6 11.3 10.4 10.7 42.3

GoKP Funding

4.2.1 Development of Provincial Annual

Work Plan (3 day workshop) 500,000 1 1 1 1 1 0.6 0.6 0.7 0.7 2.6

4.2.2

Development of District Annual

Work-plans (5 districts per 2-day

workshop)

375,000 5 5 5 5 5 1.9 2.1 2.3 2.5 2.7 11.4

4.2.3 District Immunization Waste Action

Planning (DIWAP) workshops - - - - - - - - - -

4.2.4 Implementation of DIWAP - - - - - -

4.2.5 Revision of Comprehensive

Multiyear Plan (5-day workshop) 1,000,000 - - 1 - - - - 1.2 - - 1.2

Sub Total 1.9 2.6 4.1 3.2 3.5 15.2


71


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

FED EPI Cell Funding


Work Plan (3 day workshop) -

4.2.2



workshop)

-


Planning (DIWAP) workshops 610,000 5 5.0 5.0

4.2.4 Implementation of DIWAP 7,200,000 - - 1 1 1 7.2 7.2 7.2 21.6


Multiyear Plan (5-day workshop) -

Sub Total 5.0 - 7.2 7.2 7.2 26.6


72


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

Donor Funding


Work Plan (3 day workshop) 0.5 - - - - 0.5

4.2.2



workshop)

- - - - - -


Planning (DIWAP) workshops - - - - - -

4.2.4 Implementation of DIWAP - - - - - -


Multiyear Plan (5-day workshop) - - - - - -

Sub Total 0.5 - - - - 0.5


73


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

4.3 Strengthening monitoring system through computerization of

Union Council micro plans 16.2 - 19.6 21.6 23.7 81.1

GoKP Funding

4.3.1 Training on RED Strategy (Batch of

25) 139700 116 0 116 0 116 12.7 - 19.6 21.6 23.7 77.6

Sub Total 12.7 - 19.6 21.6 23.7 77.6

Donor Funding

4.3.1 Training on RED Strategy (Batch of

25) 3.5 3.5

Sub Total 3.5 - - - - 3.5


74


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

4.4 Institutionalizing regular

performance reviews 5.0 5.3 5.6 6.0 6.4 28.3

GoKP Funding

4.4.1 Biannual Provincial Program

Reviews (3-day per review) 1,200,000 2 2 2 2 2 0.4 0.6 0.9 1.2 1.5 4.7

4.4.2 Monthly District Review Meetings 2,000 300 300 300 300 300 0.6 0.7 0.7 0.8 0.9 3.7

4.4.3 Independent Monitoring by Third

Party Vendor (TPV) 2,000,000 1 1 1 1 1 - - - - - -

Sub Total 1.0 1.3 1.6 2.0 2.4 8.3


75


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

FED EPI CELL Funding


Reviews (3-day per review) - - - - - -

4.4.2 Monthly District Review Meetings - - - - - -


Party Vendor (TPV) 2.0 2.0 2.0 2.0 2.0 10.0

Sub Total 2.0 2.0 2.0 2.0 2.0 10.0

Donor Funding


Reviews (3-day per review) 2.0 2.0 2.0 2.0 2.0 10.0

4.4.2 Monthly District Review Meetings - - - - - -


76


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20


Party Vendor (TPV) - - - - - -

Sub Total 2.0 2.0 2.0 2.0 2.0 10.0

4.5 Strengthening field monitoring

and supervisory systems 154.3 75.7 83.3 91.6 100.7 505.6

GoKP Funding

4.5.1 District Multipurpose Field

Supervisor BPS 16 (1 per district) 312,000 25 25 25 25 25 7.8 8.6 9.4 10.4 11.4 47.6

4.5.2 Multipurpose Field Supervisor BPS

14 (5 per district) 253,800 125 125 125 125 125 31.7 34.9 38.4 42.2 46.4 193.7

4.5.3 Drivers BPS 5 (1 per district) 180,000 25 25 25 25 25 4.5 5.0 5.4 6.0 6.6 27.5

4.5.4 Suzuki Jimny Jeep for Provincial

Office 2,200,000 5 - - - - 11.0 - - - - 11.0


77


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

4.5.5 Suzuki Jimny Jeep (25 District

Coordinators) 2,200,000 25 - - - - 55.0 - - - - 55.0

4.5.6 Motorcycles Honda Deluxe 125 cc

(25 + 125 Field Supervisors) 130,000 150 - - - - 19.5 - - - - 19.5

4.5.7

Contracting out Repair and

Maintenance of Vehicles at

provincial level

360,000 1 1 1 1 1 0.4 0.4 0.4 0.5 0.5 2.2

4.5.8

Contracting out Repair and

Maintenance of Vehicles at district

level

300,000 25 25 25 25 25 7.5 8.3 9.1 10.0 11.0 45.8

4.5.9

Supervisory Visits by Provincial

Supervisors (5000 per person per

visit for 10 visits per month)

- 600 600 600 600 600 - - - - - -

4.5.10

Supervisory Visits by EPI

Coordinators & Surveillance

Officers (3000 per person per visit

for 10 visits per month, 5 for each

officer in one district)

3,000 3,000 3,000 3,000 3,000 3,000 9.0 9.9 10.9 12.0 13.2 54.9

4.5.11

Supervisory Visits by District

Multipurpose Supervisor (400 per

person per visit for 16 visits per

month in one district)

400 4,800 4,800 4,800 4,800 4,800 1.9 2.1 2.3 2.6 2.8 11.7


78


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

4.5.12

Supervisory Visits by Multipurpose

Field Supervisor (250 per person per

visit for 16 visits per month in one

district)

250 24,000 24,000 24,000 24,000 24,000 6.0 6.6 7.3 8.0 8.8 36.6

Sub Total 154.3 75.7 83.3 91.6 100.7 505.6

Donor Funding

Sub Total - - - - - -

4.6 Innovative technologies for oversight and

robust monitoring 1.3 4.7 5.1 5.7 6.2 22.9

GoKP Funding

4.6.1

GPRS Tracking System for

Supervisors and Vaccinators (per

district)

