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Analysis of Immunization

Financing Indicators of the

WHO-UNICEF Joint

Reporting Form (JRF)

2010-2015

Department of Immunization Vaccines and

Biologicals, World Health Organization

October 2017

1

Acknowledgements

This report has been prepared by S. Mona Aghdaee (WHO consultant), Antonello Lenti (WHO

intern) and Claudio Politi (WHO/HQ), with inputs and contributions from Patrick Lydon

(WHO/HQ), Xiao Xian Huang (WHO consultant), Cara Bess Janusz (WHO/AMRO), Amos Petu

(WHO/AFRO ES), Alexis Satoulou (WHO/AFRO CW), Irtaza Chaudhri (WHO/EMRO) and Niyazi

Cakmak (WHO/EURO).

2

Contents

Acknowledgements ............................................................................................................................................. 1

List of abbreviation.............................................................................................................................................. 3

Executive summary ............................................................................................................................................. 4

1. Introduction ................................................................................................................................................. 5

2. Data and Methodology ................................................................................................................................ 6

2.1 WHO-UNICEF Joint Reporting Forms (JRF) ........................................................................................... 6

2.2 Additional data sources ............................................................................................................................. 7

2.3 Identification and estimation of missing and inconsistent data ................................................................. 8

2.4 Reporting Statistics .................................................................................................................................... 9

2.5 Country Selection Criteria ....................................................................................................................... 11

3. Global Analysis ............................................................................................................................................. 13

4. Regional Analysis .......................................................................................................................................... 17

4.1. African Region ....................................................................................................................................... 17

4.2. Region of the Americas .......................................................................................................................... 21

4.3 Eastern Mediterranean Region ................................................................................................................ 25

4.4. European Region .................................................................................................................................... 29

4.5. South East Asia Region .......................................................................................................................... 33

4.6 Western Pacific Region ........................................................................................................................... 37

5. Analysis for Gavi eligible countries .............................................................................................................. 41

6. Analysis by Income Classification ................................................................................................................ 48

7. Discussion and Conclusions .......................................................................................................................... 54

3

List of abbreviation

AFR WHO African Region

AMR WHO Region of the Americas

cMYP comprehensive Multi-Year Plan

EMR WHO Eastern Mediterranean Region

EUR WHO European Region

GVAP Global Vaccine Action Plan

HIC High Income Country

JRF Joint Reporting Form

LIC Low Income Country

LMIC Lower Middle Income Country

PWA Population Weighted Average

RI Routine Immunization

SEAR WHO South Eastern Asia Region

UMIC Upper Middle Income Country

WPR WHO Western Pacific Region

4

Executive summary

The report presents the analysis of the financing indicators from the WHO-UNICEF Joint Reporting Form

(JRF) for the period 2010-2015. The immunization financing indicators included in this analysis are the

following:

- Existence of specific line item in the national budget for the purchase of vaccines used in routine

immunization.

- Total expenditure (from all sources) on routine immunization, including vaccines.

- Government expenditure on routine immunization, including vaccines.

- Total expenditure (from all sources) on vaccines used for routine immunization.

- Government expenditure on vaccines used for routine immunization.

JRF financing data were cross-checked by analyzing time series, data from Gavi co-financing

payments and from comprehensive Multi-Year Plans for immunization (cMYPs); missing data and

inconsistencies were corrected and replaced by WHO estimates when it was considered appropriate.

To allow consistent time trend analyses, countries with completed time series of observations on the

four JRF financial indicators for the entire period 2010-2015 have been selected, 77 countries fit this criteria.

By selecting the countries with full six years observations on the four indicators, the analysis provides

unbiased trends of immunization expenditure.

The majority of selected countries for this analysis, 63 out of 77 (82%), reported to have specific line

item in their national budgets for purchasing vaccines in 2015.

