EFTA01072417.pdf

RI strategic initiative orking Retreat Pre-reads/handouts I BILLetMELINDA GATESfradad- 1 EFTA01072417 RI Retreat agenda CI= 11154:45 a amain( evattabIo 540630 fro Welcome. overview or the day and contend VIO Mitchell 41304, 10 an, Introchralon to 'WON a' strategy refresh process John *IWO How RI lean gallon the soon of thalr program • One ortvotnol deInnon MItchMI and Malt Manton 4146-104) am moo (Mate non may cosh** Mallon of RI • Dissamiga.MIOch toads me mai catIcal la tons/di Fstaloj7 10:30410)am Brag How RI Ste Into founctabon's Melon for WHAM • Moore ttol Ponoon tootkm and obi Matt Hansen and Molly 11.00.120)pm natuuom Maw Ctrs RI anatla prograMgOals of (1004010 IMml AbblULZOI4 enhIVCOTVOS to RI ca/0 twee a trzroknmMw moor, 12:0012:4S pm Mach RI currant and future pnoblVr. klenlincation • Manley MOW gaps that Oolong* louniatIon ablIM 10 reel gods Core team My I 00 0)" 12:45.2:30pen • °mow= hch Spa sooti4 be 10P pn00y IV he glotol comely-0y 10 Strategy oddrem, Thy 23043/0 an Ore* WIMAII tlW leunceselon could and should engage Whallit team NS rowdfrom fr-may 100430 ph • woo am C moose.] Rots tor to 5.10. 25 'MU Talk VloMllonMi and Skye Gilbert • QYuMpr Mimeo IVCci0 fink tho kordotoo Provo/ engem. • RrM'Olo•m GeMaW b-ndalloo ammo:mom 416620 ph Recap al the day and not slope VI* Mitchel 2 2 EFTA01072418 RI team charter EFTA01072419 Project Charter (I) Team Name Routine Immunization Steering Group: Global Development Program The goals of the RI Steering Group are as follows: - Develop routine immunization strategy; Work Group Goal - Identify resources that can be employed toward RI goals (potential partners, catalytic funding, voice); — Identify strategic opportunities for future RI Investments; — Monitor initial implementation of RI strategic initiatives. Strong routine immunization systems are the core of our Vaccine Delivery goals (as listed on the ScorecardI: — Eradicate Polio — Prevent re-emergence of polio from either wild or vaccine-derived viruses GD Goal this effort — Reduce measles morbidity and mortality (from 2000-2008, 2/3 of reduction in measles mortality due to RI' relates to — Save 6.0M lives in 69 high burden countries over 2010-2019 with currently available (DTP Measles, Nib, pneumo, rota) and new vaccines (malaria) — Reach 90% of the children n the poorest countries with sustained coverage of vaccines nationally and no district <80%. — Achieve the DoV effort. Work Group Steve Landry Work Group Lead: Violaine Mitchell Executive Sponsor Acting DD, RI Time Frame Eleven Months: February 1, 2012 — December 31, 2012 Updated on April 30, 2012; and August 31, 2012 4 EFTA01072420 Project Charter (II) Opportunity Ratemen& • Wattehraa twine an . pa, .1 ratan.. rerbdtv reciartvebtad wt., w fre,entall, 015215r. • WmManRrwnru,rn-unuuo+evRrlbwlxnnLaMGaWrUl4lryvrytlnmuyanohteunnnavllorlof role 414.1401, rif e 'ha to0r an vier. end Ilan pixy ity ljart.K.Jalve w1o+r0✓nc 02..ntrat end thaw within kn[atashed traliMs9.0,2 • yrient routine Demtnitabe WAtera.122 46O A. Attest!, e1,2.222. e)she.lit ma. Mum wat th•cath new nbeduchen • $0.011.:1utite ~ere Pelovn.zwe apinst Mute measse, oabreaa. sudi 'WOW t•PtAeKed a Justification 2010.2011. 4,2 vMl rare the way lor <imago. • 11 e ...pt., that e• .42Fontly sgintsunt Inancul ennerliferfeumlawne natµ taxad pole on.ohcalsen rif Summary ranvottthelrtr0'Ja11M.Mh101.2011101~ NittConite45)341., Pea> «20<et JCIMOty On, WX2et $.2521.1 Ito GAV1 • len,ntaben alw•Oalorrn up.n whaho11,e manna and c2d11 Hath trUnantnnt may tárd.rband.11,ts cen1212utárs cut halal gash • 1N>er>HOhaWnNMl5ppM11tsirorOtO,tlrSW?em>6trORa, ImlmintOmOMhatemynteUMxatxelnr nun,/ cc...num.:tom loch A, Ip.ct. to With 20111 • lbw le,datsen Nearer, ettantrehonath bur pc teen mi. as lahlrary 4 4444444 Ette.nt the *fiat GAM Scud-nil V20«, ,N220 2.11.11«.212.2»tr, .1.201htfe..22.141b2C.mentrt• As áent(Ore. • A anlega.cocedruhnl•pwait..to wan,' snmankra un bet (*Wan nr-enuagra our 'ninon • 02 4,21,^1.2. 