Table 4.

Summary of facilitators, barriers and threats for sustaining coverage post-transition by themes of the Walt and Gilson’s (1994) health policy analysis framework

Facilitator/barrier/threat	Expanded programme for immunization (EPI)	Anti-malaria campaign (AMC)
Context
Political commitment for health by successive governments—Sri Lankan health system is built on principles of financial protection, close-to-client services and primary health care	EPI is a national priority programme explicitly identified in health policies. Immunization services are free and accessible to all Sri Lankans through a network of decentralized 356 Medical Officer of Health (MOOH) units and health facilities covering the entire Sri Lankan population. EPI vaccines can be obtained free to those who access the private sector.	AMC over the years has received political commitment for malaria control and elimination efforts. Malaria being the highest priority health challenge in the Ministry of Health (MoH)’s formative period (1930–1960) influenced the MoH’s organizational structure and orientation and development of health facilities particularly in malaria endemic regions. Preventive and curative interventions are available free-of-charge and anti-malaria interventions are implemented island wide based on need.
Historically well-established programme with strong domestic financing base	Established in 1978. Prior experience of successful donor transition.	First anti-malaria unit established in 1911. Continuous domestic financing base although external assistance received from multiple donors over the years.
Tangible programme success reinforces political commitment	High vaccine coverage rates and zero or low incidence of vaccine preventable diseases. Public demand for immunization services.	Near elimination effort in 1963. Malaria-free certification in 2016. As observed historically, political commitment can wane due to low prioritization in the context of elimination.
Government health spending—relatively low, but stable	New vaccines added even without external support.	Domestic financing base maintained supplemented with external assistance.
Macroeconomic context—increasing GDP growth and movement of income bracket followed by economic downturn	Increasing GDP growth during Gavi transition. Sri Lanka graduated to middle income country status (IMF criteria), a reason to trigger Gavi accelerated transition.	Economy slowing down during GFATM transition.
Health system inputs Governance
Controlled devolution of health to subnational (provincial) level. Decentralized preventive health services under the purview of nine provincial ministries of health (PMoHs). Central MoH retained functions of policy development, procurement, human resources and training, monitoring and evaluation and stewardship	Epidemiology Unit of the central MoH holds the functions of policy development, monitoring and evaluation and stewardship. Procurement, human resources and training are further integrated within the larger health system. Immunization service delivery is under the purview of the PMoHs. EPI is fully integrated with maternal and child health (MCH) services.	A semi-vertical programme. Central directorate holds the functions of policy development, procurement, human resource training, monitoring and evaluation and stewardship. Decentralized at the regional level, regional malaria officers (RMOs) and their teams are responsible for programme implementation. Some limited integration with MOOH units for some activities. RMOs report to the PMoHs and are accountable to the AMC directorate.
Central responsibility for equitable allocation of resources to achieve national health goals including channelling of external assistance to subnational levels based on need	The Epidemiology Unit ensures equitable access to resources including that of external assistance for achieving national health goals (e.g, Gavi health systems strengthening grant channelled towards development of infrastructure and human resources (HR) to post-conflict areas).	The AMC directorate ensures equitable allocation of resources including that of external assistance for achieving national health goals. The AMC directorate negotiates external assistance on behalf of the provinces whose needs can vary based on disease burden and other reasons (e.g. underserved post-conflict areas).
Multi-tiered system of monitoring from regional, provincial to national level ensures subnational and national level health goals are met	The EPI is monitored at the regional, provincial and national level. Direct monitoring of programme implementers by the Epidemiology Unit occurs when needed.	Due to the semi-vertical nature of the AMC, RMOs at the regional level report directly to the provincial level and are accountable to the central directorate.
Advisory committees including experts from outside MoH provide technical input for evidence-based decision-making. Committee chaired by the director general of health services (DGHS) can facilitate support from the highest level of the MoH	The advisory committee on communicable diseases (ACCD) chaired by the DGHS functions as the equivalent of a national immunization technical advisory group (NITAG). Vaccines excluded from the EPI even when external assistance for vaccine initiation was available, based on evidence-based deliberations at the ACCD.	The technical support group (TSG) chaired by the DGHS, provides technical support to the AMC. Central MoH administration support for the AMC has been forthcoming even in the context of elimination likely contributed by the institutional memory of malaria among the current administration which can wane over time.
Opportunities for broader stakeholder participation	Forums such as national immunization summits organized by the Epidemiology Unit facilitate participation of a range of stakeholders for deliberations pertaining to immunization programme. This creates transparency enabling buy-in for implementation of the EPI and financial support from Ministry of Finance (MoF).	Decreased following malaria elimination. Community-based organizations (CBOs) were involved in the anti-malaria programme prior to malaria elimination. Collaborations with the military and international organizations (UNHCR and UNOPS) are stronger due to the nature of high imported malaria risk groups—UN Peacekeeping forces and refugees, respectively.