Globally, government expenditures on routine immunization and on vaccines have increased over the

six-year period. The average (population weighted) of expenditure on routine immunization per live birth in

the 77 selected countries increased from US$ 29 in 2010 to US$ 36 in 2015 (+23%). The average (population

weighted) expenditure on vaccines per live birth increased from US$ 25 in 2010 to US$ 30 in 2015 (+20%).

However, percentage of government funding vaccine expenditure shows a declining trend, this is because

external funds for introduction of new vaccines increased at a faster pace leading the percentage of total

vaccine costs funded by government decreasing from 84% in 2010 to 60% in 2015. Similar trend is visible in

government expenditures on routine immunization, which fell from 84% in 2010 to 63% in 2015. Overall

during the period 2010-2015, governments have allocated more funds towards purchasing vaccines than other

cost of immunization programs such as service delivery: the government share allocated to purchase vaccines

has increased from 65% to 74%. This could be affected by the introduction of new vaccines supported by Gavi

5

and related co-financing policy. Gavi might provide incentives to countries with limited financial resources to

prioritize vaccine expenditures.

Analysis of JRF indicators in Gavi countries confirms the positive impact of Gavi co-financing policy in

mobilizing domestic funds for immunization: Aggregate government funding on routine immunization in Gavi

eligible countries has increased in absolute values from US$ 336 million in 2010 to US$ 381 million although

the government expenditure as percentage of the total expenditure on routine immunization declined.

Analysis of JRF indicators by countries’ income shows large disparity among low and high income

countries, with high income countries spending on average US$ 500 per live birth on their routine

immunization, while expenditure on routine immunization is only US$ 6.3 on average in low income

countries. High and upper-middle income counties are fully funding their immunization program and low

income countries on average, rely on external fund for financing over 70% of their immunization costs.

1. Introduction

Although over last decades remarkable progress has been made in immunization coverage, the vaccine-

preventable diseases remain a major cause of infant morbidity and mortality worldwide and coverage gaps

persist between high, middle and low income countries. In December 2010, global health leaders committed

to address challenges in immunization field by launching the decades of vaccines initiative (2011-2020).

Fulfilling this commitment WHO, UNICEF, Gavi and Bill & Melinda Gates Foundation, with collaboration

of other partners, developed the Global Vaccine Action Plan (GVAP) for the period 2011-2020 as a new

roadmap to address vaccination gaps and prevent millions of vaccine-preventable diseases and deaths. The

plan was endorsed by the 194 Member States of the World Health Assembly in May 2012.

With the presence of numerous international organizations, public and private donors in health and

immunization, substantial financial resources have been mobilized for vaccination and immunization. Among

GVAP six strategic objectives, two objectives focus on financing issue: all countries commit to immunization

as a priority (strategic objective 1) and immunization programs have sustainable access to predictable funding,

quality supply and innovative technologies (strategic objective 5). Key indicator to monitor progress towards

the strategic objective 1 is the domestic expenditure for immunization per person targeted. The final goal of

global community is to lead countries to be self-sufficient and to ensure sustainable flow of funds to

immunization. Sustainable financing and country ownership are key GVAP principles. Countries agreed to

report their progress towards the GVAP goals annually through its monitoring and evaluation framework.

Since 1998, the WHO-UNICEF Joint Reporting Form (JRF) mechanism has been collecting data on

immunization financing as part of a set of immunization indicators, designed to measure immunization

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coverage and system performance in WHO member states. The financing indicators included in the JRF aim

to capture the expenditure on routine immunization, the expenditure on vaccines, the percentage financed by

government and the existence of a national budget line for the purchase of vaccines. JRF financial indicators

are key elements for sustainability and self-sufficiency of any immunization program. Their analysis provides

evidence on countries moving towards ownership and commitment of GVAP goals as well as success of Gavi

policies.

This report presents an analysis of financing indicators for the period 2010-2015. The trend analysis

highlights improvements in government commitments to sustain the immunization programs. The analysis is

conducted at four different levels: global, WHO regional offices, for Gavi eligible countries and by income

levels.