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StItage.0.2.a.41ereili te intustallafte EFTA01072421 Project Charter (III) >fcctesta • Articulate RI goals — Within global context — Specific to the foundation — Specific to key geographies • Mmdmize RI resources Objectives — Identify key partner strengths — SUategiae as to potential external partnerships — Coordinate with other Internal efforts • Outline Strategic Initiative In RI — Identi Investments • Ultimately, to achieve the new DoV goals Success Measures • Shorter-term Increase in RI coverage in key geographies fic success measures 7B13 on a initiative basis 6 EFTA01072422 Project Charter (IV) a • RI leans nt.,,,, s .. Voters* Mitchell Man Hanson Core Steering Group Rap Rao members and their Molly Abbrunese s Pr/ Division • INDIA TEAM Devendra Mandan • ()then IN) in-country prese • None Steering Group Memberare expected to coordinate across the foundation Gobal Health teams, and vitth Codaboration with the Gbbal Development ou as appropriate. other foundation terns (CD &FM • F MOH In key countries Partite • Bilateral Donors, such as: USAID. UK/DrID. and Norway • Other Partners: GAVI Secretariat, UNICEF, WHO. World Bank • Violaine Mitchell, Acting DD for RI, will serve as the key contact person for FMOMs in Role of team key geographies members / staff • Steering Group Members will advise the Acting DD of new opportunities and topics under mann ing sPecifIc discussion with partners activities with • Acting DD and RI Program Officer(s) will be available to pm/support these discussions with MOH internal staff and external partners, as requested or appropriate , ,,.,,,,,,,,,,, o. <.,,,,..., i 7 EFTA01072423 Project Charter (V) Proposed Timeline and Deliverables: 1 year High-level Milestones for Year One of Routine Immunization Steering Group Date Complete Review and adoption of RI Steering Group Charter 2/01/2012 Development of Year One Work Plan 2/01/2012 Meetings with External Advisors 06/2012, 09/2012 Development of Metrics for Project See Scorecard Initiation of 3 RI Emblematic Grants Ql, Q2 2012 8 EFTA01072424 Project Charter (VI) IVOPOINIA010tilt0 R0k$10414$0300001Ple Cieung 6, 04 StEns-te - Chris Oa% Presibtm.Glabal DeallOPmait Po Steed, . Group - YbOlailt MOIChtll Ilan( INA IlVataltilMatinbielSen C4ocinate..1•44tiltez rant Gcts..aht T.dr.crtnpv.ans.nomtwanne.ntKeeColiltillnin..nra, bArylarrm emanil ,Cetro.ctrim Mx",,,—. :••••• whi est ro iron 11.1, 'dont law datnn:%•11•St-tarca,rm, Ludzan.in COw ns/I 'Am •cepaetneart ,,,,, • (WC., C'PAI Maio:am vs. ' ow C.Idil4020, B1 ton, in, trolAid, Ins Slitnig Cron, (44rdelatet.. pmt D.....itneie 4-oittipOlect :may. Ott, .11.1igatAlta• IA:Mtn cliabn't.........ve.. rd'S•11:1¢1.•InSevain ra •ntry *eau Imorvne .C.ron.t..,.mkt,. wt. entathid %Firm{ &imp age.an. Omen. slew lit. et It•I•gir Ifnoun rent as to'inurscnoldianiannyen0 ram' •.C.-.) oxID•unto.r. atop , .. rig ntrek rent Iran Stli Gnu: .p.4:nutz cline:we:n:4. a$ Kay.. ICIN:01P140 Ca ha.. a; ..... rt ans eh gr man ProgramOf/kir nosiorling bSt.11,10.u. p ird plain On.n,..* oC, OfCalntugc pWel(WINN/ 'not-% ityors .. , r., navy ups(et •tgot af.lyits 'Moto Presort/ St narn(uvelo.p,00. plse cats itowasitts B4000 wn..ten. rde.artt4n9.t• (0.01.”,514W00/(01. 45,41.0 9 EFTA01072425  10 EFTA01072426 Global Immunization 1980-2009 - DTP3 coverage 100 80 cn E 60 4.) 