NATIONAL EXPANDED PROGRAMME ON IMMUNIZATION MULTI … · Republic of South Sudan Multiyear Plan for Immunization, 2012 – 2016 5 Executive Summary The multi-year plan EPI in South

THE REPUBLIC OF SOUTH SUDAN

NATIONAL EXPANDED

PROGRAMME ON IMMUNIZATION

MULTI YEAR PLAN

2012 – 2016

January 2012

Republic of South Sudan Multiyear Plan for Immunization, 2012 – 2016 1

Figure 1: Map of the Republic of South Sudan


Foreword

Immunization is a key priority of the Basic Package of health and nutrition services in South Sudan.

Over the CPA period, implementation of the first Multi-year plan for EPI (2007-2011) has accelerated

government‟s efforts to achieve better health for the children and women of South Sudan, thereby

contributing to the enhancement of the quality of life and productivity.

An external comprehensive review of the immunization programme conducted in October 2011

provided enormous information on best practices, weaknesses, opportunities and lessons learned over

the previous 5 years that forms the basis for development the 1st multiyear plan (2012-2016) of the

newly founded Republic of South Sudan. The EPI review 2011 documented several achievements

namely: improvements in immunization coverage despite the failures to attain previously set targets;

Immunization policy, practice standards and training manuals that conform to GIVs aspirations,

WHO/UNICEF and CDC immunization practice standards have been developed for program use at all

levels; Establishment of the structures for immunization program management at the national, state

and county levels that never existed at the beginning of the cMYP (in 2007); All vaccines, injection

materials and equipment used at all levels conform to WHO/UNICEF standards/specifications;

Strong support and collaboration from Development Partners for EPI; Reductions in the morbidity

and mortality of vaccine preventable diseases namely, interruption of Wild Polio Virus Outbreak, no

single measles outbreak and community reported cessation of whooping cough outbreaks.

In spite of the gains made, several challenges experienced over the past 5 years (2007-2011) in

delivery of EPI services exist. At all levels of the immunization program delivery systems, many

personnel do not have the qualifications required by the positions they hold. The national cold chain

system is lacking in inventory, volume and maintenance systems to hold vaccines adequate for a three

months supply period. A lot of staff managing the EPI program have not had any training in

immunization practice or management. Poor estimates of vaccine needs, unexplained shortages, high

wastage rates, expired vaccines still in stock and misuse of the vaccines remain rampant in the

program. All levels of the EPI program are not regularly supervised and the few that were supervised

had not received any written feedback. Various levels of the health/EPI system have no Advocacy and

Communication plans to systematically address the social mobilization issues of a young

immunization program.

The process of development of the new comprehensive multi-year plan 2012-2016, has accorded the

programme and partners an opportunity to reorganize approaches to address the current challenges, to

explore opportunities for more efficient delivery of services and to formulate strategies conforming to

the global vision for immunization (GIVS) as the new country strives to start the journey to achieve

the Millennium Development Goal of childhood morbidity and mortality reduction by 2015, and the

national goals as articulated in the Health Sector Development Plan (2011-2015). Focus will be made

on sustaining immunization coverage improvements in a rapidly growing population and reaching all

un-immunized children in every county; introduction of new and underused vaccines like Hepatitis B,

Haemophilus Influenzae type B, pneumococcal and rotavirus vaccines; and maintaining a high quality

and sensitive disease surveillance system at all levels in order to detect and respond timely to any

VPD outbreaks.

Lastly, I wish to express my appreciation to all those who have contributed to development of this

multi-year plan including the technical support provided by our partners in WHO, UNICEF,

CDC/GID, MSH/SIAPS and USAID. We pledge full government support in implementation of the

plan and look forward to attainment of the objectives set.

Dr. Makur Matur Kariom

Undersecretary, Ministry of Health


Table of Contents

FOREWORD ........................................................................................................................................................ 2

TABLE OF CONTENTS ..................................................................................................................................... 3

LIST OF TABLES .................................................................................................................................................. 3

1. INTRODUCTION ....................................................................................................................................... 6

1.1 COUNTRY PROFILE ............................................................................................................................... 6 1.2 THE NATIONAL HEALTH SYSTEM ......................................................................................................... 7 1.3 EPI WITHIN THE NATIONAL HEALTH SYSTEM ...................................................................................... 9

2. SITUATION ANALYSIS ......................................................................................................................... 11

3. PROGRAMME OBJECTIVES AND MILESTONES, S/SUDAN MULTI-YEAR PLAN, 2012-2016 ... 26

4. STRATEGIES, KEY ACTIVITIES AND TIMELINE, S/SUDAN MULTI YEAR PLAN, 2012-2016 .. 36

5. IMMUNIZATION PROGRAM COSTS AND FINANCING(CURRENT AND FUTURE) ................. 45

5.1 OVERVIEW .............................................................................................................................................. 45 5.2 DETAILED INFORMATION ON PROGRAMME COST BY CATEGORIES .................................... 45

5.2.1 Macroeconomic indicators .......................................................................................................... 45 5.2.2 Demographic information ........................................................................................................... 45 5.2.3 Vaccines & Injection Supplies ..................................................................................................... 46 5.2.4 Personnel Cost ............................................................................................................................. 47 5.2.5 Vehicles and transport cost .......................................................................................................... 47 5.2.6 Cold chain equipment .................................................................................................................. 47 5.2.7 operational cost of campaigns ..................................................................................................... 48 5.2.8 Program Activities, Other Recurrent Costs and Surveillance .................................................... 48 5.2.9 Other Equipment Needs and Capital costs .................................................................................. 48 5.2.10 Building and Building Overhead ............................................................................................ 48 5.2.11 Past Costs by categories .......................................................................................................... 48

5.3 DETAILED INFORMATION ON PROGRAMME FINANCING ........................................................ 49 5.3.1 Financing sheet ............................................................................................................................ 49 5.3.2 Past Financing ............................................................................................................................. 50

5.4 FUTURE RESOURCE REQUIREMENTS, FINANCING AND FUNDING GAP ...................................................... 51

List of Tables

TABLE 1. HEALTH AND HEALTH RELATED MDGS IN SOUTH SUDAN ....................................................................... 8 TABLE 2: IMMUNIZATION SCHEDULE FOR SOUTH SUDAN ..................................................................................... 11 TABLE 3: ADMINISTRATIVE DPT3 AND DTP-1 TO DTP-3 DROPOUT RATES BY STATE OF S/SUDAN, 2007-2011 13 TABLE 4: SITUATIONAL ANALYSIS OF ROUTINE EPI SYSTEM COMPONENT: ........................................................... 15 TABLE 5: BASELINE AND ANNUAL TARGETS FOR EPI IN SOUTH SUDAN, 2012 – 2016 ........................................... 17 TABLE 6: SITUATION ANALYSIS BY ACCELERATED DISEASE CONTROL INITIATIVES, SOUTH SUDAN, 2007-2011 18 TABLE 7: STRENGTHS AND WEAKNESSES OF EPI BY SYSTEM COMPONENTS, S/SUDAN, 2011 .......................... 19

List of Figures

FIGURE 1: MAP OF THE REPUBLIC OF SOUTH SUDAN .............................................................................................. 1 FIGURE 2: STATE AND COUNTY MAP OF SOUTH SUDAN ....................................................................................... 6 FIGURE 3: FUNCTIONAL ORGANIZATIONAL STRUCTURE OF EPI IN SOUTH SUDAN ................................................ 10 FIGURE 4: CONCEPTUAL FRAMEWORK FOR EPI PROGRAM IN SOUTH SUDAN 2011. ....................................... 12 FIGURE 5: ATTAINED AND TARGETED DPT-3 COVERAGE IN SOUTH SUDAN; 2006-2011 ...................................... 12 FIGURE 6: ANNUAL NUMBER OF IMMUNIZATIONS BY ANTIGEN IN SOUTH SUDAN; 2007-2011 ............................. 13 FIGURE 7: DTP-1 TO DTP-3 DROPOUT RATE MONITORING FOR SOUTH SUDAN; 2007-2010 ................................. 14 FIGURE 1: TOTAL IMMUNIZATION EXPENDITURE, 2011 ........................................................................................ 48 FIGURE 2: BASELINE SCENARIO – COST PROFILE ................................................................................................... 49 FIGURE 3: BASELINE SCENARIO – FINANCING PROFILE .......................................................................................... 50 FIGURE 4: EXPENDITURE – FUTURE RESOURCE REQUIREMENTS ........................................................................... 51


FIGURE 5: PROJECTION ON FUTURE RESOURCE REQUIREMENTS (EXCL. SHARED COSTS, IN MILLION US$) ........... 52 FIGURE 6: RESOURCE REQUIREMENTS, FINANCING AND GAPS .............................................................................. 52 FIGURE 7: COMPOSITION OF THE FUNDING GAP .................................................................................................... 53 FIGURE 8: SUSTAINABILITY ANALYSIS .................................................................................................................. 54 FIGURE 9: MACROECONOMIC AND SUSTAINABILITY INDICATORS INCLUDING SHARED COSTS .............................. 55


Executive Summary

The multi-year plan EPI in South Sudan (2012-2016) highlights the areas of focus for the

immunization programme development over the next 5 years based on previous programme

performance, priorities for the health sector as stipulated in the Health Sector Development

Plan (2011 – 2015) and the global and regional goals set for child health and survival. The

Global and Immunization Vision and Strategy (GIVS), Millennium development Goals on

mortality and morbidity reduction and the WHO Regional Strategic Plans provided the

overall strategic framework for development of the plan as well as priorities set in this cMYP.

EPI performance in South Sudan continued to show progressive improvements routine

immunization coverage and surveillance indicators between 2007 and 2010, when DPT3

coverage increasing from 22% in 2007 to 82% in 2010. Several investments in to the

programme over the years such as GAVI (ISS and HSS grants), WHO, UNICEF, USAID

(through WHO and MSH) and the roll out of Reaching Every County/Child (REC) approach

contributed to the successes attained. The impact of the immunization programme is evident:

the country interrupted the wild polio virus outbreak that started in 2008; morbidity/mortality

due to measles declined with no confirmed outbreak or measles deaths between 2008 and

2010; and the community reported cessation of whooping cough outbreaks

Successes notwithstanding, challenges in routine service delivery remained resulting in

persistent failure to attain the cMYP set targets for DTP-3 and DTP-1 to DTP-3 dropout rates.

Secondly, new vaccines (like Hepatitis B) were not introduced contrary to cMYP aspirations.

County variability in performance remained with the proportion of counties achieving the set

80% DTP-3 targets for routine immunization falling short of the targeted 60% throughout the

cMYP period. Vaccine stock outs were controlled but not eliminated and the aspiration to

have vaccine stores in all counties was not realized. Maintaining a high quality and sensitive

vaccine preventable diseases surveillance system at all levels remained in the hands of WHO

contrary to the aspiration of developing a national owned system.

Over the next 5 years the programme will focus on the County and lower levels to improve

routine immunization and surveillance performance; strengthen logistics management at all

levels; introduce Hepatitis and Haemophillus Influenzae Type B vaccines; strengthen

capacity of mid level managers, operational level health workers and pre service trainees to

deliver quality EPI services; advocate for sustainable financing of the programme; Sustain

polio free status, Achieve Neonatal tetanus and measles elimination targets. Strategies such as

REC, integration of activities (outreaches, vaccination week days, routine immunization

acceleration days, supplemental immunization activities), and advocacy for the programme

using evidence-based data will be used to achieve the targets set.

The programme cost (including shared costs) for the 5 years is US$ 167,380,940 (One

hundred and sixty seven millions, three hundred and eighty thousands, nine hundred and forty

united states dollars only). Of this cost, 27% are for vaccines and supplies. The programme

intends to introduce two new vaccines (in form of DTP-HepB-Hib) and to construct a

national vaccines store commensurate with the needs of a new nation, conduct polio and

measles supplementary immunization activities. The programme is faced with funding gap,

that are expected to increase with dwindling common humanitarian funding that contributed

the large chunks of WHO and UNICEF funding in the baseline year.


1. Introduction

1.1 Country profile

South Sudan lies between latitudes 3o and 13

oN, and longitudes 24

o and 36

oE. It is covered in

tropical forest, swamps, and grassland. South Sudan covers an estimated area of 619,745 km2,

of which 18% consists of White Nile and its related tributaries and swamps, with the rest

being made up of plateaus with numerous small hills and extensive savannah plains. It

receives abundant rainfall and is rich in tillable land.

As at the end of FY 2010/2011, South Sudan was administratively divided into 10 States and

78 counties. The counties are further divided into 605 Payams, 2,532 Bomas and 26,544

major villages.

Figure 2: State and county Map of South Sudan

Source: South Sudan Centre for Census, Statistics & Evaluation (SSCCSE, 2010)

According to a census carried out in April 2008, the population of South Sudan was

8,260,490, a figure that was disputed both locally and internationally. In fact, the American

chief technical advisor to the census estimated that the census reached 89% of the total

population which in turn would translate into 9,281,445 people as at April 2008. The annual

population growth rate of 3.2% is used to project the annual populations after 2008. The

majority (88%) of the population lives in rural areas.

Some demographic factors in South Sudan have been summarized in table 1 as quoted from

the 2010 South Sudan health household survey (SHHS)1.

1 Government of Southern Sudan 2010 household health survey


Table 1: Key demographic figures for South Sudan

Estimated population (at 89% census reach) 8,260,490

Population density 15/sqkm

Population composition Male 48%, Female 52%

Population growth per year Average 3.2 %

Life expectancy at birth 42 years *

South Sudan is one of the poorest countries in the world with about half of its population

(50.6%)2 living on less than 1 US$ per day. The vast majority of the population is engaged in

rural subsistence farming and cattle herding. Living conditions are very deprived with poor

access to potable drinking water (less than 50%), poor access to proper sanitation (less than

7%) and high illiteracy rates among adult population (88% among women and 63% men).