50,000 25 25 25 25 25 1.3 1.4 1.5 1.7 1.8 7.6


79


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

4.6.2 Procurement of Cell phones for

GPRS Tracking System 15,000 - 200 200 200 200 - 3.3 3.6 4.0 4.4 15.3

Sub Total 1.3 4.7 5.1 5.7 6.2 22.9

Donor Funding

Sub Total - - - - - -

4.7 Adequately financed management support systems and

program operations 29.7 41.0 51.7 56.8 62.5 241.7

GoKP Funding

4.7.1 Fuel for Electricity Generators at

Provincial EPI Stores (per month) 300,000 12 12 12 12 12 3.6 4.0 4.4 4.8 5.3 22.0

4.7.2

Fuel for Electricity Generators at

District EPI Stores (per month per

district)

50,000 300 300 300 300 300 15.0 16.5 18.2 20.0 22.0 91.6


80


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

4.7.3

Operating Expenses of Provincial

EPI Office (TA/DA, Other Misc.,

Telephone, Fax, Postage, Couriers,

Telegraph, and Sui Gas etc.)

- 12 12 12 12 12 - - - - - -

4.7.4 Electricity Expenses for Provincial

EPI Stores (per month) 300,000 12 12 12 12 12 3.6 4.0 4.4 4.8 5.3 22.0

4.7.5 Printing and Stationary (per district

per annum) 600,000 - 16 25 25 25 - 10.6 18.2 20.0 22.0 70.6

4.7.6 Transportation of Vaccines &

Logistics at Provincial Level 500,000 1 1 1 1 1 0.5 0.6 0.6 0.7 0.7 3.1

4.7.7 Transportation of Vaccines &

Logistics at District Level 200,000 25 25 25 25 25 5.0 5.5 6.1 6.7 7.3 30.5

4.7.8 Computers and Accessories for

Provincial EPI Team 1,000,000 1 - - - - 1.0 - - - - 1.0

4.7.9 Office Equipment for Provincial

Office 1,000,000 1 - - - - 1.0 - - - - 1.0

Sub Total 29.7 41.0 51.7 56.8 62.5 241.7


81


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

Donor Funding

Sub Total - - - - - -

5 Objective 5: Improved performance of surveillance system, data quality and routine

monitoring/reporting 85.9 60.3 23.1 29.9 12.7 211.9

5.1 Strengthening of surveillance system and epidemiological response to

disease-outbreaks 6.7 5.6 6.1 6.8 7.4 32.6

GoKP Funding

5.1.1 Training on Surveillance (Batch of

25) 71,800 44 22 22 22 22 3.2 1.7 1.9 2.1 2.3 11.2

5.1.2 Surveillance Activities (Materials,

transportation, lab expenses etc.) 3,500,000 1 1 1 1 1 3.5 3.9 4.2 4.7 5.1 21.4

Sub Total 6.7 5.6 6.1 6.8 7.4 32.6

Donor Funding

Sub Total - - - - - -


82


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

5.2 Innovative IT solutions for improving quality of

surveillance data 4.1 8.7 14.2 20.7 1.8 49.4

GoKP Funding

5.2.1

Procurement of Server for Android-

based online Surveillance Reporting

System

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

5.2.2

Development of Software for

Android-based online Surveillance

Reporting System

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

5.2.3

Procurement of Android Cell

Phones for Android-based online

Surveillance Reporting System (1

per health facility)

71,400 50 100 150 200 - 3.6 7.9 13.0 19.0 - 43.4

5.2.4

Operating Expenses for Android-

operated Surveillance Reporting

(surveillance site per month)

500 1,000 1,500 2,000 2,500 2,500 0.5 0.8 1.2 1.7 1.8 6.0

Sub Total 4.1 8.7 14.2 20.7 1.8 49.4

Donor Funding

Sub Total - - - - - -


83


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

5.3 Strengthening of routine immunization data reporting

and feedback systems 3.4 1.6 2.4 1.9 2.9 12.2

GoKP Funding

5.3.1 Training on Data Quality Self-

Assessment (Batch of 20) 486,700 7 3 4 3 4 3.4 1.6 2.4 1.9 2.9 12.2

Sub Total 3.4 1.6 2.4 1.9 2.9 12.2

Donor Funding

Sub Total - - - - - -

5.4 Scaling-up of Vaccine Logistic Management

Information System/ Online EPI MIS 71.8 44.4 0.5 0.5 0.6 117.8

GoKP Funding

5.4.1

Technical Assistance for

strengthening vLMIS/ Online EPI

MIS/ eVaccs implementation

40,000,000

1

1

-

-

- 40.0 44.0 - - - 84.0

5.4.2 Training on vLMIS/ Online EPI

MIS (Batch of 25) 68,600

4

2

2

2

2 0.3 0.2 0.2 0.2 0.2 1.0


84


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

5.4.3 Operating Expenses for vLMIS/

Online EPI MIS/ eVaccs Project 1,000 250 250 250 250 250 0.3 0.3 0.3 0.3 0.4 1.5

5.4.4

Computers and Accessories for

vLMIS/ Online EPI MIS/ eVaccs

(per district)

