Author: King, L.; World Bank
The Expanded Program on Immunization (EPI) was established in 1979 and is currently one of the priority programs of His Majesty's Government (HMG). DHS surveys conducted in 1991, 1996, and 2001 indicate that there has been a significant improvement in DPT3 coverage, from 42.4% in 1991 to 72.1% in 2001. The results, however, also show that there is still an issue of access to routine EPI services. DPT1 (and BCG) coverage in 2001 was 84%, suggesting that about 16% of infants in Nepal are still not reached by routine EPI activities. While the EPI in Nepal has made significant progress over the last decade, there is clearly a need to further improve routine immunization coverage as part of a systematic effort to further strengthen the program. In order to help this process, a financial analysis of EPI was carried out by the World Bank, with assistance from HMG and UNICEF.
Purpose / Objective
The aim of this study was to:
- To describe the past trend in expenditures on EPI in Nepal
- To depict the sources and uses of these findings
- Estimate the cost of sustaining and strengthening routine EPI over the next five years
- Examining the availability of financing for EPI over next five years
- Analyze the long-term financial sustainability of EPI
The EPI expenditure data were collected from various sources, including: (i) various issues of HMG's Red Book; (ii) Economic Survey 2000/2001, Ministry of Finance; (iii) various yearly financial reports of the Department of Health Services, HMG; and (iv) records of donors/partners. Collecting this data involved many hours of discussions with the people responsible for the financing of EPI. It is important to realize that the data reflect a number of difficulties, including: categories of expenditure are not consistent between partners or the Government; it is not always clear on the source of funds in HMG's development (capital) budget; loss of records; and inconsistent accounting of actual expenditures. The data presented here are, therefore, approximate.
Key Findings and Conclusions
There has been a fairly consistent increase in public health expenditures and HMG health expenditures in real terms from FY 1995 to 2001. During the period 1995-2001, HMG's health expenditure has been growing consistently rapidly. If this trend were to continue, total public health expenditure would be $67 million in 2007 or $2.6 per capita, a 28% increase on current level. HMG now buys all vaccines for routine EPI, with the exception of BCG.
Despite increases in real expenditures, public spending on health care remains very low at Rs.149 (US$2.03). More than two-thirds of these expenditures have gone to pay the salaries and allowances of the Ministry of Health personnel involved in EPI, and about one fifth of the expenditures have been devoted to vaccines and syringes. Based on recent assessments, it appears that there is an urgent need for new investments in cold chain equipment.
The future cost of the Hepatitis B vaccine is difficult to predict although it is almost certainly going to decrease. Assuming that GAVI covers the cost of Hep B vaccine for the next 5 years, HMG will face the financial liability in 2007 of having to absorb the cost of the new vaccine and the AD syringes.
The recommendations made to the Ministry of Health were:
- Make an explicit commitment to steadily increase its expenditures on the operational costs of routine EPI
- Avail of the funds being provided by GAVI for both the introduction of new vaccines and the strengthening of immunization services
- Request greater support of EPI from existing partner agencies and pursue working with new partners
- Make an explicit commitment to meet the long-term costs of introducing Hep B vaccine after GAVI support ends in 2007
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Government of Nepal