The South Sudan Development Plan emphasizes a sector wide and comprehensive

development of all sectors, including health, in order to reduce poverty and accelerate

progress towards socio-economic development. The principles of gender mainstreaming have

been stated by government as critical to public policy in all sectors and are incorporated in

this plan.

The economy of South Sudan is one of the world's weakest and most underdeveloped with

South Sudan having little existing infrastructure and the highest maternal mortality and

female illiteracy rates in the world as of 2011. South Sudan exports timber to the international

market. The country also contains many natural resources such as petroleum, iron ore,

copper, chromium ore, zinc, tungsten, mica, silver, gold and hydropower. The country's

economy, as in many other developing countries, is heavily dependent on agriculture.

Currently, the total Gross Domestic Product (GDP) is estimated at $13.227 billion ($1,506

per capita).

The national health development plan (HSDP 2011-2015) has been developed within the

framework of the South Sudan Development Plan 2011-2013. The latter has four „Pillars‟

namely governance, economic development, social and human development and conflict

prevention and security. Health is one of four sectors in the social and human development

pillar; the other three are education, social protection, and culture & youth/sports.

The section on health in the social and human development pillar has five programme areas

with targets to be achieved within the next three years. The five programme areas reflect

priorities within the three objectives for this five year health development plan. The five

programmes are:

1. Increasing access to basic health services and health promotion

2. Strengthening human resources in the health sector

3. Expanding the pharmaceutical and medical equipment supply chains

4. Strengthening the health management system

5. Strengthening provision of HIV and AIDS services

1.2 The National Health System

In the framework for state building in South Sudan, the MoH is taking a sector wide approach

in that it acknowledges the important role a number of different stakeholders play in health.

This is irrespective of whether the stakeholder is the Ministry of Health whose main mandate

is providing public health and clinical services, other line ministries, or the business sector.

2 National Household survey, 2009


The Ministry of Health recognizes for example, the present and future role of the private

sector in health service delivery. This includes FBOs, NGOs (local and international) and

private clinical facilities. In addition, there are on-going plans toward pooled financing and

geographical focus.

Through the inter-ministerial committee and other channels at national level, the MoH works

to ensure that all sectors consider health nationwide (central, state and county levels).

Important sectors for health include agriculture, animal, industry, water, education,

community development and finance and economic planning. Such inter-ministerial and

inter-sectorial functioning is important when working for example, on trying to achieve the

millennium development goals (MDGs) that have been domesticated in the national HSDP.

Table 1. Health and health related MDGs in South Sudan

MDG Baseline Latest estimate Target 2015

Maternal mortality ratio (per 100,000

live births) 2054 (*SHHS 2006) 2054 (SHHS 2006)

1643 (20%

reduction)

Infant mortality rate (per 1,000 live

births) 102 (SHHS 2006) 84 (SHHS 2010)

59 (30%

reduction)

Under-five mortality rate (per 1,000 live

births) 135 (SHHS 2006) 106 (SHHS 2010)

74 (30%

reduction)

Proportion of under-fives moderately

and severely underweight (weight for

age)

32.9% (SHHS 2006) 30.3% (SHHS 2010) 20%

Proportion of under-fives moderately

and severely stunted (height for age)

34.4% (SHHS 2006) 25% (SHH 2010) 22%

HIV prevalence among 15-24 year old

women 3% (ANC 2009) 3% (ANC 2009) 3%

Percentage of HIV positive women

receiving ARVs for PMTCT 4.66% (ANC 2009) 4.66% (ANC 2009) 20%

Proportion of pregnant women receiving

two doses of preventive intermittent

treatment for malaria

<5%(2006 Estimate) 13% (SSMIS 2009) 30%

Under 5-years of age sleeping under an

ITN the previous night <5% (2006 Estimate) 25% (SSMIS 2009) 70%

Proportion of children under 1 year

vaccinated against DTP-3

24.0% (SHHS 2006) 13.8% (SHHS 2020) 85%

Proportion of children under 1 year

fully immunized (card only)

NA 2.6% (SHHS 2010) 50%

Tuberculosis notification rate new

sputum smear positives (per 100,000) 25 (NTLBP 2006) 27 (NTLBP 2010 79

Tuberculosis Notification rate, all forms

(per 100,000)

58 (NTLCP-Database

2006)

72 (NTLBP-Database

2010) 140

Tuberculosis treatment success rate 78% (NTLBP 2006) 78% (NTLBP 2010) 85%

Use of improved drinking water sources 48.3% (SHHS 2006) 55% (SHHS 2010) 65%

Use of improved sanitation facilities 6.4% (SHHS 2006) 15.4% (SHHS 2010) 40% *SHHS = South Sudan health household survey; SSMIS = South Sudan Malaria Indicator Survey NTLBP = National TB, Leprosy,

Buruli Ulcer Programme

The national standard is to have the following structures in place and functional.

i) Ministry of Health and other National Level Institutions ii) Regional Referral and Teaching Hospitals (serving approximately 2 million people)

iii) State Ministries of Health (State level)

iv) County Health Department (in all counties)

Referral Facility - County Hospital (serving approximately - 200,000 people)


Primary Health Care Centre – Payam Level (serving approximately - 20,000

people)

Primary Health Care Unit – Boma Level (serving approximately - 5,000 people)

The functions and responsibilities of each level of the delivery system have been defined in

the Basic Package of Health Services. Minimum service standards and staffing levels have

also been set for each tier of service delivery.

The framework for delivery of community level health interventions is still being developed.

This definition shall specify the institutions required and how they should function at this

level

The main challenges to current institutional functioning include: a) lack of functional

institutional arrangements especially at county and lower levels; b) weak linkage between the

national, state, county and lower levels; c) financial and logistical shortfalls making broader

mechanisms such as the National health Assembly irregular. The need to strengthen the

technical, organizational and management capacities of the institutions at national, state,

county and lower levels cannot be over emphasized.

1.3 EPI within the National Health System

The EPI program is located in Directorate of Community and Public Health services. The

vision of program is to ensure that the population of South Sudan is free of vaccine-

preventable diseases and its mission is to contribute to the overall objective of the HSDP in

reducing morbidity, mortality and disability due to childhood vaccine preventable diseases.

The programme aims at ensuring that every child is fully immunized by the first birthday

against targeted diseases, and every newborn is protected from neonatal tetanus. The targeted

diseases are tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles.

The programme has 3 focus areas namely:

1) Strengthening routine immunisation;

2) Supplemental immunisation activities to achieve globally set targets of polio eradication,

elimination of maternal and neonatal tetanus, and accelerated measles control;

3) Establishing a sensitive disease surveillance system.

The immunization program in South Sudan is countrywide covering all Counties. And in line

with the mandates of the Ministry of Health, the EPI program is responsible for policy,

standards and priority setting, capacity building, coordinating with other stakeholders and

partners, resource mobilisation, procurement of inputs such as vaccines and injection safety

materials, monitoring and technical support supervision to states and lower levels. The states

and counties are responsible for planning, management and delivery of EPI services. The

community is involved in mobilization and bringing the children for immunization.

Immunization is part of the Primary Health Care Approach used in the country and is

integrated into the child survival at all levels.


Figure 3: Functional organizational structure of EPI in South Sudan

Director of EPI/New Vaccines

(Programme Manager)

Deputy Director of EPI/New

vaccines

National EPI Operations

Officer (Vacant)

EPI Cold Chain Manager

(Function executed by UNICEF) VPD Surveillance & EPI

Monitoring Officer (Function

executed by WHO)

Accelerated Disease Control

Officer (Functions executed by

WHO and UNICEF)

Operations

Research officer

(Vacant)

New Vaccines

& Technologies

Officer (Vacant)

2 Cold Chain

Technicians (1 is

Vacant)

Vaccine

Management

Officer (Vacant)

EPI Inspector

(Vacant)

EPI Data

Officer

SIAs Officer

(Vacant)

Emerging VPD

control officer

(Vacanf)

EPI Technical Advisor

(MSH/USAID)

Director Health

Promotion and

Education

CORE Group

Polio Project


Table 2: Immunization Schedule for South Sudan

Vaccine/

Antigen

Dosage Doses

Required Minimum Interval

Between Doses

Minimum Age to

Start

Mode of

Administration

Site of

Administration

BCG 0.05ml up to

11 months,

0.10ml after

11 months

1 None At birth (or first

contact)

Intra-dermal Right Forearm

DPT

0.5 ml 3 One month

(4 weeks)

At 6 weeks (or first

contact after that

age)

Intra-muscularly Outer Upper

Aspect of Left

Thigh

Polio 2 drops 0+3 One month

(4 weeks)

At birth or within

the first 2 weeks

(Polio 0) and six

weeks or first

contact after 6

weeks (Polio 1)

Orally Mouth

Measles 0.5 ml 1 None At 9 months (or

first contact after

that age)

Sub-cutaneuosly Right Upper

Arm

Tetanus

Toxoid

0.5 ml

5

TT1 & TT2; 4 weeks

TT2 & TT3; Six months

TT3 & TT4; One year

TT4 & TT5; One year

At first contact

with a pregnant

woman or women

of child bearing

age (15-45 years)

Intra-muscularly

Upper Arm

(Right or left)

2. Situation Analysis

Following the signing of the Comprehensive Peace Agreement (CPA) in 2005, the

Government of Southern Sudan (GoSS) formulated the “Health Policy for the Government

of Southern Sudan, 2007-2011” and the “Basic Package of Health Services for Southern

Sudan”(BPHS) .On the basis of these policies, the MoH prepared the “Comprehensive Multi-

Year Plan (cMYP) for the Expanded Program me on Immunization (2007-2011)”. The

“South Sudan Policy for EPI” Implementation guidelines were also adopted in 2009.

On 9th

July 2011, the Republic of South Sudan was born. Renewed hope and expectations for

the new nation are towards the expansion and consolidation of the immunization services. In

accordance with the interim transitional constitution, health and immunization specifically is

defined as a fundamental right of children and women of South Sudan. Equity in access and

delivery of quality immunization services are the guiding principles of the joint efforts of

MOH and all immunization partners. To achieve universal protection of all South Sudanese

women and children, the following conceptual framework for immunization services delivery

has been adapted to guide program development:

Routine immunization services are delivered through a mix of fixed sites (4,405), outreach

services (1,960) and accelerated campaigns that use the same service delivery points to mop

up immunization defaulters (drop outs or missed children).


Figure 4: Conceptual framework for EPI program in South Sudan 2011.

Routine immunization coverage as measured by DTP-3 improved from 12% to 71% between

2005 and 2010 respectively.

Figure 5: Attained and Targeted DPT-3 coverage in South Sudan; 2006-2011

0

10

20

30

40

50

60

70

80

90

2006 2007 2008 2009 2010 2011

14

1820

38

63

80

Att

ain

ed

Co

vera

ge (%

)

cMYP Targeted DPT-3 Adjusted Annual DPT-3 Targets Attained DPT-3 Coverage

Health Systems

Policy development

Financing

Human resource

Health Service delivery

External environment

Forces and trends e.g. –

political, economic social etc

Partners/stakeholders e.g. – the

public, politicians

Development partners

Collaborators e.g. private sector,

NGOs etc.

Role of Community

Community involvement

Community initiatives

Client satisfaction with service

Immunization operations

Immunization service delivery

Disease surveillance

Logistics, ,injection safety &

waste mgt

Vaccine supply and quantity

Advocacy & Communication

Advocacy and communications

(UNEPI)

Immunization outcome

Trend of coverage

Trend of dropout rate

vaccine utilization

wastage rates

Incidence/burden of

vaccine preventable

diseases


DTP-1 defaulters and DPT-1 to DTP-3 drop out monitoring has also been routinely done in

South Sudan to understand numbers of children not accessing EPI services and those that

accessed but could not complete their series and thus remained unprotected. .

Table 3: Administrative DPT3 and DTP-1 to DTP-3 Dropout rates by State of S/Sudan,

2007-2011

Administrative DPT-3 coverage

(%)

DPT-1 to DPT-3 Dropout rate (%)

2007 2008 2009 2010 2011 2007 2008 2009 2010 2011

CEQ 57 37 52 70 105 34 34 27 21 6

EEQ 15 22 60 79 63 69 46 20 20 1

Jonglei 3 18 21 40 64 71 57 50 13 24

Lakes 22 26 28 41 99 47 31 47 45 27

NBEG 6 6 24 74 87 55 70 65 15 28

Unity 7 26 40 78 104 70 48 44 28 18

U/Nile 11 21 33 50 73 52 51 40 23 16

Warrap 4 11 29 82 84 52 25 53 43 39

WBEG 31 13 84 97 71 10 46 18 23 27

WEQ 38 30 53 48 55 39 26 32 29 16

S/Sudan 18 20 38 63 80 41 42 39 27 21

Figure 6: Annual Number of Immunizations by Antigen in South Sudan; 2007-2011

-

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Ab

solu

te N

um

be

rs I

mm

un

ize

d

Antigen

2007

2008

2009

2010

2011


Figure 7: DTP-1 to DTP-3 dropout rate Monitoring for South Sudan; 2007-2010

6

1

2427 28

1816

39

27

16

21

0

10

20

30

40

50

60

70

80

2007

2008

2009

2010

2011

The improvements in routine immunization performance indicators are attributable to several

factors that include:

Improvements in routine EPI reporting, that improved from 10% to 79% between

2007 and 2011 respectively

Leveraging the institutional memory of Polio and Measles SIAs to introduction and

perfect routine immunization acceleration campaigns that bolstered the attained

coverage

Introduction of cumulative DTP immunization monitoring and the resultant use of

data for actions to correct program failures

Leveraging the Polio Infrastructure following interruption of the WPV outbreak

Enthusiasm of an emerging nation

Re-capitalization of the EPI Program that among others included renewal and

Expansion of the EPI Technical team, investments in expansion of the cold chain

network and increasing availability of Operational financing

However, the program documents that the highest ever attained DTP-3 coverage of 80%, in

2011 was nevertheless less than the national, regional and global targets of 90%. Secondly,

there are wide coverage disparities between the states and in each state, between the counties.