125,000 250 - - - - 31.3 - - - - 31.3

Sub Total 71.8 44.4 0.5 0.5 0.6 117.8

Donor Funding

Sub Total - - - - - -

6 Objective 6: Demand generation through effective

communication and advocacy 5.0 31.9 41.1 38.6 49.8 166.4

6.1 Advocacy and partnership

building - 31.9 35.1 38.6 42.5 148.0

GoKP Funding

6.1.1 Demand Generation, Advocacy &

Communication (per annum) 38,900,000 1 - 1 1 1 (14.0) 31.9 35.1 38.6 42.5 134.1

Sub Total (14.0) 31.9 35.1 38.6 42.5 134.1


85


Activities



2015-16 2016-17 2017-18 2018-19 2019-20 2015-16 2016-17 2017-18 2018-19 2019-20

Donor Funding o

6.1.1 Demand Generation, Advocacy &

Communication (per annum) 14.0 - - - - 14.0

Sub Total 14.0 - - - - 14.0

6.3 Research, evidence generation and

dissemination 5.0 - 6.1 - 7.3 18.4

GoKP Funding

6.3.1 Operations Research 5000000 1 0 1 0 1 5.0 - 6.1 - 7.3 18.4

Sub Total 5.0 - 6.1 - 7.3 18.4

Donor Funding

Sub Total - - - - - -


86

CAPITAL COST BREAKUP Rs. In Million

S. No Items Funding Source

Total WB, GAVI, UNICEF, JICA Federal EPI GoKPK

1 Availability of skilled staff 24.0 244.6 268.6

2 Vaccines and injection equipment 17,857.0 3,559.1 21,416.1

3 Cold chain and storage capacity 120.0 310.1 430.1

4 Cold chain monitoring 4.4 5.0 9.4

5 Vaccine management/ Planning 28.5 28.5

6 Cold chain repair/ Maintenance 23.0 23.0

7 Immunization service delivery/ strengthening existing services 445.5 445.5

8 Immunization service delivery - out sourcing of UCs 315.9 315.9

9 Technical assistance/ Reporting system 5.0 5.0

10 Development of annual work plans 0.5 26.6 15.2 42.3

11 Monitoring system/ UC MP computerization 3.5 77.6 81.1

12 Performance reviews 10.0 10.0 8.4 28.4

13 Field monitoring and supervisory systems 505.6 505.6

14 GPRS tracking system/ online data reporting 22.9 22.9

15 Program operations 241.7 241.7

16 VPD surveillance system/ vLMIS/ EPI MIS 211.9 211.9

17 Demand generation/ advocacy/ communication 13.9 134.0 147.9

18 Operations research 18.3 18.3

TOTAL 18,033.3 36.6 6,172.3 24,242.2


87

Annex-9: Cost of Vaccines: Shares of GAVI Financing & Govt. Co-Financing

TOTAL COST OF VACCINE

Rs. million

2015-16 2016-17 2017-18 2018-19 2019-20 TOTAL

BCG 14.2 21.5 24.1 27.1 30.3 117.3

Penta * 780.3 875.1 981.5 1,100.8 1,234.6 4,972.3

PCV-10 * 1,080.4 1,211.6 1,358.9 1,524.1 1,709.3 6,884.2

IPV 0 0 77.9 87.3 98 263.2

bOPV 37.6 85.1 95.5 107.1 120.1 445.4

Measles 23.7 104.8 117.5 131.8 147.8 525.5

Rota Virus * 0 1,605.5 1,800.6 2,019.5 2,264.9 7,690.5

TT 8.2 22.9 25.6 28.7 32.2 117.7

TOTAL VACCINE COST 1,944.4 3,926.6 4,481.6 5,026.3 5,637.2 21,016.1

FINANCING OF VACCINES AND INJECTION SUPPLIES Rs. million

2015-16 2016-17 2017-18 2018-19 2019-20 TOTAL COST

TOTAL GAVI FINANCING FOR VACCINES 1,687.8 3,412.8 3,795.1 4,231.6 4,729.7 17,857.0

a. Govt. Co-Financing for Penta, PCV10 & Rotavirus

vaccines 172.9 239.6 279.4 319.5 359.3 1,370.7

b. Govt. Financing for BCG, OPV, Measles, TT, IPV &

MR 83.7 274.2 407.1 475.2 548.2 1,788.4

TOTAL GOVT. FINANCING FOR VACCINES (a+b) 256.6 513.8 686.5 794.7 907.5 3,159.1

c. KPK Govt. financing for syringes & safety boxes 28.5 69.6 89.2 100.2 112.4 399.9

TOTAL GOVT FINANCING FOR VACCINES &

SYRINGES/ SAFETY BOXES (a+b+c) 285.1 583.4 775.7 894.9 1,019.8 3,559.1


88

REQUIREMENT OF POLIO VACCINE

P O P U L A T I O N Y E A R

2015-16 2016-17 2017-18 2018-19 2019-20

CHILDREN 0 - 11 MONTHS 887,876 905,256 922,976 941,044 959,465

Routine Immunization (90% Coverage) (Rs. In million)

YEARS TARGET

AGE GROUP

NO. OF

DOSES

TOTAL

DOSES

WASTAGE

MULTIPLIER

TOTAL DOSES PRICE

PER DOSE

TOTAL

PRICE

2015-16 tOPV 799,088 4 3,196,353 1.25 0 17.00 0

bOPV 799,088 4 3,196,353 1.25 1,977,864 19.00 37,579,421

TOTAL AMOUNT 37,579,421

2016-17 bOPV 814,730 4 3,258,922 1.25 4,073,652 20.90 85,139,328


2017-18 bOPV 830,679 4 3,322,715 1.25 4,153,394 22.99 95,486,523

IPV 830,679 1 830,679 1.25 1,038,348 75.00 77,876,134


2018-19 bOPV 846,939 4 3,387,757 1.25 4,234,696 25.29 107,091,239

IPV 846,939 1 846,939 1.25 1,058,674 82.50 87,340,615


2019-20 bOPV 863,518 4 3,454,073 1.25 4,317,591 27.82 120,106,305

IPV 863,518 1 863,518 1.25 1,079,398 90.75 97,955,338


G. TOTAL AMOUNT 708,574,904


89

REQUIREMENT OF BCG VACCINE

TARGET P O P U L A T I O N Y E A R

2015-16 2016-17 2017-18 2018-19 2019-20

CHILDREN 0 - 11 MONTHS (3.5%) 887,876 905,256 922,976 941,044 959,465

Routine Immunization (90% Coverage) (Rs. In

million)

YEARS TARGET

AGE GROUP

Estimated

Targeted

Coverage

TARGET

POP.