40 20 feeigg slgiwggeleigg ggiegg Global —American — Eastern Mediterranean —European —South East Asian — Western Padfle SwevYMOVNCEFixwiseatliVeon0,209.4.0y2M 11 EFTA01072427 DPT3 coverage levels in key geographies OTP3 covetage (a) 12 EFTA01072428 Trends in DTP3 Coverage in Nigeria, 1980 - 2010 EPI re-launched. EPI renamed NPI. UCI implemented made a paraslatal EPI initiated UCI 5$ end NPI 4NPHCDA 07 70 CO 50 Key 140 Afti, Nig I.WHO/ UNICEF 20 10 2. NICS 2010 a 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 ton Sone' 1 WHON/1020:40mol 0a 10/01/2010 ha. tmLappautigunanmni.”1.:tnoltocres.012221/enn- 2.N800.1111 Immuntalen paler Survey MUGS). 2010. MOH and teHODA EFTA01072429  Coverage and risk comparison of DTP3 shows that hardest to reach are those most in need of intervention Compared coverage rates and risk by wealth quintile 100% icrft • Using child mortality rates (1- ■ a 10% 59 months) as a proxy for risk • of vaccine preventable disease • • Each line represents a single country. with individual points for each wealth quintile For most vaccines and most countries, lower wealth quintiles have higher mortality risks and lower coverage rates — however the pattern differs between countries o a 100 I50 20) • Assuming infections targeted Vida 50V) irCenno by new vaccines are distributed similarly to child Each Nom represents one county. ladWdual point, miasma each wealth quintile mortality. existing programs may miss substantial fraction of high risk children =IIIMMEMe tad Four graphs of coverage by quintile for all countries, recent year. BCG, DPT2, Polio 2, Measles. Like tableau lower left, but only most recent year 14 EFTA01072430 Case-study of impact of equitable distribution with Rotavirus Estimated distributional effects of totavirus vx Rotavirus mortality and coverage curves mortality reduction and cost effectiveness NM. mi.*. caul Mown. I.......1. anew. tawdry linos nes Nan PpLinna SS *NOS as wand ~nal non,. Mame .P.A4 MIMS VO3 la INS WM 4...~ M Car WI lille an 44.1 >754 Rent MO) IN • a in as 21•1 • 5. MS I an OS Mn 544 4/0 :MI PM )110 04 4.14 110m1 1e11. .01.11 In 2n ran.. Itei PM 147 249 MT TI 1414 pp 2M 251 PI MIS 14 00 I•15 2/1 )70 M IMO 00 10 Ill I Oa 121 Plemi PM Mn 10 10 aa is tie MOM ten I M ill 5740 Ma I SY i PO >at) ini I M I le I re, Well I N I 11 N4 MO 0le Me Me as MP UM no 1M sie IMO KM 215 SW ON et MY 2L •44 2n • • 1 It i• Pal. NM • an.. man. co ova Each lino represents a county: Individual points Innen miennlina coal 4•0 represent each wealth quintile • a+.. tim.4.7.40 newly ...no, Wen Coverage decreases and deaths from rotavirus tmeni• 444.4.644 Nan &NA retell Fa ; x.c • IMNIMOMMSYMMISMOT ny atilt lower wealth ant ---D=wir /MSC 15 EFTA01072431  Countries with DTP3 coverage below 70% 40 countries in 1990 37 countries in 2000 20 countries in 2009 © 2010 Bill & Melinda Gates Foundation 16 EFTA01072432 Demands on vaccine delivery systems are rising dramatically Demands on delivery systems are vowing dramatically Cumulus-4w nulae and volume q vorrines used An imam.- childhood Amenummlion [Myopia lalanket Rib 10000/0.11 OR KO 101,00.X.1 Total Valw, OW USD) I1 1012 1954 1986 191% 1990 19W II% In 19% 200) 1001 133. 1006 MOS 1010 IOW 20% Mintz %MSS.Caw Onl Swim Welds,/ lelfsels Odom?:el ant aloleesimmallaw. 17 EFTA01072433 Health worker shortfall is affecting immunization coverage Immunization coverage improves with increased density of vaccinators 90 - 80 - O-4 70 - a) 60 - - O 0 30 - ••• Ilurrenmearc:e3 to -• 20 - Doclorg NJIOS 10 - 0 10 100 Density (per 100 000) WHO esthrolas VatInns then z . MISICOrOpOleeekeelli:traic,-,- rases. end RiclatgOOPer100,cr,. 0:0111400 a dal tiberlaCt, 18 EFTA01072434 57 countries are facing a critical shortage of health workers ft 4 i ri v 1al l c eh 1 - Abt ti r alli y Canines tort Crital 'Notate of health torten Countries...ghoul cnbcal shortage <IMAM wodtn Reaching target levels of health worker availability would roquir 2.4 million additional health workers in critical countries 19 EFTA01072435  Tech wrovelc, Many technological innovations could improve RI supply-chain, but need to be effectively implemented/deployed Temperature monitoring innovations: e.g. VVIA. freeze-tags. 30-day temperature recorders IT systems innovations HERMES: supply-chain modeling tool lutuwa diva..