Thirdly, the program reports that the significant gains in routine DTP-3 coverage are

attributable to acceleration campaigns that are a) expensive and therefore unsustainable, b)

provide poor quality immunizations as they promote late vaccination uptake and thus leaving

children susceptible to vaccine preventable diseases in periods they should have been

protected and c) exert pressure on the already constrained human resources. Both internal and


external program reviews conducted in 2011 documented that failure to attain the national

and regional immunization coverage indicators were attributed to:

Poor accessibility to immunization services to a poor cold chain coverage

Inadequate capacity for management and delivery of immunization services

Weak vaccine management practices that make stock outs a frequent occurrence that

interrupts service delivery

Poor cold chain maintenance and injection safety practices

Irregular vaccine deliveries to the states given that the country still runs quarterly delivery

schedules

Weak community involvement and initiatives.

Inadequate community awareness on the benefits of immunization coupled with

circulation of rumors and misconceptions about immunizations.

Conflict and displacement that make mobilization for priority interventions including

immunization was very difficult.

The following table summarizes the progress of key EPI program subsystems indicators

during the five years of the first cMYP (2007-2011):

Table 4: Situational analysis of routine EPI system component:

System

components Suggested indicators*

National

2007 2008 2009 2010 2011

Routine EPI service

delivery

DTP3 coverage (%) 18 20 38 63 80

% of counties with less than 50% coverage 94 97 65 42 25

National DTP1–DTP3 drop-out rate (%) 41 42 39 29 21

Percentage (%) of counties with drop-out rate

DTP1 to DTP3 > 10 96 87 89 80 66

Vaccination card retention rate (% of 12-23 months) ND ND ND ND 40%

Routine

surveillance % of surveillance reports received at national level from

counties compared to number of reports expected NA NA ND ND ND

Cold

chain/Logistics

Percentage (%) of counties with adequate numbers of

functional cold chain equipment 30 40 50 70 90

Immunization

safety

Percentage of counties that have been supplied with

adequate number of AD syringes for all routine

immunizations

100% 100% 100% 100% 100%

Vaccine supply

Was there a stock-out at national level during the last

year? Yes No No Yes No

If yes, specify duration in months 0.5/12 0/12 0/12 1/12 0/12

If yes, specify which antigen(s). BCG DTP

Communication Availability of a plan No No No Yes No

Financial

sustainability What percentage of total routine vaccine spending was

financed using government funds 0% 0% 0% 0% 0%

Linking to other

health interventions

Were immunization services systematically linked with

delivery of other interventions (malaria, nutrition, child

health) established

Yes Yes Yes Yes Yes

Human resources

availability No. of health workers/vaccinators per 10,000 population. ND ND ND ND ND


System

components Suggested indicators*

National

2007 2008 2009 2010 2011 Management

planning Are a series of counties indicators collected regularly at

national level?(Y/N) Yes Yes Yes Yes Yes

NRA Number of functions conducted 0 0 0 0 0

Waste disposal Availability of a waste management plan N N N N N

Programme

management and

efficiency

Number of ICC meetings held 2 3 3 3 2

Percentage of total routine vaccine spending financed

using government funds 0 1 6 10 10

Vaccine wastage monitoring at national level for all

vaccines Y Y Y Y Y

Timeliness of disbursement of funds to district and

service delivery level ND ND 30% 50% 75%

* Double underline is indicating to weak indicator which needs to be improved

Several investments in to the programme over the years such as GAVI, introduction of

acceleration campaigns and the Reaching Every County/Child (REC) approach contributed to

the successes attained. The impact of the immunization programme in the country is evident:

the country interrupted the biggest Wild Polio Virus outbreak; morbidity due to measles

declined by over 90% compared to 2005 with no confirmed deaths in the period between

2007 and 2009 and the community reported cessation of whooping cough outbreaks.

At the end of the maiden cMYP, the immunization program in South Sudan has carried

forwards four strategic aspirations into the future namely:

1. Routine EPI service delivery coverage not reaching 80% of children in 80% of

counties. The high DTP-1 to DTP-3 dropout rate recognized as key of the factors in

attainment of this target

2. Failure to introduce new and under-used vaccines (Hepatitis B + Hib) despite the

significant contribution of the two diseases in infant and child mortality

3. Vaccine stock outs have been controlled but not eliminated

4. Limited vaccine storage volume (at all levels) and coverage.

Over the next 5 years the programme will focus on the State and County levels to improve

routine immunization and surveillance performance; strengthen logistics management at all

levels; introduce Hepatitis B and Haemophillus Influenzae type B vaccines; strengthen

capacity of mid level managers, operational level health workers and pre service training for

quality improvements in the EPI services; advocate for sustainable national financing of the

immunization services; Sustain polio free status, attain and sustain neonatal tetanus as well as

measles elimination. Strategies such as REC, integration of activities (outreaches, child

Health Week, defaulter tracing campaigns), and advocacy for the programme using evidence-

based data will be used to achieve the targets set. The targets for routine immunization are as

shown in Table 5.


Table 5: Baseline and annual targets for EPI in South Sudan, 2012 – 2016

2011 2012 2013 2014 2015 2016

Total population 10,142,

090

10,446,

353

10,759,

744

11,082,

536

11,415,01

2

11,757,4

62

Births (4.0%) 405,684 417,854 430,390 443,301 456,600 470,298

Infant deaths 41,380 42,621 43,900 45,217 46,573 47,970

Surviving infants 364,304 375,233 386,490 398,085 410,027 422,328

Pregnant women (5 %) 507,105 522,318 537,987 554,142 570,751 587,873

BCG Coverage (Survey) 33 38 43 48 53 58

DPT-1 (Survey Coverage) 33 38 43 48 53 58

DPT-3 (Admin Coverage) 80 85 90 92 94 96

DPT-3 (Survey Coverage) 27 32 37 42 47 52

OPV3 (Admin Coverage) 80 85 90 92 94 96

Measles (Survey Coverage) 24 29 34 39 44 49

TT2+ Preg (Survey Coverage) 20% 25% 30% 35% 40% 45%

Vaccine Wastage Rate 41% 31% 21% 16% 13% 10%

DPT1 to DTP-3 Admin dropout 21 18% 15% 12% 10% <10%

DPT-HebB+Hib 1 (Survey coverage) 48

53

58

DPT-HebB+Hib 3 (Admin coverage) 92 94 96


Table 6: Situation Analysis by Accelerated Disease Control Initiatives, South

Sudan, 2007-2011

Component Suggested indicators National 2007 2008 2009 2010 2011

National routine OPV-3 coverage (%) 3 18% 20% 38% 63% 80%

Proportion (%) of Counties with OPV-3

coverage > 80% 5 0 10 25 47

Number of NIDs Rounds conducted 4 2 5 9 4 4

H-to-H NIDs PCE coverage for Round 1 100.1 100.1 89.1 89.9 94.7

H-to-H NIDs PCE coverage for Round 2 100.8 101.9 70.4 92.0 95.8

H-to-H NIDs PCE coverage for Round 3 102.9 88.0 92.4 95.7

H-to-H NIDs PCE coverage for Round 4 100.4 89.5 94.4 95.8

H-to-H NIDs PCE coverage for Round 5 90.4





Non polio AFP rate per 100,000 children

under 15 years of age 2.30 2.60 2.38 4.06 4.50

Proportion of Counties (%) with non polio

AFP rate > 1 per 100,000 ND 82 71 89 89

Number of confirmed WPV cases 0 24 40 0 0

Non-Polio Virus Isolation Rates (%) 15.4 14.6 10.2 13.7 16.3

Maternal and

Neonatal

Tetanus

Elimination

TT2+ coverage (Pregnant and Non-Preg) 21 25 43 82 98

Number of Counties reporting > 1 case per

1,000 live births ND ND ND ND ND

Number of Counties completing 3 rounds

of TT SIAs 0 0 10 20 9

Measles Control Routine Measles coverage (%) 3 35 39 63 95 100

Proportion of counties (%) with measles

coverage > 90% 5 4 23 41 62

Reported (n) measles cases (HMIS) ND ND 211 342 1,818

Proportion (%) of suspected measles cases

with serum investigation ND ND ND 70 28

Proportion (%) of Counties reporting

1/100,000 Non measles suspected cases ND ND ND 17 33

Measles NIDS/ SNIDS conducted; Coverage (%) attained

79 ND ND ND 83

N.B. The administrative counties used are 79 for all the reporting years

3 Source of data: MOH Health Management Information System

4 NIDs data is derived from the Polio Control room of WHO. Reported coverage are administrative for 2007-

2008 but PCE derived for 2009-2011


Table 7: Strengths and weaknesses of EPI by system components, S/Sudan, 2011 System component Strengths Weaknesses

Vaccine supply

and quality

Procurement and distribution

Timely forecast and procurement for vaccines and injection

safety materials through UNICEF

All vaccines, injection safety materials and equipment used in

the EPI program and at all levels in South Sudan conform to

WHO standards and are contained in the WHO Product

Information sheet (PIS)

Vaccine management Vaccines and vaccine management standards defined in the

national guidelines for monitoring and supervision of

immunization

Vaccines are stored under appropriate storage conditions and

monitored through twice-daily temperature monitoring.

VVM on all vaccines; Multi Dose Vial Policy (MDVP)

introduced and adapted in the national Policy implementation

guidelines for immunization adopted in 2009. MDVP

documented to be practiced at service delivery level.

Inclusion of vaccine utilization monitoring for all vaccines in

the EPI reporting system. EPI vaccines utilization monitoring

also included in the evolving HMIS system.

Planned to complete the vaccine management assessment in

early 2012.

The government of South Sudan does not pay for any immunization

materials used in the country and thus Funds to procure the vaccines

and injection safety materials are all mobilized by UNICEF through

donor appeals

There is no active stock control system for vaccines and other EPI

supplies at all levels.

There is no national vaccine store (dry and cold stores on a designated

[Plot or service area) and thus program depends on UNICEF cold

rooms hosted at the CMS

Bundling concept not practiced at central level. The practice of the

concept at state and lower levels is also not adequate.

Quarterly vaccine deliveries to the states while Injection safety

materials are delivered every six months. No pre-approved scheduled

are available Occasional delays in distribution of vaccines due to dependency on the

United Nations Humanitarian Air Service for all states

Vaccine potency testing not done at any level of the vaccine chain in South

Sudan. Inadequate capacity for vaccine stock management at all levels contributed by

lack of institutional human resources for vaccine management and limited

skills in the available stores assistants. Main tool (Vaccine and Injection Materials Control book) for stock control

unavailable at all levels

There exists no stock management tool at all levels and thus system is unable

to identify gaps that need to be addressed.

Vaccine utilization monitoring data reported through the EPI reporting system

is not analyzed and in turn is not utilized at all levels. Poor vaccine management practices at peripheral level and during

transportation to outreaches due to lack of selected materials (sponges) and

mainly lack of skills by the vaccinators.


System component Strengths Weaknesses

Cold

chain/Logistics

Cold Chain Carried out inventory of cold chain equipment in 2008

and the data was updated in 2012.

Procured 3 cold rooms (50 cubic meters each) for the 3

regional hubs using GAVI/HSS grant through

UNICEF. This may have created additional storage

space for introduction of Pentavalent vaccine but is

been eroded by the breakdown of the aging two cold

rooms

Existence of cold chain corrective and maintenance

teams at central level and in 79/80 districts

Improvement in the frequency and regularity technical

support for cold chain maintenance to the counties by

the central technicians.

Injection safety and waste management AD syringes are now widely available for immunization

services.

All ADs and reconstitution syringes are supplied with

adequate safety boxes for safe disposal

Health workers exhibited fair knowledge of injection safety

and waste management theory

Waste segregation is being applied for both immunization

and other curative services in the health facilities.

Lack of integrated LMIS for immunization which has resulted in irregular

updating of cold chain equipment and vaccines/supplies utilization.

Irregular cold chain maintenance at all levels due to lack of technicians,

funds and transport to reach all cold storage centres.

Cold chain network still has refrigerators that are not CFC free.

Storage capacity at national level is not adequate for introduction of

pentavalent or other new vaccine technologies that are bulkier.

Inadequate transport for supplies and vaccines delivery, monitoring and

supportive supervision at all levels

Irregular energy (gas or kerosene) supply to the states and lower levels

Inadequate supply of spare parts for the aging refrigerator network.

Majority of cold chain equipment needs replacement at county and health

facility levels due to age, malfunction, inadequate storage capacity and cost

of maintenance;

There is a transport crisis in the program with no single vaccine delivery

truck while 13 of the 15 field support vehicles are salvages from the fleet

that was procured to facilitate the mass measles campaigns.

Inadequate immunization waste management policies and practices at all levels

The national injection safety policy was not revised to include use of

ADs for all health services.