NO. OF

DOSES

TOTAL

DOSES

WASTAGE

MULTIPLIER

TOTAL

DOSES

PRICE

PER

DOSE

TOTAL PRICE

2015-

16

Routine 0-11

MONTHS 90%. 799,088 1 799,088 2 1,186,711 12.00 14,240,533

2016-

17

Routine 0-11

MONTHS 90%. 814,730 1 814,730 2 1,629,461 13.20 21,508,883

2017-

18

Routine 0-11

MONTHS 90%. 830,679 1 830,679 2 1,661,358 14.52 24,122,911

2018-

19

Routine 0-11

MONTHS 90%. 846,939 1 846,939 2 1,693,879 15.97 27,054,629

2019-

20

Routine 0-11

MONTHS 90%. 863,518 1 863,518 2 1,727,036 17.57 30,342,646



90

REQUIREMENT OF PENTAVALENT VACCINE

TARGET P O P U L A T I O

N

Y E A R

2015-16 2016-17 2017-18 2018-19 2019-20

CHILDREN 0 - 11 MONTHS

(3.5%)

887,876 905,256 922,976 941,044 959,465


million)

YEARS

TARGET

AGE

GROUP

Estimated

Targeted

Coverage

TARGET

POP.

NO. OF

DOSES

TOTAL

DOSES

WASTAGE

MULTIPLIE

R

TOTAL

DOSES

Country

Share

PRICE

PER

DOSE

TOTAL

PRICE

2015-

16

Routine 0-11

MONTHS 90%. 887,876 3 2,663,628 1.05 2,796,809 343,226 310.00 106,400,035

2016-

17

Routine 0-11

MONTHS 90%. 905,256 3 2,715,768 1.05 2,851,556 234,018 341.00 79,800,009

2017-

18

Routine 0-11

MONTHS 90%. 922,976 3 2,768,929 1.05 2,907,376 248,267 375.10 93,124,843

2018-

19

Routine 0-11

MONTHS 90%. 941,044 3 2,823,131 1.05 2,964,288 258,252 412.61 106,557,557

2019-

20

Routine 0-11

MONTHS 90%. 959,465 3 2,878,394 1.05 3,022,313 263,732 453.87 119,700,465



91

REQUIREMENT OF PNEUMOCOCCAL VACCINE

TARGET P O P U L A T I

O N

Y E A R

2015-16 2016-17 2017-18 2018-19 2019-20


(3.5%)

887,876 905,256 922,976 941,044 959,465


million)

YEARS

TARGET

AGE

GROUP

Estimated

Targeted

Coverage

TARGET

POP.

NO. OF

DOSES

TOTAL

DOSES

WASTAGE

MULTIPLIER

TOTAL

DOSES

Country

Share

PRICE

PER

DOSE

TOTAL

PRICE

2015-

16

Routine 0-11

MONTHS 90%. 887,876 3 2,663,628 1.11 2,956,627 163,793 406.00 66,500,049

2016-

17

Routine 0-11

MONTHS 90%. 905,256 3 2,715,768 1.11 3,014,503 357,848 446.60 159,814,711

2017-

18

Routine 0-11

MONTHS 90%. 922,976 3 2,768,929 1.11 3,073,511 379,226 491.26 186,298,610

2018-

19

Routine 0-11

MONTHS 90%. 941,044 3 2,823,131 1.11 3,133,675 394,074 540.39 212,952,115

2019-

20

Routine 0-11

MONTHS 90%. 959,465 3 2,878,394 1.11 3,195,017 403,030 594.42 239,571,124



92

REQUIREMENT OF ROTAVIRUS VACCINE

TARGET P O P U L A T I

O N

Y E A R

2015-16 2016-17 2017-18 2018-19 2019-20


(3.5%)

887,876 905,256 922,976 941,044 959,465


million)

YEARS

TARGET

AGE

GROUP

Estimated

Targeted

Coverage

TARGET

POP.

NO. OF

DOSES

TOTAL

DOSES

WASTAGE

MULTIPLIER

TOTAL

DOSES

Country

Share

PRICE

PER

DOSE

TOTAL

PRICE

2015-

16

BASIC 0-11

MONTHS 90%.

887,876 2 1,775,752 1.05 1,864,539 130,518 0.00 -

2016-

17

BASIC 0-11

MONTHS 90%.

905,256 2 1,810,512 1.05 1,901,038 67,627 590.00 39,900,033

2017-

18

BASIC 0-11

MONTHS 90%.

922,976 2 1,845,953 1.05 1,938,250 102,465 649.00 66,500,084

2018-

19

BASIC 0-11

MONTHS 90%.

941,044 2 1,882,087 1.05 1,976,192 130,575 713.90 93,217,500

2019-

20

BASIC 0-11

MONTHS 90%.

959,465 2 1,918,929 1.05 2,014,876 152,484 785.29 119,744,240



93

REQUIREMENT OF MEASLES VACCINE

P O P U L A T I O N (IN MILLION) Y E A R

2015-16 2016-17 2017-18 2018-19 2019-20

CHILDREN 0 - 11 MONTHS (3.5%) 887,876 905,256 922,976 941,044 959,465

Routine Immunization (90% Coverage) and SIA (95% coverage) (Rs. million)

YEARS TARGET

AGE GROUP

Estimated

Targeted

Coverage

TARGET

POP.

NO. OF

DOSES

TOTAL

DOSES

WASTAGE

MULTIPLIER

TOTAL

DOSES

PRIC

E PER

DOSE

TOTAL

PRICE

2015

-16

Routine 0-11

MONTHS 90%. 799,088 2 1,598,177 1.67 676,954 35.00 23,693,387

WI Week 9 months to 5

year

2016

-17

Routine 0-11

MONTHS 90%. 814,730 2 1,629,461 1.67 2,721,200 38.50 104,766,184

Measles follow up

campaign

09-59

MONTHS - 1 - 1.10 - 38.50 -

2017

- 18

Routine 0-11

MONTHS 90%. 830,679 2 1,661,358 1.67 2,774,467 42.35 117,498,680

2018

-19

Routine 0-11

MONTHS 90%. 846,939 2 1,693,879 1.67 2,828,777 46.59 131,778,588

Measles follow up

campaign

09-59

MONTHS - 1 - 1.10 - 46.59 -

Mop-up operation 09-59

MONTHS - 1 - 1.10 - 46.59 -

2019

-20

Routine 0-11

MONTHS 90% 863,518 2 1,727,036 1.67 2,884,151 51.24 147,793,969

Mop-up operation 09-59

MONTHS - 2 - 1.10 - 51.24 -



94

REQUIREMENT OF TT VACCINE

P O P U L A T I O N Y E A R

2015-16 2016-17 2017-18 2018-19 2019-20

TARGET FEMALES 905,633 923,361 941,436 959,865 978,654

Routine Immunization (80% Coverage) (Rs. In million)

YEAR TARGET AGE GROUP

Estimated

Targeted

Coverage

TARGET

POP.