• az i s EVM+: next generation EVM toc 42)::"Zil eth IR,' RFID tags: inventory monitoring too' re:. et...44es S Others... • 20 EFTA01072436 New touchpoints for vaccination (e.g. schools) have been deployed effectively in developed world In developing world. greater proportion of Comparison of school-based versus health- out-of-school children can be a barrier to facility touchpoints in developed world school-based immunizations Coverage raon fat 3 deo:G.11) V of school alien:lance ICO UK swan relied as Ngh- atorellmata h '<boob s -7---- AV* UK anal USA eau • Mawr corforteowato noes UK 213 Fe I UK 4-18 Feteeth.° 0:1,70 CI US 3.1irti 40 32 UK 3 Ocoee USA 3 eases Pray Low Pray Law Panty Isar .00:01INAIMIO iffiX•040,116. 14.444.0W9Ity UK:HA/vaccine LISA:WV...wane dawn:demo", Sherpa Mrouell North Amence SubStoran SouthandYAW school' regutor hoavn Women EU Meta Asia Chennets, 21 EFTA01072437 Other services often integrated with routine immunization Health Facilities Integrating Services with Routine Immunization In 2007 RED evaluated countries) 0 OR POW) •CcadtN-133I Wiftn-fl I i€ h -1 Integrated service • The RI infrastructure provides a platform for the delivery of additional services during fixed and outreach vaccination sessions • In both fixed and outreach sessions. the services combined with immunization varied, even within the same country (see figure above) • Health facilities report that services are more frequently combined at fixed sites than during outreach sessions In addition to straining delivery system with new vaccines. health workers are also providing multitude of additional services with each interaction I 22 EFTA01072438 Our initial thinking on barriers to successful immunization 23 EFTA01072439 State of routine immunization today We have achieved significant Impact • In 2010. 109 million infants worldwide receive DTP3 vaccinations each year • 130 countries met the 2010 target of z90% national coverage of DTP3 • More than 2.5 million deaths are averted per year of children <5 years of age However, an unfinished agenda remains • In 2010. 19.3 million (-20%) children did not receive some or all of the routinely recommended childhood vaccines • DTP3 coverage was below 70% in 18 countries in 2010. only 59 countries (31%) achieved ≥80% coverage of DTP3 in every district • --2 million additional child deaths could be avoided if we can reach GIVS target of immunizing 90% of children < 5 years of age We cannot afford to be complacent in addressing these key gaps • RI coverage fell. or remained stagnant in 22 low-income countries between 2005 and 2009 • Hardest to reach children are those most in need of intervention and represent the most potential lives saved 24 EFTA01072440 Initial framework for thinking about components of routine immunization Data for decision•making For routine immunization to occur. three processes must be successful: • Demand: Individual must be present at the point of interaction where they can receive a vaccination • Snonly: The vaccine needs to anive at a designated point of i-iteraction where it can be administered to an individual • At the point of vaccination a health worker must actively identify an individual's vaccination needs and follow the right steps to administer and record the vaccination In addition, one enabler of routine immunization must be in place: • Data for decision-making must be collected, analyzed, and used. The data includes disease surveillance, coverage rates, and other metrics