Plan Pluri Annuel Complet du Programme Élargi de Vaccination (PPAc-PEV 2011-2015)

Objectives

Haiti’s 2011–2015 Comprehensive Multi-Year Plan for the Expanded Programme on Immunisation seeks to build an ambitious, efficient and nationally owned immunisation system that protects children, pregnant women and wider population groups from vaccine-preventable diseases. Its central disease-control goals are to maintain interruption of poliovirus, measles and rubella transmission, eliminate maternal and neonatal tetanus, and control diphtheria, tetanus and pertussis.[1][2]The plan frames immunisation as a contribution to reducing under-five mortality and as an integral element of the national Minimum Service Package.[3][4]

• Achieve at least 90% national coverage among children under one year for routine vaccines other than Bacillus Calmette–Guérin by 2015, increasing from 70% in 2011.[5][6]
• Reach at least 80% coverage among pregnant women with two or more doses of diphtheria-tetanus vaccine by 2015, compared with 55% in 2011.[5][7]
• Maintain zero confirmed cases of polio, measles and rubella, and reduce maternal and neonatal tetanus incidence to fewer than one case per 1,000 live births.[8][9]
• Revitalise routine immunisation, reduce geographical inequities, recover low-coverage communes, reduce missed opportunities, trace defaulters, and lessen reliance on repeated catch-up campaigns.[5][10][11][12]
• Introduce pentavalent vaccine nationally in 2012 and pneumococcal and rotavirus vaccines nationally in 2013, alongside replacement of measles-rubella vaccine with measles-mumps-rubella vaccine.[13][10][14]
• Strengthen surveillance in every department, halve the diphtheria-tetanus-pertussis first-dose to third-dose dropout rate from its 2009 level, and establish dependable vaccine and supply management.[5][13][15]
• Maintain year-round cold-chain functionality in at least 80% of participating institutions, achieve at least 80% compliance with injection-safety and waste-management standards, and reduce vaccine wastage by 70% relative to the preceding financial year.[5][16]
• Implement an integrated national communication plan and annual departmental operational plans, supported by advocacy, social mobilisation and communication for behaviour change.[13][16]

The strategy is organised around six axes: protect more people; revitalise routine immunisation; strengthen Ministry of Public Health and Population leadership; adopt new vaccines and technologies; integrate immunisation with related health interventions and surveillance; and address vaccination in an interdependent world.[5][10]These priorities respond to persistent access barriers in rural and remote communities, weaknesses in outreach services, stock-outs, cold-chain limitations, unequal coverage, and the risks associated with migration and disease importation.[17][18][19][6]

Implementation

Implementation combines routine daily vaccination through participating institutions with outreach services, gathering-point sessions, supplementary immunisation activities, school-based vaccination, community tracing of defaulters, and targeted action in low-coverage or high-risk communes.[6][7][12]The Expanded Programme on Immunisation is intended to function as an entry point for an integrated package of preventive, promotional and nutritional services for mothers and children, including vitamin A supplementation and family deworming.[10][14]

• Deliver vaccination daily through all participating institutions, revive outreach services, ensure gathering-point sessions at least quarterly, and prioritise communes with substantial unvaccinated populations.[6][12][20]
• Prepare departmental operational plans and institutional microplans incorporating communication, supervision, supply and service-delivery requirements.[6][19]
• Recruit, train, supervise and support institutional, community and outreach personnel, including through non-governmental organisation contracting and Cuban cooperation support.[7][21]
• Strengthen coordination between the Directorate of the Expanded Programme on Immunisation and the Directorate of Epidemiology, Laboratories and Research for notification, investigation, response and active case-finding for vaccine-preventable diseases.[22][23]
• Reinforce governance through central and departmental managers, the Technical Committee for the Expanded Programme on Immunisation, the Inter-Agency Coordinating Committee for Immunisation, and a proposed national commission for verification and documentation of vaccine-preventable diseases.[10][24][7]
• Improve supply systems through quarterly departmental needs estimation, decentralised storage, refrigerated transport, regular inventories, batch traceability, reliable propane and other inputs, and assessment of cold-storage capacity.[25][26]
• Upgrade the cold chain by maintaining and repairing equipment, progressively replacing propane refrigerators with solar units, supplying spare parts, retraining technicians, and expanding electronic temperature indicators.[25][27]
• Improve injection safety and waste management through training, protective equipment, waste-treatment infrastructure, incineration networks and transport arrangements.[27]

Oversight is to use routine administrative data, supervision reports, targeted surveys, focused evaluations, quarterly feedback bulletins, quarterly database updates and semi-annual monitoring and evaluation workshops.[16][28][27]Communal focal points are to identify service-delivery problems and escalate them to departmental level; departmental health directorates are to coordinate services, supply, communication, surveillance and data transmission; and the national immunisation directorate is to monitor implementation and report through Ministry of Public Health and Population mechanisms.[24]A formative evaluation was planned for the end of 2012 to identify bottlenecks and realign the plan with the health-sector strategy, followed by a summative evaluation in the second quarter of the fifth year to inform the next multi-year plan.[24]

The plan’s financing framework covers 2011–2015 and has a total budget of US dollars 114.4 million.[29]It anticipates Government and partner financing, including support from GAVI, the Pan American Health Organization/World Health Organization, UNICEF, the Canadian International Development Agency, the Japan International Cooperation Agency and the United States Centers for Disease Control and Prevention.[29]The financing gap varies by scenario: it is reported at approximately US dollars 45.5 million without co-financing for new vaccines and cold-chain fuel, and approximately US dollars 15.7 million where the Haitian Government fulfils commitments to co-finance new vaccines and propane costs.[30]The gap particularly affects vaccines and injection materials, outreach allowances, transport, and other recurrent activities; the detailed figures exclude shared costs.[31][30]