Service delivery
Level of integration	Gavi funded vaccine was incorporated within the EPI. EPI is fully integrated within MCH services implemented by MOOH units.	A semi-vertical programme. Limited integration in some programme components. Organization of the AMC largely unchanged even following several programmatic shifts following malaria elimination and GFATM funding transition.
Service delivery within existing structures	Delivery of Gavi funded vaccines fully integrated within the existing service delivery structures of the EPI. No parallel structures created due to Gavi funding.	Service delivery underwent several major changes due to: (1) scale-up of interventions until malaria elimination through creation of parallel structures for service delivery; (2) programmatic change by addition of interventions pertaining to prevention of reintroduction and re-establishement following elimination and expansion of AMC to previously malaria non-endemic regions due to geographical change in disease burden; and (3) programme reorientation to prevention of reintroduction (POR) only phase triggered by the GFATM funding transition. GFATM supported staff incorporated within existing structures.
Financing
Financing history of health programme—mix and level of domestic financing and donor support	EPI fully graduated from UNICEF funding for vaccines between the period from 1990–1995. EPI continued to receive limited but critical support from UNICEF and WHO for capacity building of staff and continuous quality improvement of the EPI.	Prior to GFATM funding initiation, AMC has received external support over the years through several different donors including technical assistance. These supplemented the existing domestic financing base.
Mix of financing sources for health programme components. The domestic and donor financing mix at central and provincial levels for different components of the health programme has implications for transition	Financing for vaccines integrated within overall budget for medicines and medical supplies of the central MoH’s medical supplies division (MSD). Gavi funding was predominantly for vaccines (∼80%). Therefore, a successful transition from Gavi predominantly required bridging the financing gap left by the donor by negotiating with the MoF to increase the vaccine budget under the MSD. EPI implementation (i.e. service delivery) predominantly under provincial health budgets. Negotiation at provincial level not required since Gavi funding not used for service delivery.	GFATM funding was used across all programme components with varying domestic and donor financing mix. This requires mobilization of domestic financing from both the central and provincial levels. In effect, the financial transition from GFATM for the AMC can be largely categorized as a transition for: (1) operational expenses for which domestic financing has largely been mobilized); (2) non-operational expenses for which domestic financing is harder to mobilize; and (3) anti-malarials and other commodities for which AMC has largely continued to seek external assistance.
Ear marked financing for health programme or components of health programme	A separate budget line item for vaccines in the MSD budget was implemented since 2008. No earmarked financing for other components of the EPI due to full integration with the Epidemiology Unit at the central level and within MCH services largely delivered at the provincial level.	A separate budget line item for the AMC directorate under the central MoH budget.
Human resources
Health resource (HR) arrangement to implement donor-funded components of the health programme	No parallel HR structures created for delivery of Gavi funded vaccines due to full integration within EPI. Part of Gavi health systems strengthening grant utilized for infrastructure development of training facility and training of HR recruited by MoH for delivery of immunization services, particularly in underserved areas.	Parallel HR structures created to scale-up interventions for malaria elimination during GFATM grants awarded to community-based organizations (CBOs) (2003–2014). GFATM-supported staff incorporated within same organization structure and salary scales throughout GFATM funding period. HR transition required with both GFATM funding transition as well as transition triggered programme reorientation to POR only phase.
HR recruitment policies adheres to overall MoH policies and beyond	Seemingly no major impact on HR for EPI due to service integration.	With malaria elimination, an additional programmatic component to the AMC focusing on rapid detection and follow-up of imported malaria cases resulted in expansion of the AMC to previous malaria non-endemic regions thus requiring new recruitment of RMOs and RMO teams Not all positions are filled due to HR recruitment policies beyond the control of the AMC. Furthermore, creating and recruiting specialized staff categories (e.g. GIS expertise) within existing structures is difficult, and can impede optimal programme implementation.
HR training for new staff and refresher training for existing staff conducted and coordinated by the MoH	Gavi supported training is fully integrated within educational and training programmes of the MoH.	GFATM supported training is fully integrated within educational and training programmes of the MoH. Training and refresher training often funded predominantly through GFATM and other external donors making this programme component vulnerable to lack of domestic financing and can be a threat to the quality of the AMC.