NO. OF

DOSES

TOTAL

DOSES

WASTAGE

MULTIPLIER

TOTAL

DOSES

PRICE

PER

DOSE

TOTAL PRICE

2015-16

PREGNANT LADIES 90%. 815,070 2 1,630,140 1.25 818,413 10.00 8,184,131

HIGH RISK AREA

APPROACH 25% OF

CBA TARGET

-

3 - 1.25 - 10.00 -

2016-17

PREGNANT LADIES 90%. 831,025 2 1,662,050 1.25 2,077,563 11.00 22,853,188

INTERMEDIATE RISK

AREA APPROACH 25%

OF CBA TARGET

-

2 - 1.25 - 11.00 -

2017-18 PREGNANT LADIES 90%. 847,292 2 1,694,585 1.25 2,118,231 12.10 25,630,593

2018-19 PREGNANT LADIES 90%. 863,878 2 1,727,756 1.25 2,159,695 13.31 28,745,543

2019-20 PREGNANT LADIES 90%. 880,788 2 1,761,577 1.25 2,201,971 14.64 32,239,061



95

REQUIREMENT OF AUTO-DISABLE (AD) AND RECONSTITUTION SYRINGES AND SAFETY BOXES

(Rs. In million)

ITEM 2015-16 2016-17 2017-18 2018-19 2019-20 TOTAL

ROUTINE

BCG: AD Syringes (0.05 ml) with fixed

needle size 26Gx3/8” or 27G x10mm 8,900,333 13,443,052 15,076,819 16,909,143 18,964,153 73,293,500

MEASLES: AD Syringes (0.5 ml) with fixed

needle size 24x25mm or 24G x3/4 2,574,194 1,930,645 2,253,020 2,578,005 2,895,985 12,231,849

TT: AD Syringes (0.5 ml) with fixed needle

size 24x25mm or 24G x3/4 1,228,449 2,952,242 3,441,477 3,933,815 4,425,609 15,981,592

PENTA: AD Syringes (0.5 ml) with fixed

needle size 24x25mm or 24G x3/4 0 0 9,423,012 10,568,214 11,852,596 31,843,822

PNEUMO:AD Syringes (0.5 ml) with fixed

needle size 24x25mm or 24G x3/4 5,077,154 22,449,896 25,178,289 28,238,269 31,670,136 112,613,744

IPV: AD Syringes (0.5 ml) with fixed needle

size 24x25mm or 24G x3/4 6,138,098 17,139,891 19,222,945 21,559,157 24,179,296 88,239,387

TOTAL PRICE AUTO DISABLE

SYRINGES WITH FIXED NEEDLES 23,918,228 57,915,726 74,595,562 83,786,603 93,987,775 334,203,894

BCG (DISPOSABLE SYRINGE 2ML

21G/1.5"(for Reconstitution) 391,615 591,494 663,380 744,002 834,423 3,224,914

MEASLES: Disposable Syringes 5ml

21G/1.5" (for reconstitution of measles) 446,790 1,975,591 2,215,689 2,484,968 2,786,972 9,910,010

TOTAL RECONSTITUTION SYRINGES

WITH NEEDLES 838,405 2,567,085 2,879,069 3,228,970 3,621,395 13,134,924

TOTAL PRICE OF SAFETY BOXES 3,747,225 9,165,486 11,731,996 13,176,687 14,780,852 52,602,246

GRAND TOTAL 28,503,858 69,648,297 89,206,627 100,192,260 112,390,022 399,941,064


96

Mid-Level-Managers (MLM) Training on EPI (Batch of 20)

Trainees: Provincial Staff, District Coordinators and Field Supervisors Unit Price Quantity Days Total (PKR)

Local participants

Supplies per participant 200 5 1 1,000

Meal & teas per participant 300 5 7 10,500

Out-station participants

Average travel cost per participant 3000 15 1 45,000

Average daily allowance per participant = 2050 x 3 6150 15 7 645,750



Facilitator

Daily Lecture's allowance 3,000 3 7 63,000

Average travel cost per facilitator 3,000 0 0 0

Average daily allowance per facilitator = DA 2050 x 3 6,150 0 0 0

Meal & teas per facilitator 400 3 7 8,400

Venue/Hall charges 10,000 1 7 70,000

Total Cost (PKR) 878,150


97

Training of District Master Trainers (Batch of 25)

Trainees: District Coordinators/Supervisors Unit Price Quantity Days Total (PKR)

Local participants



Out-station participants

Average travel cost per participant 3000 15 1 45,000

Average daily allowance per participant = 2050 x 3 6150 15 3 276,750



Facilitator








98

Trainings of Vaccinators (batch of 20/training)

Trainees: Vaccinators Unit Price Quantity Days Total (PKR)

Local participants



Average travel cost per participant (Rs. 10/Km, Average Distance 30 km) 300 15 3 13,500

Average daily allowance per participant (Half daily of BS - 17) 0 15 3 0

Facilitator


Average travel cost per facilitator 3,000 3 1 9,000

Average daily allowance per facilitator = DA 2050 x 3 6,150 3 3 55,350





99

Skill building of Paramedics on EPI (Batch of 25)

Trainees: Lady Health Visitors, Medical Technicians etc. Unit Price Quantity Days Total (PKR)

Local participants




Average daily allowance per participant (Half daily of BS - 17) 1500 25 2 75,000

Facilitator








100

LHW's Training on EPI (batch of 20/training)

Trainees: Vaccinators Unit Price Quantity Days Total (PKR)