around the RI process 23 EFTA01072441 Demand barriers (I) Demand Barrier Rationale, evidence, assumptions il l EdUall1011 p y 111 Slalus. • Niemen with low educational ilaltr3 may have less aCals 10 eseciad orwooen information. as well as lesser degree of socio-economic (mothers. caregivers) independence. Nilsnate,' relates to decisimmialting power) • Evidence: Often correlated with chid health indicators. cited as risk factor for lack of vaconation Political banters • Chicken who he in conflict-affected areas. or who have recently migrated from those areas are less 'hely to be vaccinated. Reasons may range from lack of personal financial lemmas. lack a service delivery systems. and lack of trust in 'authority.' • Evidence: TBD Lack of caregiver education • Rationale: Some caregivers may not realize (or may not have been about vaccination told) linen to come back for subsequent doses. and villy* is Tech- important to do so nology • Evidence: Cutts S Eliellik (e.g. t0SURS of PaleiMan studyusing home' based education: study usng redesign c4 ot card to hilllight return dates and education on importance of full series) Lack of inkrmatico /Anti- • Rationale. May stem from misenformation: or from a lack of vaccine movements int:malice) regarding AtiFts • Caregivers may • Some indications that anti-vaccinahon movements are growing with Opera- choose not to have coverage rates increase as people see less evidence of trzEii. tions child vaccinated • Evidence: TBD Cultural / religious beliefs • Cultural or religious resistance to receiving vaccination, • Evidence: TBD 26 EFTA01072442 Demand barriers (II) Demand Barrier Rationale, evidence, assumptions IM= Geography • Distance to point of vaoariation is a border (often related to line and finance, but also in its own righl) • Some geographic areas. we 'off the grid' (e.g. urban slums). and not accounted for n a designated service delivery area • Evidence: Cuttstieild pacer; Walt Orensteinn and Stanley Flotiliin Lack of financial resources • Delivery system does not account fee the cost and opponunily cost of binreang to a vaccination of waiting, and of any 'Unofficial' charges • Evidence: TED Lack of rpm/van:on • If no other services are offered at the same silelsame lime. it not be perceived as weer the cost & time • Evidence:TED Opera Lack of btasernaliChld • Chidren been at home I without a skated birth attendant are les: tionS ll eallh Service UUizalion likely to be vaccinated Cont.) • This priori lack of service uttizadon. presumably for similar operational reasons. spits over into lack of senuse utlizaticei for imrnortirdtion • Evidence: TBD Poo service deivery • Missed opporkwities. whereby 'lockouts. concerns of wastage rhos no opening of a new multi-dose vial). or other cancellation of vaccination discourage completion of a series • Evidence: TBD Bad experience • Drepouts can also be caused by someone having a bad priori experience at a health censer - ride trealment by a healthcare worker. unexpected Sees. local vaccine ranchero, ex. • Evidence: TBD 27 EFTA01072443 Surveys in Nigeria and Ethiopia shows that majority of un- Demand vaccination driven by lack of awareness or willingness Total patient pool Main reasons C44•0 BY IIIIWN 1111/11 gram Compliance Total untunder vaccinated' • La:444i* • fee, ado .6140 • Post too fa. Lifer nearn A ratter for chid n04 • blew.. mc • Foordikluagte Clik wasobsent recemnp vaccine' : Own wok Seam • UnelatabAlvel • RAMS note • Lac* mamma • e3.4 04% et BO% 4, nib 69% • Nigeria size ofunAinder vaotinaied 31% 306 18% 12% e =1 WA (All vaccines? 