There are no functional injection safety institutional arrangements

(injection or immunization safety technical working committee) to

steer health system-wide changes in policy and practice

Recapping of used needles/syringes was observed in 50% of health

facilities visited during the EPI review mission 2011

Improper use of pits at health facilities.

There is no inventory of incinerators or alternative injection waste

disposal facilities anywhere in South Sudan

Lack of guidelines for disposal of used/empty vaccine vial wastes.



Service delivery Adaptation of REC approach to EPI planning and service

delivery in which outreaches functionality play a major

role

Implementation of innovations to improve access to EPI

services such as acceleration campaigns and vaccination

week defaulter tracing

Good access to immunization services as evidenced by

BCG coverage of 98% and DPT1coverage of 111%.

Improvements in reported coverage from 22% to 84% in


Completeness of reporting reached 82% and 80% in


Reductions in morbidity due to VPDs e.g. interruption of

Wild Polio Virus Outbreak, unquantified measles and

whooping cough control.

Integration of EPI with other Child survival strategies

e.g. Vit A supplementation, deworming, and ITN

distribution.

50% of Counties attained DPT3 coverage less than 80% in 2011.

High Dropout Rates (DOR) in many counties with 52 of them (66%)

reporting > 10% in 2011

Lack of disaggregated TT2+ coverage amongst pregnant women

Catchment area for health facilities not clearly defined/known.

Poor utilization of data for decision making at points of collection

Immunization services provision delegated to non-skilled health workers

at facility levels

Minimal and/or no involvement of the private sector and community in

planning and implementation of services especially outreaches.

Irregular functioning of outreaches due to lack of transport and delayed

payment of duty facilitating allowances.

Failed to attain all 2007-2011 cMYP immunization coverage milestones

despite the massive improvements in coverage

Limited number of counties and health facilities implementing the REC

operational micro-plans as defined and funded by the National Program

Advocacy and

communication - The impact of immunization on the decline of VPDs There

exists a national communication strategy for the health sector

that articulates the targets, channels and activities for

generating demand for immunization activities

- EPI communication activities are articulated in both the

cMYP and annual plans of action for the immunization

program

- Availability of media houses (local FM radios) in almost all

the States that are used for dissemination of health messages

including immunization.

- UNICEF supported C4D project supporting recruitment of

communication experts in all 10 states of South Sudan

- The UNICEF C4D project has supported development of a

national communication strategy and state-wide

commmunization plans, both for routine and supplemental

Immunization activities.

- Poor/inadequate inter-personal communication between health workers and

caretakers as no single exit interview documented a single mother who knew

the 5 key messages for immunization

- Low community participation in planning and delivery of EPI services

- limited presence and coverage of IEC materials mainly for routine compared

to SIAs

- The decision-makers are not adequately sensitized and do not feel responsible

for promoting immunization.

- Advocacy and Political commitment was limited to 1st mention of

immunization in presidential speech in July, 2011

- No facility presented an advocacy and communication plan for immunization

services regardless of the fact that health facilities form the link between

service provision and the community.

- Village Health committees are expected to document community related

issues to immunization service providers and discuss them at quarterly health

facility functionality meetings, and yet they do not.



- Positive perceptions of immunization

o Reductions in vaccine preventable diseases

generating community confidence and demand

for immunization

o Routine EPI services through outreaches and

house-to-house campaigns are bringing

services closer to homes

- Negative community perceptions on immunization namely:

“Vaccines make children sick”, indicating the defects in health

education at EPI sessions

Immunization not priority amongst the competing gender roles of

women

Routine immunization centers considered far

Cost (direct and indirect) of routine immunization considered high

Community members felt that their needs are not listened too and

properly attended.

EPI Monitoring

and VPD

Surveillance

Surveillance for vaccine preventable diseases is being

implemented within the Integrated Disease Surveillance

(IDSR) framework. Interrupted the biggest wild polio virus outbreak in June

2009. There is a functional and adequately constituted National

Polio Expert Review Committee (NPERC) Case definition guidelines for MOH priority diseases have

been developed, printed and charts of these definitions are

available in all States and Counties Standard OPD morbidity registers have been developed and

printed for all health facilities to use as the HMIS evolves Introduced child immunization registers at every health

facility for tracking drop outs

External review of surveillance system carried out In every state there exists a surveillance officer

Active surveillance for EPI target diseases is limited to AFP surveillance

with little or no active surveillance for Measles, NNT and AEFI.

There exists no system for establishing burden of disease for vaccines

planned for introduction namely (Hepatitis B, and Haemophillus Influenzae

type B)

There are no functional National polio Certification Committee (NCC) and

National Polio Laboratory Containment Task Force (NTF) Private sector not involved in VPD/IDSR surveillance activities.

Community based surveillance system is very strong for AFP/Polio.

However, these community surveillance structures are not used for other

IDSR priority diseases

Delays in specimen referral to the nearest WHO accredited laboratory for

measles and Polio in Nairobi leading to delays in outbreaks confirmation.

Irregular supply of data collection tools (Tally sheets, Child health Cards,

Summary sheets) causing stock out at health facility and county levels. Lack of a system for monitoring of AEFIs in the country.

Child registers are not being used to track drop outs.

Data Quality Audits and self assessment not being done regularly

Programme

management

Policy, planning and management

- Presence of EPI Policy at the national level - Structures for partner coordination are in place at the national

level: ICC remains a functional coordination mechanism for

all immunization partners.

- EPI Policy not disseminated to state and lower levels - The current EPI policy does not address the upcoming new vaccines and

technologies



- Regular EPI technical meetings at national level

Supervision

- Presence of standards and guidelines for

monitoring/supervision at National level - Electronic Feedback provided to the States on a regular basis - Technical assistance provided by partners for specific areas.

Operational Research

- On-going research to document the prevalence of Hepatitis B

at Birth to support new vaccine introduction

- EPI documents not widely circulated to lower levels. - Adhoc activities disrupt planned activities at national and State levels. - Inadequate coordination of partners at state and county levels. - Lack of routine review meetings at County & lower levels - Lack of institutional arrangements for health services planning (bottom

up) and financing for routine immunization services in the country

- Weak managerial capacity for routine immunization in the most

counties

- Irregular technical support supervision visits especially from center to states,

from States to counties and from counties to health facilities. - Lack of monitoring and supervision guidelines at State and lower

levels

- Lack of support supervision tools at State and lower levels. - Limited feedback practices between the states and counties

- No/inadequate Operational research being done - Lack of skills and practical experiences in EPI operations research

Strengthening

human and

institutional

resources

The structure of the Ministry of Health is being

reviewed and therefore provides an opportunity for

more personnel at the National EPI program.

There exists a National Policy and Standards for

immunization services

The immunization in practice manual is adapted

for the republic of south Sudan and used to train

vaccinators and Supervisors 50 trainers and 200 staff trained in immunization in

Practice. Plan to train 200 staff in Immunization

practice in the next 4 years institutionalized

Despite the good proposed structure of the National Immunization

program, there is no matched recruitment to fill the many approved

positions Similarly, the proposed staffing norms at State, County and health

facility levels are not filled Limited coverage of training of vaccinators using the

Immunization in practice manual

No national adaptation of the MLM training manuals and

therefore, there are only limited trained EPI managers receiving

this kind of training from outside the country More emphasis on on-job training versus pre-service training Insufficient EPI content in the pre-service curricula of Health training

institutions.



Sustainable

financing

A budget line for EPI operations financing was established in

the financial year 2008 and remains until this date

GAVI/ISS and USAID/WHO funds available at State and

County levels for implementation of EPI activities through

direct disbursements Several NGOs implementing Primary Health Care in the

states consider and provide immunization as a basic

intervention in their package of services

The Government of the Republic of South Sudan, dismally contributing to

immunization operational financing.

Lack of Vaccine Independence as UNICEF in South Sudan finances and

procures all the vaccine and supplies needs of the program.

Few partners supporting EPI at national level with an undefined

immunization partnership at the state and county levels.

The conditional grants for Primary Health Care to the State Ministries of

Health are not adequate to provide minimal EPI operational costs at county

and health facility levels

No documented contribution of State governments to immunization

operations from the local revenue sources

New and

underused

vaccines

Political and technical will to introduce new and underused

vaccines

New and underused vaccines introduction defined in the

completed cMYP for S/Sudan

GAVI eligible for NUVI at 80% DTP-3 coverage and GDP

of less than 1000USD per capita

Still using traditional (six) antigens in the routine immunization program

despite the documented high risk and prevalence of Hepatitis B infections

Never applied for GAVI/NUVI despite eligibility since 2011



Accelerated

Disease Control

Polio Eradication

Interrupted the the biggest ever WPV outbreak in June 2009

and continues to enjoy Polio free status for the 30 months

running

Polio importation and preparedness plans with defined social

mapping available at state and National Levels. Preventive and outbreak response activities successfully

continuing through 2010 and 2011 with 4 rounds of

OPV/NIDs conducted annually National routine OPV-3 coverage continued on an upward

trend reaching 89% in 2011 Field review of the surveillance conducted in all 10 states to

assess the sensitivity of the surveillance system

Maternal and Neonatal Tetanus Elimination

Gradual increase in TT2+ coverage among women of

child bearing age Integration and phased implementation of TT SIAs

targeting women 15-49 years in high-risk counties

during the UNICEF funded Accelerated Child Survival

Initiative (ACSI) campaigns conducted between 2009-

2011

Measles Control

- Mass measles “Catch up” campaigns were conducted and

completed in 2007 resulting in >90% reduction in measles

morbidity and mortality. - Routine measles vaccination coverage improving

alongside the improving national trends of all other

antigens

- Measles follow up campaigns were conducted in 7 out of the

10 states with 3 remaining states confirmed to conduct their

SIAs in 2012 - Measles surveillance integrated in the evolving IDSR system

South Sudan yet to be declared Polio-free

NIDS fatigue after implementation of 24 rounds of House-to-House OPV

vaccination campaigns bearing a toll on the quality of future rounds. 9 Counties reported a non-polio AFP rate below 2/100,000; 1 County did not report any AFP case in two consecutive years of 2010 and

2011 (Abiemnhom/Unity State). All human and financial resources for the PEI programs being met by

WHO, UNICEF, CDC and more recently, the Bill and Melinda Gates

foundation grant to the CRE Group Polio project in South Sudan Lack of a national laboratory for confirmation of Wild Polio Virus

Infection Accessibility identified as a major barrier to AFP surveillance activities

No Maternal and Neonatal Tetanus Elimination status review and

documentation in South Sudan

National TT2+ coverage among pregnant women not being dissagregated

and monitored at the National and Sub-national levels

No county disaggregated TT SIAs coverage to determine the success of

ACSI in attaining the targeted 80% TT3 coverage required to achieve

MNTE risk reduction. TT card like Child Health Card retention is still poor among WCBA

- Case-based measles surveillance system is being initiated but remains largely

limited in coverage.

- No national measles control plan or investment strategy and therefore erratic

investments and monitoring of interventions in place

- Lack of a national laboratory for confirmation of measles cases


3. Programme Objectives and Milestones, S/Sudan Multi-Year Plan, 2012-2016

Description of problem or

national priority

Programme objective Targets and Milestones Regional and

global goals

Order of

priority

(By objective)

Service delivery

1. 50% of counties have not

attained 80% DPT-3

coverage

2. 52 of the 79 (66%) of

Counties have DTP-1 to

DTP-3 dropout rates

higher than 10%

3. Lack of disaggregated

TT2+ coverage amongst

pregnant women

- To achieve at least 80%

coverage for all routine

childhood antigens (using

DPT- 3 as a tracer indicator)

in 80 % of counties by 2016

- To attain a DTP-1 to DTP-3

dropout of less than 10% in

at least 90% of counties by

2016

- To achieve at least 60% of

counties with 80% TT2+

coverage for pregnant

women by 2016

2012: National DPT3/OPV3 coverage at 85%; 60% counties above 80%; 2013:National DPT3/OPV3 coverage at 90%; 65% counties above 80%; 2014: National DPT3/OPV3 coverage at 92%; 70% counties above 80%; 2015:National DPT3/OPV3 coverage at 94% ; 75% counties above 80%; 2016:National DPT3/OPV3 coverage at 96%; 80% counties above 80%;

2012: DTP-1 to DTP-3 dropout of 18; 70% counties with DOR <10% 2013: DTP-1 to DTP-3 dropout of 15; 75% counties with DOR <10%

2014: DTP-1 to DTP-3 dropout of 12; 80% counties with DOR <10%



2012: 20% of counties with 80% TT2+ coverage amongst

pregnant women;


pregnant women;


pregnant women;


pregnant women;


pregnant women;

By 2010 or sooner, all

countries will have

routine immunization

coverage at 90%

nationally with at least

80% coverage in

every district (GIVS

2005)

By 2009, at least 80%

of countries will attain

at least 80% DPT3

coverage in all

counties (AFRO)

Reduce child

mortality by two-

thirds between 1990

and 2015 (MDG4)

By 2009, at least 80%

of countries will attain

a minimum of 80%

TT2+ coverage among

women of child

bearing age

1

2

2


Cold chain/Logistics 1. Lack of integrated LMIS

for immunization

2. Irregular cold chain

maintenance at all levels

3. Cold chain network still

has refrigerators that are

not CFC free

4. Cold Storage capacity at

national level is not

adequate for

introduction of new

vaccine technologies

- To establish a logistics

management information

system (LMIS) in all 10

states by 2016

To establish a national

preventive and corrective

cold chain maintenance

system for EPI in South

Sudan

To build an

environmentally

compliant cold chain

system in the Republic of

South Sudan by 2016

To expand the cold

storage capacity to levels

adequate to take

pentavalent vaccine by

2014 or earlier

2012: Establish LMIS at national level 2013: Establish the LMIS in 40% of the State vaccine stores. 2014: Establish the LMIS in 60% of the State vaccine stores. 2015: Establish the LMIS in 80% of the State vaccine stores. 2016: Establish the LMIS in 100% of the State vaccine

stores.