Local participants




Average daily allowance per participant (Half daily of BS - 17) 0 15 3 0

Facilitator


Average travel cost per facilitator 3,000 2 1 6,000

Average daily allowance per facilitator = DA 2050 2,050 2 3 12,300


Venue/Hall charges 0 1 3 0



101

Annex-10: Results Based Framework KPISP

Indicators Baseline

(2012) Source

Target Responsibility

for verification 2015-

16

2016-

17

2017-

18

2018-

19

2019-

20

Project Goal: To reduce the morbidity and mortality due to Vaccine Preventable Diseases (VPD) in children under 5 years and reduction in

tetanus morbidity in pregnant women

Under 5 mortality rate 89 PDHS 86 84 80 76 74 PDHS

% of children fully immunized between 12-23 months

disaggregated by gender, income, and district 53%

PDHS/

PSLM

S

60% 65% 70% 75% 80% Third Party

Validation

% of districts with revised computerized UC level micro

plans for 80% of UCs available at district level 35% 55% 65% 75% 95%

Third Party

Validation

% of UCs reporting at least 80% coverage of full

immunization in children between 12-23 months, which

have these reports validated by TMV

60% 70% 80% 90% 95% Third Party

Validation

% of reported outbreaks/ notifiable diseases countered

with an appropriate response by the system 70% 90% 90% 100% 100%

Third Party

Validation

Technical framework and policy guidelines for LHWs

involvement as social mobilizer and further

involvement as vaccinators subject to fully trained in

vaccinations and follow standards of vaccine wastage

rates

x Third Party

Validation

CSO/Private Sector involvement notified and

implemented X


102

% critical positions filled at provincial level by skilled

staff with appropriate qualifications and experience

(FM, procurement, M&E, Surveillance, Data

Management, Epidemiologist)

100% 100% 100% 100% 100% Third Party

Validation

% of districts reporting at least 01 month buffer stock

available within the district (source: LMIS) 60% 100% 100% 100% 100%

Third Party

Validation

Functional cold chain equipment in place as per

specifications >95% in each tier of health system

(including at least 1 month buffer stock capacity at

district level)

70% 90% 100% 100% 100% Third Party

Validation

%age of districts submitting online routine monthly

reports to provinces by agreed timelines 50% 80% 100% 100% 100%

Third Party

Validation

% of districts receiving feedback on monthly reports

from provincial directorate 90% 100% 100% 100% 100%

Third Party

Validation

IT-based solutions (surveillance, monitoring, reporting)

functional in 80% districts X

GPRS tracking of vaccinators, supervisors at all levels

functional in 80% of districts X

% quarterly meetings of the provincial vaccine

management committee held (LMIS) at provincial and

district levels

50% 100% 100% 100% 100% Third Party

Validation

% districts reporting on vLMIS with 80% timeliness &

completeness 24% 75% 100% 100% 100%

Third Party

Validation


103

Number of planned bi-annual meetings of provincial

coordination committee held chaired by Secretary

health

2 2 2 2 2 Third Party

Validation

No. of quarterly review meetings held at

provincial/regional level 4 4 4 4 4

Third Party

Validation

No. of monthly review meetings held at district level 25 25 25 25 25 Third Party

Validation

% of UCs validated for immunization coverage by

provincial office having more than 80% and less than

50% coverage

10% 10% 10% 10% 10% Third Party

Validation

% of UCs validated by districts having less than 40%

coverage 80% 80% 80% 80% 80%

Third Party

Validation

% of districts reporting UC level verified coverage 80% 90% 100% 100% 100% Third Party

Validation

% of districts competing for performance bonuses 60% 80% 80% Third Party

Validation

% of UCs having a functional VPD surveillance system

reporting online 24% 65% 80% 90% 90%

Third Party

Validation

% of districts in which complete online surveillance

including zero reporting for VPD & AEFI system is

functional for 80% or more of health facilities

24% 75% 100% 100% 100% Third Party

Validation


104

% of population having access to EPI services (fixed or

outreach) within 30 minutes walking distance at least

once a month

Third Party

Validation

% of UC with at least 02 skilled staff capable of

providing immunization 70% 80% 80% 80% 80%

Third Party

Validation

% of UCs reporting no vaccines out of stock 80% 100% 100% 100% 100% Third Party

Validation

% of UC without EPI centers 10% 5% 0% 0% 0% 0% Third Party

Validation

Dropout rates: DPT1-DPT3 10% 9% 9% 8% 8% 7% Third Party

Validation

Dropout rates: DPT3-Measles 1 Third Party

Validation

Population uncovered by EPI services/vaccinators/EPI

program

Third Party

Validation

% of population covered in collaboration with LHWs Third Party

Validation

% of population covered in collaboration with

NGOs/CSOs


105

Number of private institutions providing immunization

services in urban areas

No. of contracts with NGOs/CSOs for provision of

immunization services in urban slums awarded

% of immunization services through private

sector/NGOs/CSOs by urban/rural

% of sanctioned posts for vaccinators lying vacant Third Party

Validation

% of vaccinators(HF staff, LHWs) given

refresher/technical trainings 90% 90% 90% 90% 90%

Third Party

Validation

% EDOs/EDO(H) s have attended MLM course 90% 90% 90% 90% 90% Third Party

Validation

% of districts with functional cold chain equipment as

per specifications at ALL health facilities

Third Party

Validation

% of districts/tehsils having alternate electric supply

available at all EPI stores 90% 100% 100% 100% 100%

Third Party

Validation

% of EPI staff working according to the approved tour

plans 70% 80% 90% 100% 100%

Third Party

Validation


106

% of UCs with notified immunization teams in districts 90% 100% 100% 100% 100% Third Party

Validation

% of immunization staff having access to functional

transport 90% 100% 100% 100% 100%

Third Party

Validation

% of districts submitting online supervisory monitoring

reports to higher level 90% 100% 100% 100% 100%

Third Party

Validation

% of districts with full complement of supervisory staff

available 90% 100% 100% 100% 100%

Third Party

Validation

% of districts with detailed supervisory plans available

at district level 90% 100% 100% 100% 100%

Third Party

Validation

Expenditure on public awareness campaigns through

electronic media (in Rs.)