100% ”- 02%rt i. 88% 47•-• 04% St% • Ohio& size ohm. 41Th. II Su, vactinslims 41% 23% 18% 18% WA (Measles vaccines) 1.4ajOnty of unrunder• Smni8cani source of VaCCII130011 unAmder vaccination 28 EFTA01072444 Mothers education appears to be a positive factor for immunization Coverage in Khartoum, Sudan Key findings on education from correlated to mothers education other studies • Generally. the studies reviewed suppore“ the conventional wisdom that education. schooV9 particularly mothers education, is a positive factor for immunization Primer/ • However, the relationship is not always dean and consistent Inforceoalalo • e.g. in one Kenya study fathers education correlated well with vaccination in urban areas and Sezenenr mothers education in rural areas • In Nigeria. educated people were less Unwise,• likely to immunize their children than illiterates 40 60 BO ICO % Coverage 29 EFTA01072445 Lack of information on vaccination presents a barrier Country examples • Liberia: Over 1/3 of mothers said they were not informed about the return date • 2008 EPI review in Benin found that one d the pincipal reasons for non-vaccination was mothers being unaware of the need to return or when or where to return • In Mozambique. 3/4 of health workers said they always write the return dates on the child's card, but only 1/4 of the cards actually had the return date written • However..-i Uganda. 80% of parents claimed that health staff advised them to retsn for more vaccinations • In one area of Bangladesh. with a 30% dropout rate. 63% of mothers claimed they were not informed about the time and place of EPI sessions 30 EFTA01072446 Case study: addressing demand in rural India has more Demand impact than addressing supply-issues only Note: This is a controversial issue( Immunization rates by type of immunization camp in rural India Key findings Fuly ;34 novas temente/ me mee room immunized 1%) •el+ dewed meoleaten nem epos Improving reliability of services so improves immunization rates by -3x. but adding small incentives improves 6.5x uptake of by -6.5x • Primary impact of incentive is to increase full compliance 30 Offering incentives proves to be more 20 cost effective than purely improving supply • Average cost 1child is actually lower when offering incentives - since daily 0 fixed cost (mainly health worker Control Reliable Incentives' + salary) is spread over more children camps only reliable camps Study indicates that size of incentive %coverage 6% 18% 39% does not matter beyond the fact that a positive incentive is offered Avg cost! 555.83 527.94 child However. coverage still remains very Note. CCTs • V TOD low despite interventions 31 EFTA01072447 Epidemiology of unimmunized child — access Impact of distance in Khartoum State. Sudan Impact of distance in Senegal lip Ici-clale irmnunizabon (%) Full imrriunizalica (%) 40 78 so ro 60 60 40 40 20 93 10 o ..— 0 WO ire 4 GO inns Atilt hire a GO mns Um wain i0 ims Welk awe a 30 32 EFTA01072448  Nigeria: Closer look at disparities by wealth quintile Vaccination coverage rates by Methods • 2003 and 2008 data wealth quintile: Nigeria DHS 2008, • Analyzed by region. wealth, children 12-23 months vulnerability (nutritional 100% status) and time 90% BOG • BCG. DPT1. DPT2. DPT3. 80% — OPTI Polio 0. Polio 1. Polio 2. >0% Polio 3. Measles 0012 00% - OPT, Table show coverage rates of Polo 0 40% different vaccines by wealth — Polo, Quintile 30% Polo 2 20% — Polo Key findings 10% Mooth•• • Children in poorer 0% households are less likely to Penegi Pvcrtc ‘1019 fbc/Ro linen< be vaccinated • Disparities in coverage for all vaccines 1 figure (most recent year) with multiple vaccines coverage rates by quintile (national) 33 EFTA01072449 Epidemiology of unimmunized child Demand Barriers Utilization difficulties: country examples Lack of motivation • In Dhaka. 21% of mothers in one study stated that immunizations were not necessary for thee children Previous use of health • Studies in West Africa. India. and