2012: Pilot a preventive cold chain maintenance system in 2

states 2013: Expand the preventive cold chain maintenance system

to 4 states. 2014: Expand the preventive cold chain maintenance system

in 6 states 2015: Expand the preventive cold chain maintenance system

in 8 states. 2016: Expand the preventive cold chain maintenance system

in all 10 states

2012: Attain CFC-compliant cold chain system at national

level 2013: Attain CFC-compliant cold chain system in 40% of

the State cold stores. 2014: Attain CFC-compliant cold chain system in 60% of

the State cold stores. 2015: Attain CFC-compliant cold chain system in 80% of

the State cold stores.. 2016: Attain CFC-compliant cold chain system in 100% of

the State cold stores.

2012: Develop a cold chain expansion proposal for

resources mobilization

2013:Initiate construction of the National vaccine

store/warehouse

2013 or earlier: Install 2 new cold rooms at the CVS

2

2

2

1


5. Inadequate transport for

supplies and vaccine

delivery, monitoring and

supportive supervision at

all levels.

6. Inadequate immunization

waste management

practices at health facility

levels

To strengthen the transport

system for logistics and field

monitoring of EPI services

by 2014 Effective and efficient

storage and distribution

system for EPI vaccines and

logistics

To attain 100% safe

injection practices for all

immunizations in South

Sudan by 2013.

2012– 2014: Procure and maintain 2 field vehicles, 2 trucks,

10 state multi-purpose vehicles, 80 motorcycles and 5,000

bicycles

2012-2014: Storage and distribution strategy adapted and

implemented

2013: Establish injection safety Task force in the Ministry of

Health

2014: Decree a Health worker protection statute.

By 2009, all countries

will adopt and

implement

technologies for safe

disposal and

destruction of

injection materials and

other sharps

3

3

Vaccine supply and quality 1. 100% vaccine and

immunization supplies

funded by UNICEF

2. Vaccine is stock control

system not fully functional

at all levels

- To achieve 60% Vaccine

Independence for the

Republic of South Sudan by

2016

- To achieve 100% of

counties monitoring vaccine

stocks and utilization

monthly by 2014

2013: Vaccine Independence Initiative agreement signed;

2014: 20% of Traditional Vaccines procured by Government

funding


funding


funding

2012: 100% of States adequately monitoring vaccine stocks

and utilization 2013: 40% of counties adequately monitoring vaccine

stocks and utilization 2014: 60% of counties adequately monitoring vaccine


2015: 80% of counties adequately monitoring vaccine


2016: 100% of counties adequately monitoring vaccine


By 2007, all countries

will adopt the multi

dose vial policy

1

2


3. There is no national

Vaccine store (dry and

cold) and thus program

depends on UNICEF cold

rooms hosted at the CMS

4. Bundling Concept not used

in Immunization vaccines

and supplies management

5. Quarterly Vaccines

distribution system that is not

scheduled and depends on the

UN Humanitarian Air Service

6. Lack of a vaccine Quality

Assurance system in South

Sudan

- To attain 100% storage

capacity (with a minimum

storage volume adequate for

6 months) at national level

by 2014

- To establish use of bundling

Policy in Immunization supplies

management

- To develop a monthly

delivery system for vaccines

and immunization supplies

to all states

- To operationalize vaccine

quality assurance standards

and practices in South

Sudan

2012: Procure Land (approximately 100x100 Meters for the

construction of the national Vaccine Store/Warehouse

2013: Construction of a national Vaccine (cold) Store

2014: Construction of the National EPI ware-house

2015: Construction of the National Cold chain maintenance

workshop

2016: Construction of a national EPI office Building

2012: Introduce immunization vaccines and supplies

bundling at the CVS

2013: 40% of States using Bundling of Immunization

vaccines and supplies







2012: Develop and Approve Quarterly vaccine delivery

schedules to all states

2013: Procure 2 Vaccine Delivery trucks for the CVS

2014: Initiate Monthly Vaccine Delivery schedules in 3

States

2015: Expand Monthly Vaccine Deliveries to 50% of States

2016: Monthly Vaccine Deliveries to all 10 States

2012: Develop, Print and disseminate a Vaccine and

Injection Materials control book to all levels

2013: Start Vaccine Potency Testing for Measles and OPV

at National Level

2014: Establish 10 Vaccine Utilization monitoring sentinel

sites

2015: Expand and operationalize vaccine Utilization

monitoring in 20 sentinel sites

1

1

1

2


Advocacy and

communication

1. Inadequate IPC skills

between health workers

and caretakers

2. Low community

participation in planning

for EPI services

3. Lack of IEC materials for


4. Weak advocacy & lack of

political commitment

To achieve at least 50% of

counties with health workers

who are trained in IPC by

2016.

To sensitize and use priority

community structures

(Chiefs, TBAs and VHC) on

EPI services delivery points

in 100% of counties by 2014

To produce and disseminate

immunization IEC materials

to all counties by 2014

To develop a national

advocacy and

communication plan for EPI

by 2012

To strengthen & sustain

inter-sartorial collaboration

with partners & stakeholders

by 2013

2012: Health workers in 10% of counties trained in IPC and

disseminate the 5 key messages on EPI during immunization

sessions;



sessions;



sessions;



sessions;



sessions;

2012: Boma Chiefs sensitized on EPI in monthly in all

counties

2013: TBAs sensitized on EPI in all counties

2014: VHCs sensitized and discussing EPI in monthly

meetings in all counties

2012: Immunization IEC materials produced and printed;

2013: 100% counties with electronic and printed messages

on immunization.

2012: Conduct KAP study on immunization and use findings

to develop a communication plan for EPI

2013: Disseminate the communication plan to all 10 states

2013: Conduct organized advocacy meetings with private

sectors (CBOs, FBOs, NGOs) in all states

2

1

3

2


Surveillance 1. Lack of an integrated

national surveillance

system for Vaccine

preventable diseases

despite a good AFP

infrastructure.

2. Lack of surveillance

systems for new and

under-used vaccines

(namely Hepatitis B, Hib

and Rotavirus)

3. Lack of institutional

arrangements to certify

existing VPD surveillance

systems

To expand the existing

AFP/Polio surveillance

system to include Measles,

NNT and AEFI by 2016

To establish systems for

providing epidemiological

description of Hepatitis B,

Paediatric bacterial

Meningitis and Rotavirus

Infections in S/Sudan by

2016

To establish and

operationalise surveillance

certification committees for

Vaccine preventable

diseases by 2014

2012: 80% of counties with non-polio AFP rate of

2/100,0000; 60% of IDSR reported measles cases

investigated with a serum sample for lab confirmation;

2013: : 80% of counties with non-polio AFP rate of

2/100,0000; 80% IDSR reported measles cases investigated

with a serum sample for lab confirmation;

2014: 80% of counties with non-polio AFP rate of

2/100,0000; 80% of suspected measles cases investigated for

lab confirmation; 60% of reported NNT cases investigated;

2015; 80% of counties with non-polio AFP rate of



2016; 80% of counties with non-polio AFP rate of



and 50% detected and investigated at least one AEFI

2012: Conduct Rapid Assessment for PBM/Hib burden of

disease in South Sudan 2013: Establish One NUVI sentinel surveillance site for

PBM

2014: Establish and operationalise regional NUVI sentinel

sites for PBM

2015: Expand NUVI sentinel surveillance sites to include

Rotavirus

2012: Decree formation of NITAG, NCC/Polio and

NTF/Laboratory Containment of Polio 2013: Operationalize all surveillance certification

committees for VPDs

2014: Conduct a laboratory search list for laboratory

containment of Polio

By 2007 or earlier, all

countries will achieve

at least 2 cases of AFP

notification per

100,000 By 2009 or earlier, all

countries will have

established case based

surveillance for

neonatal tetanus

By 2009 or earlier, all

countries will report

cases of AEFI from all

counties

1

2

3


Programme Management

A) Policy, Planning and

Management 1. Current policy is not

disseminated to states and

lower levels and does not

address the upcoming new

vaccine and technologies

B) Monitoring and

supervision

1. Irregular technical support

supervision at all levels

2. Lack of monitoring/

supervision guidelines and

tools at state and lower

levels

C) Operational research

1. Inadequate operational

research

2. Capacity for research at all

levels not adequate

To update and disseminate

the EPI policy by 2013

To conduct supportive

supervision at County level

on a quarterly basis and

provide feedback on

coverage, dropout rates and

vaccine wastage

Disseminate and enhance

use of monitoring and

supervision guidelines in all

counties by 2013

To strengthen operational

research capacity at national

and county levels, and

promote use of research

findings

2013: Policy update finalized and presented to the Board of

Directors; printed and disseminated;

2012-2016: 4 quarterly visits per year conducted by 80% of

counties; Feedback to counties provided quarterly; Biannual

review meetings (post supervision) on performance

2012: Train at least 4 people in the use of the EPI

monitoring and supervision guidelines in all states


monitoring and supervision guidelines in 40% of counties







2012: Develop operational research plan involving national

and state EPI operations officers 2013-2016:Conduct operations research projects for

improving EPI program efficiency and effectiveness

1

2

1

3


Strengthening human and

institutional resources

1. Unfilled positions in the

approved EPI program

structure at all levels

2. Limited coverage of the

OPL training

immunization services

providers

3. No nationally adapted

MLM training program

To recruit and fill up to

100% of all approved

staffing norms at National

and State levels by 2015

To scale up OPL training to

reach 100% of vaccinators

by 2016

Establish a Mid level manager

training program covering

all counties by 2016

2012: Recruit and fill 60% of approved staffing norms at

national level


national level


national level


national and state levels

2012: Train at least 20% vaccinators in immunization

practice


practice


practice


practice


practice

2012: MLM training conducted for all 10 state EPI

operations officers 2013: MLM training conducted for 40% of county EPI

supervisors; 2014: MLM training conducted for 60% of county EPI



supervisors;

2

1

1


Sustainable Financing

1. Inadequate government

allocation for EPI program

operational costs

To increase government


operational costs

Explore alternative sources

for EPI funding

2012-2016: Attain and sustain government‟s budget support

for routine EPI operations at 10 USD per child vaccinated

with DTP-3; Attain government funding for procurement of

traditional vaccines; Initiate government co-financing for

NUVI

By 2009 or earlier,

countries will be

contributing at least

30% of annual

vaccines procurement

costs

1

Introduction of new vaccines

and technologies 1. Country still using

traditional EPI antigens

despite the documented

high burden of Hepatitis B

virus infections

To introduce Hepatitis B

vaccine into the routine

immunization schedule by

2014

To introduce Haemophillus

inflienzae type B vaccine

into the routine


2014

2012: Make a GAVI/NUVI application

2013: To reach 20% of the surviving infants with DTP-

HepB-3


HepB-3


HepB-3


HepB-3

WHA Resolution 63.18

called for member states,

"…to integrate cost-

effective new vaccines,

such as hepatitis B

vaccine, into national

EPI programs …"

By 1997 or earlier all

countries integrate

hepatitis B vaccine into

national EPI programs

1

Accelerated disease control

activities

South Sudan is yet declared

Polio-free and neither has it

eliminated Maternal and

Neonatal Tetanus

To be certified free of Wild

Polio Virus circulation by

2014

To attain and sustain MNT

elimination status by 2014

2012-2016: Conduct 4 rounds of preventive OPV

supplemental Immunization campaigns annually

2012: Constitute the National Certification Committee for

the Republic of South Sudan

2013-2016: Collate and produce an annual certification

committee report 2014: Present a complete country documentation for

certification of Polio-free status to the Regional certification

commission

2012: Conduct a comprehensive risk analysis for MNTE in

South Sudan.

2013: Conduct TT SIAs in selected high-risk counties of

South Sudan.

2014: Achieve NNT rate of < 1 per 1,000 live births in every

County of South Sudan and thus attain MNTE

By 2009, the process of

independent certification

of polio-free status will

lead to full regional

certification

Persistence of Polio

beyond April 2011 is a

public health emergency

(WHA65.5)

By 2009, at least 80% of

countries will achieve

NNT incidence rate of

less than 1 case per

1,000 live births in all

counties

By 2010 or earlier,

1


To achieve near zero

measles morbidity and

mortality by 2016

2012: achieve 40% of counties above 90% routine measles

coverage

2013: 50% of counties attain above 90% routine measles

coverage

2014: 60% of counties above 90% routine measles coverage


and Conduct under-5 measles follow up campaign nationally

targeting 90% SIAs coverage in all counties;


mortality due to measles

will have been reduced

by 90% compared to the

2000 level (GIVS)

By 2009 or earlier,

countries with high

routine measles

coverage (> 75%) and

presumed low mortality

will eliminate

indigenous transmission

of measles virus

1


4. Strategies, Key Activities and Timeline, S/Sudan Multi Year Plan, 2012-2016 Programme objective Strategy Strategic activities Time line

2012 2013 2014 2015 2016

Service Delivery

- To achieve at least 80%

coverage for all routine

childhood antigens (using

DPT- 3 as a tracer indicator) in

80 % of counties by 2016

- To attain a DTP-1 to DTP-3

dropout of less than 10% in at

least 90% of counties by 2016

- To achieve at least 60% of

counties with 80% TT2+

coverage for pregnant women

by 2016

Infant vaccination

Build capacity at County

level to implement RED/

REC strategies

Strengthen delivery of

outreaches with emphasis

on integrated outreaches

Accelerated Routine

Immunization Activities

(ARIAs)

Drop out monitoring

Reduce missed

opportunities for

immunization

Disaggregate TT

vaccination reports by

pregnancy status

Mainstream TT vaccination

as a primary intervention in

antenatal clinics

- Integrated micro planning with the

State, County and community levels

including mapping of service areas per

health facility using the RED strategy

- Identify hard to reach populations and

make special innovations to reach them

- Audit performance of outreaches

- Bi-annual EPI program performance

reviews at National and state levels

- Quarterly EPI program reviews at

County level

- Conduct accelerated routine / catch up

immunization activities using

Vaccination week, and other initiatives

that reach infants

- Provide and assure use of child registers

at all EPI service delivery points and

institutionalize follow up of dropouts by

all vaccinators

- Daily immunization at static units with

screening for immunization status at

Outpatients clinics

- Initiate TT monitoring amongst pregnant

women

- Develop and implement an MNTE

elimination plan based on risk assessment

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X


Programme objective Strategy Strategic activities Time line

2012 2013 2014 2015 2016

Cold chain/Logistics

1. To establish a Logistics

Management Information

System (LMIS) in all states by

2016 2. To establish a national

preventive and corrective cold

chain maintenance system for

EPI in South Sudan

3. To build an environmentally

compliant cold chain system in

the republic of South Sudan by

2016

4. To expand the cold chain

storage capacity to levels

adequate to take pentavalent

vaccines by 2014

5. To strengthen the transport

system for EPI logistics and

field monitoring of EPI

services by 2014

- Establish an effective and

efficient logistics

management information

system.