50

million

Third Party

Validation

Number of annual review of communication strategy

held at provincial level 1 1 1 1 1

Third Party

Validation

% of districts reporting tools/messages and printed

materials available 90% 100% 100% 100% 100%

Third Party

Validation

Number of meetings with provincial assembly

members/standing committee on health/immunization 1 1 1 1 1

Third Party

Validation


107

number of briefing notes prepared for provincial

assembly members 2 2 2 2 2

Third Party

Validation

Number of meetings with Line departments especially

education 2 2 2 2 2

Third Party

Validation

No. of talk shows held 2 2 2 2 2 Third Party

Validation

Notification of President Pediatric Association

provincial as member of provincial coordination

committee

X Third Party

Validation

No. of advocacy sessions conducted with policy makers 1 1 1 1 1 Third Party

Validation

% of parents retaining immunization card 39.7% 45% 55% 65% 75% 80% Third Party

Validation

% of parents with children under 1 year of age who can

state the date for next immunization 35% 45% 55% 65% 70%

Third Party

Validation


108

Annex-11: Scaling-Up of Vaccine Logistics Management Information System (vLMIS)/

Online EPI MIS

Scaling-Up of Vaccine Logistics Management Information System (vLMIS)/

Online EPI MIS

Introduction:

In May 2013, the USAID Deliver Project was assigned a task by Government of Pakistan to

strengthen the vaccine logistics system in Pakistan. The system is destined to strengthen the logistics

and inventory management of vaccines in a comprehensive manner to meet the needs of an automated

logistics information management system for the vaccines and cold chain equipment other logistics.

Initially vLMIS is being implemented in two phases. During the first phase of implementation 54

high risk districts have been selected across the Pakistan. Out of which vLMIS has been implemented

in 05 districts (Peshawar, Nowshera, Charsadda, Lakki Marwat and Mardan).

For the purpose more than 280 officials of Health Department and EPI program were trained or

oriented on vLMIS. This includes policy makers, senior and mid-level managers, EPI focal persons,

store in-charges and store keepers, DSV, ASV, Vaccinators and data entry operators.

The main objective of training program is to cost effectively implementation of vLMIS in high risk

districts of province and build district level technical capacity to use, analyze and report vaccine

logistics data through the vLMIS application.

The training program will be followed by the provision of hardware support and internet connectivity

devices at data entry sites in each district. The Deliver provincial staff and master trainers are

extending technical support and supervising the data entry process through regular field monitoring

and supervisory visits.

Scaling Up of vLMIS/ Online EPI MIS:

Keeping in view the limited capacity of the software the health department and EPI, has planned to

develop a comprehensive online EPI MIS system (Integrated PC-1). It is high time to expand the

scope of vLMIS or develop comprehensive EPI MIS software and implement it throughout in

province. Looking at the districts’ administrative details and phase one implementation experience,

it is expected that all vaccinators and 4-5 officials from each district need to be trained or oriented

on the use of android phones, eVacc software and online reporting system. For regular reporting of

data, computers and internet connections would be required in remaining districts of Khyber

Pakhtunkhwa. Additional resources would also be required in terms of technical support, monitoring

and supervision and operational cost.

Allocation of Resources:

In presence of strong political, policy and program level support and commitment, scaling up of

vLMIS or developing a comprehensive online MIS and implementation in all 25 districts of province

is mainly dependent upon availability of resources. There is adequate staff available in all the districts

which can play a pivotal role in implementation in these districts. The financial aspect of scaling up

is a critical to ensure required resource from the government allocations for system sustainability.


109

Annex-12: Aide-Mémoire: NISP Appraisal Mission (March 30 – April 10, 2015)


110


111


112


113


114


115


116


117


118


119


120


121


122

Annex-13: GAVI Partnership Agreement by the provinces with commitment on Co-financing


123


124

Annex-14: Endorsement of GAVI Partnership by Government of Khyber Pakhtunkhwa


125

Annex-15: Implementation Schedule and Activity Timelines

S.

No

.

Program Activities

Financial Years

20

15-1

6

20

16-1

7

20

17-1

8

20

18-1

9

20

19-2

0

1 Objective 1: Availability of qualified human resources

1.1 Availability of skilled immunization staff

1.1.1 Recruitment of 500 Vaccinators

1.1.2 LHW's Training on EPI (batch of 20/training)

1.1.3 Skill building of Paramedics on EPI (Batch of 25)

1.2 Capacity building and skill development

1.2.1 Mid-Level-Managers (MLM) Training on EPI (Batch of 20)

1.2.2 Training of District Master Trainers (Batch of 25)

1.2.3 Trainings of Vaccinators (batch of 20/training)

1.2.4 Refresher trainings of Vaccinators (batch of 20/training)

1.2.5 Training on Introduction of New vaccines (Batch of 20)

1.3 Staff motivation for improved performance

1.3.1 Technical Assistance for Developing Pay for Performance Scheme

1.3.2 Pay for Performance Bonuses for Union Council Teams (3 per

district per Quarter)

1.3.3 Pay for Performance Bonuses for District Teams (Biannual for 3

District)

1.3.4 Pay for Performance Bonuses for Provincial Team (Annual)

2 Objective 2: Uninterrupted supply of vaccines, cold chain

equipment and other logistics

2.1 Uninterrupted supply of vaccines and injection equipment

2.1.1 Vaccines

2.1.2 Injection Supplies

2.2 Expansion in storage capacity of vaccines and logistics

2.2.1 Cold Chain

2.2.1.1 Walk in Cold Room (plus) 40 cubic meter including procurement,

shipping and installation

2.2.1.2 ILR Dometic TCW2000 (Electrical)

2.2.1.3 ILR Dometic TCW2000/40 (Solar Direct Drive)

2.2.1.4 RCW25 Cold Box

2.2.1.5 Vaccine Carriers

2.2.1.6 Generator 20 KVA for PHQ

2.2.1.7 Generator 5KVA for Districts


126

2.2.1.8 Voltage Stabilizer I & III Phase

2.2.1.9 3 Phase Servo Stabilizers (15KVA). Shipped and installed

2.2.1.10 200KVA Gensets and distribution /switchover/auto-start panels

2.2.1.11 Other Cold Chain Equipment (Thermometers, fan motors, circuit

breakers etc.)