Monitoring & Evaluation

The plan establishes a monitoring and accountability approach centred on routine administrative data, epidemiological surveillance, supervision, microplanning, periodic reporting and formal evaluations. It seeks to improve both immunisation coverage and operational quality, while addressing weak reporting completeness, inconsistent case investigation and limited programme-management capacity.[19][24][16]

• Monitor routine vaccination coverage among children under one year, coverage of pregnant women receiving two or more doses of diphtheria-tetanus vaccine, DTP1-DTP3 dropout, new-vaccine introduction and maternal and neonatal tetanus incidence.[6][7][9][13]
• Achieve at least 90% national coverage among children under one year for routine vaccines other than Bacillus Calmette–Guérin by 2015, and at least 80% coverage among pregnant women with two or more diphtheria-tetanus doses.[5][6][7]
• Maintain freedom from circulating polio, measles and rubella viruses, and keep maternal and neonatal tetanus below one case per 1,000 live births.[6][7][9]
• Strengthen surveillance through active case-finding, community participation, provider capacity-building and co-ordination between the Directorate of the Expanded Programme on Immunisation and the Directorate of Epidemiology, Laboratories and Research.[22]
• Target adequate surveillance of vaccine-preventable diseases in all departments, supported by 55 sentinel sites and surveillance personnel responsible for notification, investigation and response.[19][5]
• Measure surveillance performance through the proportion of institutions with an epidemiological-surveillance focal point and the proportion reporting notifiable diseases weekly, with a stated target of 70%.[15]
• Address very low reporting completeness, including at sentinel sites, and improve the timeliness and consistency of case investigations and responses following notifications.[19]
• Use administrative coverage data, supervision findings and periodic surveys to assess coverage, dose completion, vaccine use, wastage, cold-chain functionality, injection safety and waste management.[12][8][16]
• Interpret administrative coverage cautiously because national completeness of monthly institutional reporting was only 56% in 2010, catch-up vaccination could affect reported coverage, and survey estimates indicated higher DTP1-DTP3 dropout than administrative data.[32][33][12]
• Track annual cold-chain functionality milestones from 40% of participating institutions in 2011 to 80% in 2015, and apply the same progression to compliance with injection-safety and waste-management standards.[25][27]
• Reduce vaccine wastage by 70% compared with the previous financial year, using vaccine receipts and use recorded through routine administrative data.[15][16]
• Require reports and recommendations following supervision and technical-support activities, with quarterly reports documenting corrective measures, constraints and potential threats.[24]
• Use quarterly feedback bulletins, integrated supervision tools, quarterly database updates, semi-annual monitoring and evaluation workshops, and co-ordination meetings as oversight mechanisms.[22][27][28]
• Conduct a formative evaluation at the end of 2012 to identify bottlenecks and realign the plan with the health-sector strategic plan, followed by a summative evaluation in the second quarter of the fifth year to inform the next multi-year plan.[24]
• Strengthen accountability through departmental directorates’ responsibilities for supervision, supply, surveillance and data transmission, and through the Expanded Programme on Immunisation Directorate’s reporting to the Ministry of Public Health and Population General Directorate.[24]

Costing & Financing

The 2011–2015 Comprehensive Multi-Year Plan has a total budget of US dollars 114.4 million and relies on Government financing alongside multilateral and bilateral partners. Financial sustainability depends on reliably mobilising and efficiently using national and complementary external resources, although public funding was described as largely limited to salaries rather than programme activities.[29][19]

• Mobilise financing from the Government and partners including the Global Alliance for Vaccines and Immunisation, the Pan American Health Organization/World Health Organization, UNICEF, the Canadian International Development Agency, the Japan International Cooperation Agency and the Centers for Disease Control and Prevention.[29]
• Guarantee a minimum Government contribution, including co-financing for new vaccines and fuel for cold-chain operations, to reduce the programme financing gap.[29][30]
• Recognise financing scenarios in which the 2011–2015 gap is US dollars 45,523,928 without co-financing for new vaccines and propane or petrol, or US dollars 15.7 million when Government commitments to co-finance new vaccines and cover propane costs are fulfilled.[30]
• Address underfunding of vaccines and injection materials, outreach allowances or per diems, transport, and recurrent activities and other costs.[31]
• Note that vaccines and injection materials were reported as underfunded by US dollars 3.85 million over the period despite traditional partner support, while the 2011 vaccine budget line was estimated to be overfunded by US dollars 1.9 million.[31]
• Exclude shared costs from the reported financing-gap scenarios, which cover specific costs only.[31][30]
• Use World Health Organization PPAc costing tools, cold-chain and vaccine-management assessments, and new-vaccine applications to project costs and revise estimates for outreach, social mobilisation, information, education and communication, and distribution.[28]
• Account for the costs of introducing measles-mumps-rubella and pentavalent vaccines in 2012, pneumococcal and rotavirus vaccines in 2013, integrated community services, outreach-worker compensation and supply reimbursement for institutions unable to procure inputs.[14]
• Provide resources for cold-chain infrastructure, refrigerated transport, solar refrigerators, equipment and spare parts, motorcycles, protective equipment, waste-treatment facilities and waste transport.[25][27]
• Revise the base cost of 847 dollars for social mobilisation and information, education and communication, which was considered too low; no revised amount is specified.[28]