- Conduct Quarterly

preventive and corrective

maintenance of the cold

chain system

- Develop and implement a

cold chain replacement and

expansion plan.

- Create an independent

national vaccine store fitted

with cold/freezing capacity

for all EPI services in

S/Sudan

- Create an EPI transport fleet

suitable for the context of

South Sudan

- Design, implement and maintain LMIS

at all state vaccine stores

- Update the cold chain equipment

inventory every 2-3 years

- Develop, cost and implement Quarterly

cold chain maintenance visits to all

states

- Train cold chain technicians in

preventive cold chain maintenance

- Develop and implement a procurement

plan for C/chain consumables/supplies

- Conduct a comprehensive cold chain

inventory by 2012

- Replace 25% of CFC containing cold

chain equipment every Year

- Procure land for the NVS by 2013

- Complete the Archtectual drawings of a

NVS by 2913

- Complete the construction of a NVS

with 2 additional cold rooms installed

- Operationalize 3 regional cold chain

hubs

- Procure and maintain 12 Field

operations vehicles by 2012

- Procure and maintain 2 vaccine delivery

trucks by 2013

- Procure and maintain 80 motorcycles

and 5,000 bicycles by 2014

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X



2012 2013 2014 2015 2016

6. Effective and efficient storage

and distribution system for

EPI vaccines and supplies

7. To attain 100% safe injection

practices for all immunizations

in S/Sudan

- Create a reliable routine


distribution system at all

levels

- Develop a national Injection

safety Task Force in the

Ministry of Health

- Develop and disseminate routine EPI

vaccines distribution guidelines for

South Sudan

- Develop and implement a monthly

routine EPI vaccines and supplied

distribution schedule by 2013

- Ministerial decree on the formation of

the Injection safety Task force

- Train all vaccinators in injection safety

and waste management practices

X

X

X

X

X

X

X

X

X

X

X

Vaccine Supply and Quality

- To achieve 60% Vaccine

Independence for South Sudan

by 2016

- To have vaccine and

Immunization supplies

utilization monitoring in all

(100%) counties by 2014

- To attain 6 months vaccine

storage capacity at national

Develop and implement a

Vaccine Independence

Initiative for RSS

Develop and implement the

LMIS

Establish an independent

national vaccine store for

South Sudan

o Develop and sign the Vaccine

Independence Initiative agreement

o Government to procure 20% of

traditional vaccines





o Develop and start using the LMIS in all

10 states

o Roll out LMIS implementation in 40%

of counties

o Scale up LMIS implementation to 60%

of counties

o LMIS implementation in 80% of

counties

o LMIS implementation in 100% of

counties

o Procure land for the National vaccine

store

o Construction of the National Cold store

X

X

X

X

X

X

X

X

X

X

X

X

X

X



2012 2013 2014 2015 2016

level by 2014

- To implement use of vaccines

bundling policy in

immunization supplies

management at all levels

- To develop and implement a

monthly delivery system for

vaccines and immunization

supplies to all states

- To institutionalize vaccine

quality assurance standards

and practices in South Sudan

Adhere to immunization

supplies bundling Policy

Develop publish vaccine

and immunization delivery

schedules

Develop and implement

Quality assurance SOPs for

South Sudan

o Construction of the National

Immunization Supplies warehouse

o Construction of the National Cold chain

maintenance workshop

o Construction of the National EPI office

building

o Introduce Vaccines bundling Policy to

EPI supply from NVS to States

o 40% of states bundling vaccines in

supply to the counties

o Scale up Bundling of vaccines to 2

additional states every year

o Develop and approve Quarterly

vaccines and EPI supplies schedules

o Procure 2 vaccine delivery trucks

o Monthly vaccine delivery schedules to 3

states

o Expand monthly vaccine delivery

schedules to cover 5 states

o Monthly vaccine delivery to all 10

states

o Develop, print and disseminate Vaccine

and injection materials control book to

all levels

o Conduct Vaccine Potency testing on all

viral vaccines batches procured

o Establish 10 vaccine utilization

monitoring sentinel sites

o Expand and operationalise vaccine

utilization monitoring in 20 sites

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X



2012 2013 2014 2015 2016

Advocacy and Communication

To develop and implement a

communication plan for

immunization by 2013

To achieve 50% of counties

with health workers who are

trained in IPC by 2016. To develop and disseminate

immunization IEC materials to

all counties by 2014

To sensitize and use priority

community structure on EPI

services delivery in 100% of

counties by 2014

Communication for

behavior change

Capacity building for

communication for EPI

Leverage the UNICEF C4D

project to establish social

and community networks

for promotion of

immunization activities

Building partnerships with

the media and civil society

for promotion of EPI

activities

- Conduct a KAP study on immunization

services utilization

- Develop and implement a behaviour

change communication plan

- Production and dissemination of

communication materials including

radios/telecommunication companies

- Focused mobilization for urban

populations

- Training of health workers in IPC

- Sensitization of religious, cultural and

civil societies in EPI

- Maintain active social and community

network maps and structures

- Conduct advocacy meetings with service

organizations like Rotary,

Parliamentarians, Local/traditional

Leaders

- Orientation/sensitization of broadcasters,

reporters and media managers

- Sensitization of VHCs to include EPI in

their routine health facility management

meetings

- Conduct community dialogue/sensitization

shows to identify barriers to immunization

services utilization

- Quarterly EPI partners coordination

meetings at State and CHD levels

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X



2012 2013 2014 2015 2016

Surveillance

To Expand the existing

AFP/Polio surveillance system

to include Measles, NNT and

AEFI by 2016

To establish systems for

providing epidemiological

description of Hepatitis B and

Paediatric Bacterial Meningitis

infections in South Sudan by

2016

To establish and

operationalize surveillance

certification committees for

vaccine preventable diseases

by 2014

Provide support to counties

to achieve/maintain AFP

certification level

indicators.

Capacity building for

surveillance of EPI target

diseases within the IDSR

framework

Sentinel Surveillance for

new vaccines

Create institutional

arrangements for using

VPD surveillance data

- Technical and financial support for

surveillance operational activities in all

counties.

- Training of AFP/Polio Surveillance

human resources on measles

surveillance.

- Training . of AFP/Polio surveillance

human resources on NNT surveillance

- Conduct PBM/Hib Rapid burden of

Disease assessment in South Sudan

- Initiate PBM sentinel Surveillance in

one National or teaching Laboratory

- Expand PBM sentinel surveillance to 3

sentinel sites and Hepatitis B testing

- Decree on NITAG, NCC/Polio and

NTF/Laboratory containment of Polio

- Operationalise the surveillance

certification committees

- Conduct Laboratory search for

potentially WPV contaminated

materials

- Conduct Data Quality Audit/Self

Assessment

- Conduct Coverage Verification Surveys

- Initiate AEFI Surveillance system for

South Sudan

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X



2012 2013 2014 2015 2016

Programme Management

To update and disseminate the

EPI policy by 2013

To conduct supportive

supervision at County level on

a quarterly basis and provide

feedback on coverage, dropout

rates and vaccine wastage

Disseminate and enhance use

of monitoring and supervision

guidelines at state and lower

levels

To strengthen operational

research capacity at national

and state levels, and promote

use of research findings

Avail the EPI policies and

guidelines to all service

delivery points

Advocacy and Capacity

building on use of EPI

policies and guidelines

Use evidence-based

decision making to improve

programme performance

Identify critical programme

areas that require research

- Disseminate the EPI policies and

guidelines with an addendum on NUV

to all service points

- Quarterly EPI supportive supervision

visits to all counties

- Training of state and county supervisors

in EPI performance management

- Bi-Annual EPI review meetings to share

key issues arising out of supervision

visits

- Quarterly technical support supervision

to every State using the whole site

strategy and cross-exchange visits

- Develop operational research plan

involving National and State operations

officers

- Conduct operational research projects

for improving EPI program efficiency

and effectiveness

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Strengthening human and

institutional resources

To recruit and fill up to 100%

of all approved staffing norms

at National and state levels by

2015

To conduct OPL and MLM

training of vaccinators and EPI

managers to 100% by 2016

Equip pre- and in-service

health workers and mid-

level managers with

knowledge, skills and

competencies in EPI service

delivery.

- Recruitment to fill all vacant approved

positions at the National level

- Support to long term training courses

- Long-stay EPI program Advisor

- Training of health tutors in EPI.

- Conduct OPL training of vaccinators

- Conduct MLM training of EPI

managers/Supervisors

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X



2012 2013 2014 2015 2016

Sustainable Financing

To increase government


operational costs

Explore alternative sources for

EPI financing

Advocacy and continuous

lobbying with key

government stakeholders

for increasing government

budget for immunization

Monitor financial releases

supporting immunization

activities

- Develop, implement and jointly monitor

one business plan for immunization in

South Sudan

- Conduct a cost-benefit and cost

effectiveness studies for new and


- Develop a financial sustainability plan

for immunization in South Sudan

X

X

X

X

X

X

X

X

Introduction of New Vaccines

To introduce Hepatitis B

vaccine into the routine


2013

To introduce Haemophillus

Influenzae Type B vaccine

into the routine immunization

schedule by 2013

Initiate public health

surveillance and reporting

systems for the diseases

targeted with the new

vaccines.

Plan for introduction of new

vaccines (Hepatitis B and

Hib)

Revising the immunization

policy to include new

vaccines

- Conduct PBM/Hib Rapid burden of

Disease assessment in South Sudan

- GAVI/NUVI application

- Cold chain assessment for NUV storage

- Develop training manuals for NUVI

training and sensitizations

- Training of Health Workers on NUVI

X

X

X

X

X

X

Accelerated Disease Control

To obtain WHO-certification

of WPV polio-free status by

2014

Achieve and maintain high


coverage for OPV3

Conduct supplemental

immunization activities

Strengthen disease

surveillance for AFP

- Implement preventive and response

nationwide polio campaigns

- Conduct regular WPV importation risk

assessments

- Reviewing and updating the national polio

preparedness plan

- Support NCC, NPERC and NTF

- Complete country documentation for

WPV free-status to R.C.C

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X



2012 2013 2014 2015 2016

To attain and sustain MNT

elimination status by 2014

To achieve near zero measles

morbidity and mortality by

2016

Evaluate progress towards

MNT elimination

Initiate involvement of

other Stakeholders in

MNTE e.g. Reproductive

Health, Ministry of

Education, and other MCH

partners

Achieve high routine measles

immunization coverage

Provide a 2nd

opportunity for

measles vaccination

Scale up case based

surveillance performance at

State and County levels

- Conduct NNT risk assessment

- Implement TT campaigns in high risk

counties.

- LQA for MNT elimination

- Initiate TT vaccination in schools to build

population immunity to sustain MNT

elimination

- Review and develop the Measles Control

Plan for 2012-2016

- Training for measles case based

surveillance at all levels

- Outbreak investigation and response

- Conduct integrated measles/Vitamin A

follow up SIAs

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X


5. Immunization Program Costs and Financing(Current and Future)

5.1 Overview

The multi-year plan EPI in South Sudan (2012-2016) highlights the areas of focus for the immunization

programme development over the next 5 years based on previous programme performance, priorities for

the health sector as stipulated in the Health Sector Development Plan (2011 – 2015) and the global and

regional goals set for child health and survival.

The programme cost (including shared costs) for the 5 years is US$ 162,4 million. Of this cost, 19% are

for vaccines supplies and logistics. The programme intends to introduce new vaccine (in form of DTP-

HepB-Hib) and to construct a national vaccines store commensurate with the needs of a new nation,

conduct polio, measles, and MNT (maternal and neonatal tetanus) supplementary immunization activities.

The programme is faced with funding gap, that are expected to increase with an increase of the resource

requirements and dwindling common humanitarian funding that contributed the large chunks of WHO

and UNICEF funding in the baseline year. The national Government is committed to keep up its financing

levels, take more responsibility over financing of the traditional vaccines and provide required funding

(20 cents per doze of DTP-HepB-Hib) to co-finance the introduction of the new vaccine in the schedule.