2.2.1.12 Spare parts of cold chain equipment (10% of total cost)

2.2.2 Warehouses

2.2.2.1 Construction of 3 Divisional/district EPI Warehouses

2.2.2.1 Renovation of 3 Divisional/district EPI Warehouses

2.2.2.3 Construction of Provincial EPI Warehouse

2.3 Innovative technologies for improving cold chain temperature

management

2.3.1 Smartview Cold Room Temperature Monitoring systems for

WIC/WIF)

2.3.2 3yr Smartview service support/communications/update contract

2.3.3 30-DTR's with integrated Simm (Fridge Tag-3)

2.4 Effective vaccine management through improved planning

2.4.1 Trainings on Vaccine Management

2.5 Contracting out repair and maintenance of cold chain equipment

2.5.3 Contracting out repair and maintenance of cold chain at provincial

level (4% of cold chain)

2.5.4 Contracting out repair and maintenance of cold chain at district level

(8% of cold chain)

3 Objective 3: Strengthening and optimization of immunization

service delivery

3.1 Expansion in geographical coverage of static, outreach and mobile

EPI services

3.1.1 Fixed Traveling Allowance for Vaccinators (300 per person per day

for 16 days in one month)

3.2 Contracting-out immunization services in urban slums and hard to

reach areas

3.2.1 Contracting out immunization service delivery to private

sector/CSOs in selected Union Councils (110 UCs)

4 Objective 4: Improved oversight, coordination and program

management performance

4.1 Improving oversight and management through development of implementation guidelines and

reporting instruments

4.1.1 Technical Assistance for developing new reporting system for KPISP

4.2 Performance improvement through development of comprehensive

annual work plans

4.2.1 Development of Provincial Annual Work Plan (3 day workshop)

4.2.2 Development of District Annual Work plans (5 districts per 2-day

workshop)


127

4.2.3 District Immunization Waste Action Planning (DIWAP) workshops

4.2.4 Implementation of DIWAP

4.2.5 Revision of Comprehensive Multiyear Plan (5-day workshop)

4.3 Strengthening monitoring system through computerization of Union

Council micro plans

4.3.1 Training on RED Strategy (Batch of 25)

4.4 Institutionalizing regular performance reviews

4.4.1 Biannual Provincial Program Reviews (3-day per review)

4.4.2 Monthly District Review Meetings

4.4.3 Independent Monitoring by Third Party Vendor (TPV)

4.5 Strengthening field monitoring and supervisory systems

4.5.1 District Multipurpose Field Supervisor BPS 16 (1 per district)

4.5.2 Multipurpose Field Supervisor BPS 14 (5 per district)

4.5.3 Drivers BPS 5 (1 per district)

4.5.4 Suzuki Jimny Jeep for Provincial Office

4.5.5 Suzuki Jimny Jeep (25 District Coordinators)

4.5.6 Motorcycles Honda Deluxe 125 cc (25 + 125 Field Supervisors)

4.5.7 Contracting out Repair and Maintenance of Vehicles at provincial

level

4.5.8 Contracting out Repair and Maintenance of Vehicles at district level

4.5.9 Supervisory Visits by Provincial Supervisors (5000 per person per

visit for 10 visits per month)

4.5.10 Supervisory Visits by District Coordinators (3000 per person per

visit for 10 visits per month in one district)

4.5.11 Supervisory Visits by District Multipurpose Supervisor (300 per

person per visit for 16 visits per month in one district)

4.5.12 Supervisory Visits by Multipurpose Field Supervisor (200 per person

per visit for 16 visits per month in one district)

4.6 Innovative technologies for oversight and robust monitoring

4.6.1 GPRS Tracking System for Supervisors and Vaccinators (per district)

4.6.2 Procurement of Cell phones for GPRS Tracking System

4.7 Adequately financed management support systems and program

operations

4.7.1 Fuel for Electricity Generators at Provincial EPI Stores (per month)

4.7.2 Fuel for Electricity Generators at District EPI Stores (per month per

district)

4.7.3 Operating Expenses of Provincial EPI Office (TA/DA, Other Misc.,

Telephone, Fax, Postage, Couriers, Telegraph, and Sui Gas etc.)

4.7.4 Electricity Expenses for Provincial EPI Stores (per month)

4.7.5 Printing and Stationary (per district per annum)

4.7.6 Transportation of Vaccines & Logistics at Provincial Level

4.7.7 Transportation of Vaccines & Logistics at District Level

4.7.8 Computers and Accessories for Provincial EPI Team

4.7.9 Office Equipment for Provincial Office


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5 Objective 5: Improved performance of surveillance system, data quality and routine


5.1 Strengthening of surveillance system and epidemiological response

to disease-outbreaks

5.1.1 Training on Surveillance (Batch of 25)

5.1.2 Surveillance Activities (Materials, transportation, lab expenses etc.)

5.2 Innovative IT solutions for improving quality of surveillance data

5.2.1 Procurement of Server for Android-based online Surveillance

Reporting System

5.2.2 Development of Software for Android-based online Surveillance

Reporting System

5.2.3 Procurement of Android Cell Phones for Android-based online

Surveillance Reporting System (1 per health facility)

5.2.4 Operating Expenses for Android-operated Surveillance Reporting

(surveillance site per month)

5.3 Strengthening of routine immunization data reporting and feedback

systems

5.3.1 Training on Data Quality Self-Assessment (Batch of 20)

5.4 Scaling-up of Vaccine Logistic Management Information System

5.4.1 Technical Assistance for strengthening vLMIS implementation

5.4.2 Training on Vaccine Logistic Management Information System

(Batch of 25)

5.4.3 Operating Expenses for vLMIS Project

5.4.4 Computers and Accessories for vLMIS (per district)

6 Objective 6: Demand generation through effective

communication and advocacy

6.1 Advocacy and partnership building

6.1.1 Demand Generation, Advocacy & Communication (per annum)

6.3 Research, evidence generation and dissemination

6.3.1 Operations Research

Documents

Khyber Pakhtunkhwa Immunization Support Project (KPISP