Procurement
Centralized procurement follows national procurement guidelines and coordinated by the MoH’s procurement division. Medicines procurement mechanism is effective in obtaining low prices for pharmaceuticals due to bulk purchase through global tenders facilitating sustainability by reducing financial cost barriers. Procurement cycles are lengthy	Vaccine procurement is integrated within pharmaceutical procurement, through a central procurement agency via international tenders. WHO prequalification of suppliers is an additional requirement for vaccines. Gavi-funded vaccines procured through UNICEF supply division during Gavi co-financing period. Following Gavi transition, although eligible for ‘Gavi prices’ for five years, the Epidemiology Unit continuously assessed if the MoH pharmaceutical procurement mechanism would yield prices lower than ‘Gavi prices’ and would choose which option for procurement based on the assessment.	Procurement requirement for anti-malarials, insecticides and other non-pharmaceutical commodities decreased with malaria elimination. Utilizing existing procurement methods was challenging due to lack of bidders or bidders quoting very high prices due to low volumes. As a result, anti-malarials obtained through various sources of external assistance. Previously predominantly GFATM financed non-pharmaceutical commodities also sought through other sources of external assistance following transition.
Information systems
Monitoring of donor-funded components integrated within information systems of the health programme	Grant monitoring utilizes existing information system of the EPI.	Prior to malaria elimination parasitological surveillance separately maintained by CBO in areas under their responsibility. Following elimination, all grant monitoring utilizes existing information system of the AMC.
Information systems utilized for decision making	Immunization records have been well maintained, recorded, monitored at multiple levels and is utilized to improve immunization coverage and monitor service quality. Paper-based information systems migrated to a web-based platform, an initiative supported by UNICEF.	Maintains and utilizes four separate information systems for monitoring, evaluation and rapid response. Migrating and integrating these information systems to a single web-based platform to improve efficiency although a goal has not yet been achieved.
Transition process
Transition timelines known in advance	Transition timelines known even though transition triggered earlier than expected and Sri Lanka faced accelerated transition	Transition timelines known in advance and transition triggered due to malaria elimination and receipt of WHO malaria free certification.
Transition readiness assessment conducted		Conducted with technical assistance received through GFATM support. Occurred (in 2017) after transition was triggered (in 2016).
Transition planning carried out	Co-financing model facilitated transition planning. Financial sustainability a key concern among technical officers of the Epidemiology Unit, worked together with MoF to ensure financial sustainability.	Transition required across multiple programmatic components requiring changes in different health systems inputs. GFATM funding transition also triggered the most recent technical/programmatic transition to POR only phase. Different components of the programme and health system inputs on different transition timelines.
Funding models to facilitate transition	Gavi co-financing model required Ministry of Finance (MoF) as signatory for implementation and awareness among MoF created at inception. Gradual increase in domestic co-financing component. Five year access to ‘Gavi prices’ post-transition.	GFATM transition grant negotiated to further aid the transition process using new funding model (2019–2021). Funding model designed to mobilize domestic resources by reimbursing Treasury at the end of the year based on the AMC achieving a defined pre-negotiated deliverable critical to facilitate transition for each of the three years of funding.
Actors
Political commitment	Public demand for vaccines and tangible gains of the EPI translate to political commitment.	Political commitment during elimination efforts show signs of waning post-elimination due to low disease burden and other health priorities.
Support from MoH administration	High priority and adequate support	Well supported. Institutional memory of malaria still present among current MoH leadership.
Programme administrators together with technical advisory committees play a lead role in guiding transition	Financial sustainability and improving and maintaining quality of the EPI are key priorities for officers of the Epidemiology Unit overseeing the EPI. New vaccine introductions follow evidence-based deliberations and not simply based on availability of external assistance for vaccine introductions. Officers of the Epidemiology Unit also actively seek ways for broader stakeholder consultation in order to establish greater commitment to the EPI.	Key actors that directed the transition were officers of the central directorate, technical advisors to the AMC, with inputs from the technical leads from the subnational level. These groups were also key decision-making to retain semi-vertical organization of the AMC, notwithstanding malaria elimination, GFATM transition and the programmatic transition to POR. Technical advisors play a key role in guiding POR in the absence of clear guidelines for POR from technical agencies.
Other key influencers of transition	MoF as observers of the consultative and transparent process of vaccine-related decision-making as well as tangible benefits of the EPI supports financial sustainability of the EPI. Donor-(Gavi-)initiated co-financing model facilitated transition.	GFATM helped facilitate the transition by supporting a transition readiness assessment, monitoring transition related to programmatic components, and by providing a final transition grant linked to facilitating transition particularly in key areas that were identified as impediments to a smooth transition.

Source: Authors’ analysis of from documentary review and in-depth interviews.