5.2 DETAILED INFORMATION ON PROGRAMME COST BY CATEGORIES

5.2.1 Macroeconomic indicators

The macroeconomic indicators come from different sources. The GDP figure for the baseline year comes

from the website of the National Bureau of Statistics www.ssnbs.org and reflects 2010. There is no

information published for 2011. On the face-to-face meeting, the Senior Economist of the World Bank in

South Sudan has informed that the GDP in 2011 does not differ significantly from 2010 value. The GDP

projection includes a 70% decrease in 2012, caused by the closure of the oil production which constitutes

71% of the country‟s GDP. The implementation the austerity measures and the forecasted recovery of the

oil production sector after 2013 is expected to bring back the GDP to its pre-crisis levels in 2014 with an

increase in the following years.

The source for the Total Health Expenditures is the South Sudan Donor Book 2011, issued by Ministry of

Finance and Economic Planning every year and is available on the Government‟s website www.goss.org.

As the actual expenditures for Health programs in 2010 and the commitments for 2011 are similar, it was

decided to use 2010 actual expenditure value for the cMYP baseline year. Constant value of THE was

used as a forecast for the years of the implementation of the Plan as agreed on the national EPI technical

working group.

Government Health Expenditure for the baseline year came from the Ministry of Finance accounts and

adjusted to the current official exchange rate. The 2013-2016 projection is made considering the

increasing Government commitments in the Health sector. Indicators are presented in US Dollars.

Currency exchange rate for 2012 at 3,2 South Sudanese Pounds (SSP) per 1 US Dollar was obtained from

the Ministry of Finance.

5.2.2 Demographic information

Data on demographic and health-related indicators is obtained from the National Bureau of Statistics

(NBS) and Ministry of Health. The size of the total population comes from the Census 2008 and adjusted

http://www.ssnbs.org/

http://www.goss.org/


to the estimated number of those who were not reached by the Census team (around 11%). The projection

for the population growth is 3% annually.

The Infant Mortality Rate was one of the most discussed indicators as it has a direct impact on the number

of the surviving infants who are the target population of the most of the vaccines. It was agreed to use the

most recent IMR Survey conducted in 2010 (Sudan Household Health Survey – SHHS 2010), which

indicates the IMR of 84 per 1000 births. This was also reflected in the WHO Vaccine Forecasting Tool,

which makes a vaccine and injection supplies resource requirement projections for the cMYP Costing

Tool.

5.2.3 Vaccines & Injection Supplies

Table 1.3 Immunization schedule, Target population, Vaccine prices and other vaccine reference

information

Vaccination schedule for 2012 includes BCG (one doze in the schedule, target population: births),

OPV (four dozes in the schedule, target population: surviving infants), measles (one doze in the

schedule, target population: surviving infants), DTP (three dozes in the schedule, target population:

surviving infants), TT (two dozes in the schedule, target population: pregnant women).

Starting from 2014 Vaccination schedule will include DTP-HepB-Hib vaccine liquid which will

replace all dozes of DTP. This transition is addressed in the Basic Scenario.

The procurement of the vaccines and injection supplies is done by UNICEF. WHO Vaccine

Forecasting Tool was used to project quantities required and costs. UNICEF prices from the last

country‟s procurement were used for the traditional vaccines. Price of DTP-HepB-Hib was provided

by UNICEF. These prices are published annually in the UNICEF website.

Table 1.1 Baseline expenditure on vaccines and injection supplies

Expenditures on vaccines and injection supplies as well as other supplies in 2011 were obtained from

the UNICEF financial transaction system. Prices of the vaccines include the cost of the delivery of the

procured vaccines from a supplier to the store in Nairobi, Kenya. Vaccines are procured from various

manufacturers and shipped to Nairobi, Kenya. This cost is included in the vaccine price. From there

vaccines are stored for an average of 2-3 weeks pending approval of tax exception documents and

clearance from the Government of Kenya. From Nairobi to Juba the vaccines are air-lifted and stored

in the national vaccines store which is supported by UNICEF (Human resources and running cost).

From Juba to the state vaccines are transported by air. From the state cold chain stores vaccines are

distributed to the counties with the support of UNICEF (providing fuel for vehicles, hiring of vehicles

etc). Only in the equatorial states (EES, WES and CES) vaccines are transported by road. In counties

with different access to the state capitals vaccines are air-lifted directly from Juba central vaccines

store to the county cold chain store.

The cost of the transportation of the vaccines and injection supplies from there to the national, state

and county level are presented separately in the Table 3.3 “Other transport needs not elsewhere

covered”.

In 2011 all expenditures on vaccines and injection supplies were covered by UNICEF.

Table 0.1 Past and future DTP coverage and 1.4 Coverage and wastage

The data for this section was provided by the Ministry of Health. The baseline indicator value reflects

the most recent administrative coverage of the DTP3 from 2011.


5.2.4 Personnel Cost

Data on staff categories, gross monthly salary of the personnel involved in the immunization program at

all levels was provided by the EPI Program of the Ministry of Health and is based on the assessment of

the numbers of staff available in the immunization program.

Most of the staff fully dedicated to the immunization program is at the national, state and county level.

Most of this staff is being financed from the Government or sub-national budgets. Volunteer vaccinators

are being trained and used for the outreach activities. They do not get salaries but are paid per diems and

transportation expenses. Staff, working fixed-site is also engaged in the outreach activities.

World Health Organization has its own staff at the county level (County Surveillance Officers and Payam

Field Assistants for Surveillance), implementing campaigns. They are not involved into the routine

immunization.

The percentage of the time spent on immunization activities for the personnel is diverse and depends on

the position they occupy.

5.2.5 Vehicles and transport cost

Table 3.1 Average prices and utilization of vehicles.

The information regarding the vehicles and the projections of the future needs were provided by the

EPI Program of the MoH. Depending on the purpose and the accessibility of the areas for the

outreach, the following types of vehicles used by the immunization program: All-road vehicle 4X4,

cars, motorcycles and boats.

Information of the types (categories) of vehicles used by the immunization program, average unit

price including all taxes for new vehicles in 2012, average number of kilometers traveled per year,

average fuel consumption per 100 km for vehicles were entered in the table. Prices of the vehicles

entered into the tool are assumed as of new vehicles, although majority of them were purchased

during previous years. Although the Useful Life Years of the vehicles are stated as 5 in the cMYP

Costing Tool, for some vehicles which are engaged in the outreach program, this figure may be lower,

considering the state of the roads in South Sudan.

Table 3.3 Other transport needs not elsewhere covered

Expenditures related to transportation of vaccine form the vaccine store in Nairobi are mentioned

here. This cost is covered by UNICEF.

5.2.6 Cold chain equipment

Information on the types of the cold chain equipment, average unit prices for each type of cold chain

equipment listed in the table was agreed with the EPI Program of the Ministry of Health and provided by

UNICEF. It was decided to summon all the equipment needs at the National level, as the procurement of

it is done centrally. All the cold chain equipment is purchased by UNICEF. From the central level it

delivers the cold chain equipment to the state and, county level. The cost of installation of these

equipments is also supported by UNICEF. The average useful life year of cold chain equipment was

defined as 5 years. The cost of the fuel for the cold chain and the solar powered state hubs are mentioned

additionally in the Table 4.3.


5.2.7 operational cost of campaigns

Supplementary campaigns in South Sudan are run by WHO, covering all operational costs. Vaccines for

the campaigns are procured by UNICEF. The implementation cost of the campaigns is higher than the

cost for the vaccines for these campaigns, due to the high transportation prices, especially in the areas

which are only accessible by air. WHO covers the allowance of vaccinators, transportation of vaccines

from counties to the lower levels and supervision, while UNICEF transports the vaccines from the

national level to all 10 states, including hard-to-reach counties which are not easily accessible by road.

The deliveries in 8 states out of 10 are done through the chattered flights.

5.2.8 Program Activities, Other Recurrent Costs and Surveillance

Table 6.0 Total Spending and Future Needs for Program Activities

A simplified costing table 6.0 was used to estimate the needs for the program activities, such as short-

term training, surveillance, M&E and programme management. The new higher unit costs were

suggested by the EPI Program manager, as all these activities include transportation/travel cost, prices

for which are very high. At the moment these activities are being funded by the Government (national

and sub-national), UNICEF, WHO and USAID. In 2013 it is expected to spend part of the GAVI‟s

vaccine introduction grant for these activities.

5.2.9 Other Equipment Needs and Capital costs

Information on the total number, types and average prices including all taxes of other equipment needs

was taken from the UNICEF.

5.2.10 Building and Building Overhead

Information on the total number and type of building by administrative levels was provided by the EPI

Program of MoH. The maintenance cost of the buildings is paid by the Government. A key investment in

the infrastructure is to be made by UNICEF in 2013, when the central vaccine store is to be built.

5.2.11 Past Costs by categories

The total cost of the National Immunization Program in 2011 was $ 23,724 million (Figure 1). Shared

cost is not included in this figure, but it adds another $ 3 million to the overall immunization-related

spending in the country. The cost of the campaigns was over $10 million, while the routine immunization

was $ 13,451 million.

Figure 8: Total Immunization Expenditure, 2011

Baseline Indicators 2011

Total Immunization Expenditures $23,724,067

Campaigns $10,272,861

Routine Immunization only $13,451,206

per capita $1.3

per DTP3 child $45.2

% Vaccines and supplies 6.9%

% Government funding 17.9%

% Total health expenditures 7.5%

% Gov. health expenditures 110.7%

% GDP 0.09%

Total Shared Costs $2,926,476

% Shared health systems cost 11%


TOTAL $26,650,543

As shown in the table above, the overall resource requirements in 2011 exceeded the capacity of the

Government health budget. In 2011, as well as in the coming years, it is expected that most of the

immunization-related cost will be paid by the external donors.

The detailed cost profile for the total routine immunization (which excluding shared cost comprises 60%

of the total immunization program) expenditures in the baseline year 2011 (in Figure 2 below) shows that

the major portion, 47% of total routine immunization, belongs to personnel. This cost category was

largely supported by the Government. Second largest component is the other routine recurrent cost,

followed by 9% for the cold chain equipment.

Traditional vaccines represent only 5% of the routine immunization cost.

Figure 9: Baseline Scenario – cost profile

5.3 DETAILED INFORMATION ON PROGRAMME FINANCING

5.3.1 Financing sheet

Financing of the national immunization activities come mainly from the external sources. WHO and

UNICEF are the largest donors, covering the cost of campaigns, vaccines and supplies, cold chain, social


mobilization and advocacy etc. These organizations are committed to keep the financing levels high and

continue supporting mentioned components of the immunization program.

GAVI‟s ISS and HSS ongoing grants also contributes to the financing of the immunization activities,

however, this source of support is to expire in 2013-2014.

Government-originated funding is an important source of the salaries of the staff, implementing the

immunization activities at all levels, and the maintenance of the infrastructure. The levels of the national

and sub-national governmental funds are expected to continue funding of the health-related staff in the

facilities; however, in some places it is likely that the Government-paid health workers are not performing

any EPI-related activities. There also may be independent NGOs, conducting EPI-related activities,

specifically through contributing their human resources, but it was not possible to collect the required data

from them.

Data on their current and expected spending was obtained during interviews and reviewing spending

reports.

5.3.2 Past Financing

In 2011 the largest financing sources of the routine immunization activities were WHO and UNICEF,

each contributing 37% of the total spending. The central Government‟s contribution was 16%,

subnational – 2% of the total. GAVI‟s ISS and HSS funding comprises 6% of the routine immunization

spending profile, and another 2% came from USAID.

Figure 10: Baseline Scenario – financing profile

This graph doesn‟t include the cost of campaigns – a 36%-share of the overall immunization. The

operational cost of the campaigns, its largest component, is provided by WHO, and the vaccines and

injecting supplies, social mobilization and advocacy – by UNICEF.


5.4 Future Resource Requirements, fınancıng and funding gap

Estimated total resource requirements to implement routine immunization program in 2012-2016 amount

$ 162,4 million, main part of which will be covering supplementary immunization activities, campaigns -

36% of total spending is required for this cost area.

Figure 11: Expenditure – Future Resource Requirements

Expenditures

cMYP Component 2011 2012 2013 2014 2015 2016 Total 2012 - 2016

US$ US$ US$ US$ US$ US$ US$ %

Vaccine Supply and Logistics $4,312,384 $4,812,841 $5,314,261 $8,112,491 $7,510,446 $5,567,241 $31,317,280 19%

Service Delivery $7,009,799 $7,684,009 $8,439,489 $9,026,539 $9,382,164 $9,384,654 $43,916,855 27%

Advocacy and Communication $324,255 $340,969 $358,222 $376,348 $395,391 $415,398 $1,886,328 1%

Monitoring and Disease Surveillance $526,914 $554,075 $582,111 $611,566 $642,511 $675,022 $3,065,283 2%

Programme Management $1,277,855 $1,330,144 $1,396,522 $1,453,072 $1,512,148 $1,573,870 $7,265,756 4%

Supplemental Immunization Activities $10,272,861 $9,201,965 $17,566,699 $11,301,698 $8,592,317 $11,882,955 $58,545,633 36%

Shared Health Systems Costs $2,926,476 $2,705,444 $3,920,057 $3,059,756 $3,245,907 $3,438,280 $16,369,443 10%

GRAND TOTAL $26,650,543 $26,629,446 $37,577,361 $33,941,468 $31,280,883 $32,937,420 $162,366,578

Future Resource Requirements

Twenty seven percent (27%) or almost $ 44 million is required for the direct service delivery, 16% -

vaccine supply and logistics. The shared health systems cost is the fourth largest category, which amounts

10% of the overall immunization program or $ 16,4 million between 2012 and 2016.

In the Figure 5 the projection illustrates future resource requirement for the cMYP implementation.

Fluctuations of the needs are mainly caused by the campaigns. For instance, the increase of the resource

requirements in 2013 is explained by the conduction of four polio, one measles campaign and a part of the

3-year TT campaign. Part of the funding is secured or agreed with WHO and UNICEF, as there is a

global commitment to continue support polio eradication. For measles and TT campaigns not all funding

is secured or identified at this moment.

Starting from 2014 more resource needs are allocated for the introduction of the DTP-HepB-Hib vaccine

combination. The Government is expected to co-finance $ 0,2 cents of every dose, the rest will be coming

from GAVI if the application is successful.


Figure 12: Projection on Future Resource Requirements (excl. Shared costs, in million

US$)

Figure 13 (below) illustrates resource requirements by financing and gaps. Shared costs are not included

here. If only the secured funding is considered, the funding gap starts from 29% in the first year of

implementation and continues to increase to 82% in 2016. However, if the probable funding is included,

the overall gap for 2012-2016 is only 13% of the total resource requirements.

Figure 13: Resource Requirements, Financing and Gaps


Resource Requirements, Financing and Gaps* 2012 2013 2014 2015 2016 Avg. 2012 - 2016

Total Resource Requirements 26,629,446 37,577,361 33,941,468 31,280,883 32,937,420 162,366,578

Total Secured Financing 18,826,035 1,575,831 3,425,792 2,766,641 2,959,941 29,554,241

Government 2,443,991 1,575,831 - - - 4,019,823

Sub-national Gov. 1,674,829 - - - - 1,674,829

Gov. Co-Financing of GAVI Vaccine - - 373,180 301,533 322,609 997,323

GAVI 1,107,327 - 3,052,612 2,465,108 2,637,332 9,262,380

WHO 5,445,954 - - - - 5,445,954

UNICEF 8,153,934 - - - - 8,153,934

Funding Gap (with secured funds only) 7,803,411 36,001,529 30,515,676 28,514,242 29,977,478 132,812,337

% of Total Needs 29% 96% 90% 91% 91% 82%

Total Probable Financing 7,043,651 33,410,178 27,529,282 22,467,891 21,306,065 111,757,065

Government - - 4,305,302 3,618,094 4,066,534 11,989,929

Sub-national Gov. - 1,772,334 3,118,149 2,733,643 2,524,935 10,149,061

Gov. Co-Financing of GAVI Vaccine - - 6,685 - - 6,685

GAVI - 924,356 53,482 - - 977,837

WHO 4,247,504 16,541,678 10,881,700 8,569,954 6,726,709 46,967,545

UNICEF 2,796,147 13,890,318 7,974,694 6,542,867 7,397,148 38,601,174

USAID - 281,492 633,782 435,460 196,913 1,547,647

DFID - - 510,175 283,936 196,913 991,024

Multi-Donor Trust Funds - - 45,314 283,936 196,913 526,162

Funding Gap (with secured & probable funds) 759,760 2,591,351 2,986,395 6,046,352 8,671,413 21,055,271

% of Total Needs 3% 7% 9% 19% 26% 13%

Most of the funding which is supposed to occur after 2012 is marked as “probable” in the cMYP Costing

Tool and will mainly come from the polio eradication initiative. Assigning the funds to the “probable”

financing category was agreed with key financing organization – Government, WHO and UNICEF, as

some of them work under annual or biannual budgets and/or have not yet secured the required funding for

all the years of the implementation. At the same time the past financing levels has not decreased

throughout the previous years, which allows enough certainty about the future funding.

The composition of the funding gap is described in the Figure 7. Recurrent activities, such as short-term

training, M&E, surveillance, as well as the maintenance cost of the cold chain contribute nearly $ 7

million over the 5 years of the cMYP implementation, followed by Personnel ($ 6,6 million) and

Campaigns ($ 3,9 million). Even though the Government is committed to support the existing staff, it may

be difficult to secure the funding for the new staff required. However, the budget revisions will be done

every year to ensure additional funding for the new staff, especially at the sub-national level.

Figure 14: Composition of the Funding Gap

Composition of the funding gap 2012 2013 2014 2015 2016 Avg. 2012 - 2016

Vaccines and injection equipment $0 $0 $0 $0 $0 $0

Personnel $0 $192,348 $654,728 $2,222,818 $3,488,150 $6,558,044

Transport $0 $0 $308,400 $519,675 $422,123 $1,250,198

Activities and other recurrent costs $342,899 $2,052,051 $1,361,178 $1,902,353 $1,259,167 $6,917,648

Logistics (Vehicles, cold chain and other equipment) $416,861 $0 $25,469 $135,737 $532,375 $1,110,442

Campaigns $0 $0 $636,620 $616,587 $2,625,771 $3,878,978

Total Funding Gap* $759,760 $2,244,399 $2,986,395 $5,397,170 $8,327,585 $19,715,310

* Immunization specific resource requirements, financing and gaps. Shared costs are not included.


6. Financial Sustainability The costing exercise shows that immunization (including shared health system cost) may seem to be

an inexpensive program that only costs around $ 2,63 in per capita terms including campaigns and $

1,61 if the campaigns are excluded. The routine immunization comprises 0,1% of the Gross Domestic

Product (GDP) and routine immunization and campaigns together – 0,17% of the GDP respectively in

2011. In the following years, the average cost of the program including campaigns is 0,3%.

As shown in Figure 15, in 2011 the immunization program in South Sudan represents 15% of the total

health expenditures in the country and more than twice exceeds all available public funds on health.

Figure 15: Sustainability Analysis

GDP in South Sudan represents only the size of the economy. South Sudan‟s economy is dominated by

oil production. Exports of oil amounted to 71% of the total GDP in 2010. Since foreign investors and the

Northern Government (Government of Sudan) received a large portion of the income from oil production,

Gross National Income (GNI) in South Sudan is significantly lower than GDP - $ 984. So are the funds

that are available to finance public programs.

This situation has become worse after shut down of the oil production. The GDP forecast for 2012 is

currently being revised by the National Bureau of Statistics and will probably be at least 75% lower than

in 2010 and 2011. This and the overall problems in the public administration (after the country-s

independence in July 2011) makes the public financing of the health programs very challenging in the

following two or three years. Current negotiations and austerity measures implemented by the

Government are expected to re-start the oil industry later this year. In this case, according to the World

Bank, the full recovery of the economy is possible already in 2014.

Figure 16 presents some macroeconomic and sustainability indicators regarding the financial

requirements of the immunization program.


Figure 16: Macroeconomic and Sustainability indicators including shared costs

Macroeconomic and Sustainability Indicators 2011 2012 2013 2014 2015 2016

Reference

Per capita GDP ($) $1,546 $464 $788 $1,546 $1,639 $1,737

Total health expenditures per capita (THE per capita $) $17.6 $17.6 $17.6 $17.6 $17.6 $17.6

Population 10,142,090 10,446,353 10,759,743 11,082,535 11,415,012 11,757,462

GDP ($) $15,679,671,019 $4,845,018,345 $8,483,627,122 $17,133,599,873 $18,706,464,341 $20,423,717,768

Total Health Expenditures (THE $) $178,622,037 $183,980,698 $189,500,119 $195,185,123 $201,040,676 $207,071,897

Government Health Expenditures (GHE $) $12,146,299 $12,510,687 $15,160,010 $19,518,512 $24,124,881 $31,060,784

Resource Requirements for Immunization

Routine and Campaigns ($) $26,637,743 $26,629,446 $37,577,361 $33,941,468 $31,280,883 $32,937,420

Routine Only ($) $16,364,882 $17,427,481 $20,010,662 $22,639,771 $22,688,566 $21,054,465

per DTP3 child ($) $55.0 $53.6 $56.4 $60.6 $57.7 $50.9

% Total Health Expenditures


Routine and Campaigns 14.9% 14.5% 19.8% 17.4% 15.6% 15.9%

Routine Only 9.2% 9.5% 10.6% 11.6% 11.3% 10.2%

Funding Gap

With Secure Funds Only 4.2% 19.0% 15.6% 14.2% 14.5%

With Secure and Probable Funds 0.4% 1.4% 1.5% 3.0% 4.2%

% Government Health Expenditures



Routine Only 134.7% 139.3% 132.0% 116.0% 94.0% 67.8%

Funding Gap

With Secure Funds Only 62.4% 237.5% 156.3% 118.2% 96.5%

With Secure and Probable Funds 6.1% 17.1% 15.3% 25.1% 27.9%

% GDP



Routine Only 0.10% 0.36% 0.24% 0.13% 0.12% 0.10%

Per Capita


Routine and Campaigns $2.63 $2.55 $3.49 $3.06 $2.74 $2.80

Routine Only $1.61 $1.67 $1.86 $2.04 $1.99 $1.79

The Government of South Sudan is committed to increase its contribution to the immunization program,

specifically by taking over 20, 40 and 60% of the financing of the traditional vaccines, and co-financing

of the new vaccine in the schedule. If the recovery of the economy and systematic improvement in the

governance goes as expected, the national budget will be able to mobilize more resources for the

immunization than it is mentioned in the cMYP and decrease the funding gap after 2014.


7.0 EPI WORKPLAN FOR SOUTH SUDAN; 2012

No. Activity description Time Frame

Budget

(USD) Proposed source of funding

1.0 Service Delivery RSS/GAVI UNICEF WHO USAID/SIAPS Other

1.1 Support EPI micro-planning at all levels Jan-Mar 120,000 50,000 30,000

40,000

1.2 Approve and finance all EPI operations micro-

plans Mar 1,860.333 860,333 300,000 700,000

1.3 Focused support to poorly performing

states/counties Jun-Nov 783,000 83,000 200,000 500,000

1.4 Support Periodic Intensified Routine

Immunization Activities (include V/Week) May-Oct 1,070,000

350,000 720,000

2.0 Cold chain and EPI Logistics

2.1 Fueling the entire cold chain for South Sudan Jan-Dec 445,000 300,000 145,000

2.2 Cold chain replacement/ expansion for South

Sudan Jan-Dec 965,000

965,000

2.3 Preventive and corrective Cold chain

maintenance Jan, Apr, Jul 545,000

545,000

2.4 Maintain the cold chain human resources Jan-Dec 450,000 50,000 400,000

2.5 Construction of a National Vaccine Store Jan-Dec 1,070,000

1,070,000

3.0 Vaccine Supply and Quality

3.1 Vaccine procurement Sept-Nov 1,954,333

1,954,333

3.2 Vaccine receipt, storage and handling Jan-Dec 375,000

375,000

3.3 Vaccine distribution (all levels) Jan-Dec 303,000

303,000

3.4 Vaccine Management strengthening

(implementation of the EVM improvement plan) Jan-Dec 365,000 10,000 355,000

4.0 Advocacy and Communication

4.1 Develop a National Advocacy and social

mobilization plan (including KAP study on EPI) Jan-Jun 460,000

460,000

4.2 Advocacy for EPI services planning and delivery Jan-Dec 390,000

4.3 Development, production and dissemination of

EPI program communication and education

materials Jun-Jul 550,000 100,000 450,000


5.0 EPI monitoring and VPD Surveillance

5.1 Monitoring and Support Supervision for

improved routine Immunization performance Mar-Oct 80,000 45,000

35,000

5.2 EPI data quality assurance and self assessment Mar-Nov

5.3 Complete EPI coverage verification survey Jul 450,000

50,000 400,000

5.4 Maintain certification level AFP surveillance Jan-Dec 900,000

900,000

5.5 scale up case-based surveillance for measles Jan-Dec 500,000

500,000

5.6 Introduction of New vaccines Surveillance Oct-Dec 270,000 80,000

190,000

6.0 Programme Management

6.1 ICC and Technical partners coordination

meetings Mar-Nov 5,000 5,000

6.2 One Multi-year and annual business plan for EPI Mar 30,000

30,000

6.3 Maintenance of office plant and machinery Jan-Dec 592,000 574,000

18,000

7.0 Strengthening human and institutional

resources

7.1 OPL training (at least 500 Vaccinators) Jan-Dec 540,000 90,000 200,000 160,000 90,000

7.2 Mid-level management training for EPI

managers Jan-Dec 380,000

200,000

180,000

7.3 Maintenance of the AFP human resources Jan-Dec 2,000,000

2,000,000

7.4 Technical Advisor to the national program Jan-Sept 200,000

200,000

8.0 New Vaccines Introduction

8.1 GAVI/NUVI Application Aug 40,000 40,000

8.2 Hepatitis B in pregnancy study +FELTP Jan-Jun 60,000 50,000 10,000

8.3 Construction of the Central Vaccine store Jan-Dec 1,070,000 70,000

1,000,000

9.0 Accelerated Disease Control

9.1 WPV importation preparedness/ response Jan-Dec 450,000

450,000

9.2 4 rounds of Polio SIAs (includes Stoppers) Feb-Nov 5,494,000

2,494,000 3,000,000

9.3 Develop and implement measles control strategy

(TA, Measles campaigns and ACSI) Jan-Mar 1,260,000

960,000 300,000

9.4 Conduct MNTE risk analysis and implement TT

SIAs in at least 3 states Mar-Dec 500,000 450,000 50,000

TOTAL 25,481,066 2,442,333 10,011,333 8,848,000 500,000 190,000


Documents

NATIONAL EXPANDED PROGRAMME ON IMMUNIZATION MULTI … · Republic of South Sudan Multiyear Plan for Immunization, 2012 – 2016 5 Executive Summary The multi-year plan EPI in South