The structure of the report is the following: the next section describes the sources of data and the process

of data cleaning and estimation. Section 3 and 4 present global and regional analysis; section 5 presents the

analysis of Gavi eligible countries and section 6 presents the analysis by countries’ income. Section 7 includes

discussion and conclusions.

2. Data and Methodology

The source of data for the present analysis is WHO-UNICEF Joint Reporting Form (JRF). The WHO-

UNICEF JRF collects data on immunization financing as part of a set of indicators designed to measure

immunization coverage and system performance in WHO Member States, 194 countries. The JRF financing

indicators are used extensively by the WHO, UNICEF and other organizations and academics for the purpose

of measuring the extent to which countries are investing on their national immunization as well as the role of

external funds. Additional sources of data have been used for the analysis: countries’ comprehensive Multi-

Year Plan (cMYP)1, the UN Population Data2 and World Bank Development Indicators3.

2.1 WHO-UNICEF Joint Reporting Forms (JRF)

In an effort to minimize the burden of data gathering and monitoring, WHO and UNICEF jointly

developed a standard questionnaire for reporting data on immunization indicators starting in 1998. The content

1 http://www.who.int/immunization/programmes_systems/financing/en/

2 http://www.un.org/en/development/desa/population/publications/development/population-development-database-2014.shtm

3 http://data.worldbank.org/data-catalog/world-development-indicators

http://www.who.int/immunization/programmes_systems/financing/en/

http://www.un.org/en/development/desa/population/publications/development/population-development-database-2014.shtm

http://data.worldbank.org/data-catalog/world-development-indicators

7

of the Joint Reporting Form was developed through a consensus process among staff from UNICEF, WHO

and selected ministries of health (MOHs). Information collected through JRF include estimates of national

immunization coverage, reported cases of vaccine-preventable diseases, immunization schedule, indicators of

immunization system performances as well as financing indicators.

Concerning the financial aspect of immunization programs, JRF includes six immunization expenditure

indicators. Four indicators are expressed in absolute values of US$:

• Total expenditure (from all sources) on routine immunization, including vaccines.

• Government expenditure on routine immunization, including vaccines.

• Total expenditure (from all sources) on vaccines used for routine immunization.

• Government expenditure on vaccines used for routine immunization.

Two indicators are expressed as percentages (%):

• Percentage of routine immunization expenditure financed by government

• Percentage of vaccine expenditure used for routine immunization financed by government.

Furthermore, to reflect the level of commitment for each country in national immunization programs

investments, the following indicator is collected: Availability of a specific line item in the national budget for

the purchase of vaccines used in routine immunization.

The rationale for creating an indicator reflecting the national budget line for vaccine purchasing is based

on the assumption that the line item can contribute to improved financing. The expectation is that the presence

of a line item for vaccines will encourage national governments to increase their budgetary efforts for

immunization programs. It is assumed that governments that choose to introduce an immunization-related line

item into the national budget will have a commitment to these programs. The presence of line item also permits

tracking of allocations and increases transparency in the allocation of funds, and can allow stakeholders (EPI

managers, Members of Parliaments, Civil Societies and International Organizations) to better monitor the

government's budgetary effort.

2.2 Additional data sources

Comprehensive Multi-Year Plans are useful source of information to cross-check JRF reported data.

cMYP are multi-year plan for immunization which consolidates plans for several activities including program

management, immunization delivery, monitoring, evaluation as well as cost and expected sources of financing.

Countries’ cMYPs are thus used for the present analysis to cross-check JRF reported data, by comparing

equivalent expenditure and financing figures of the plans. UN Population Data has been used to extract the

“live birth” indicator to calculate the financing indicators per live birth as well as population weighted average

8

estimates. Furthermore, Gross National Income (GNI) per capita has been extracted from World Bank World

Development Indicators to be used for the analysis by income groups and Gavi countries.

2.3 Identification and estimation of missing and inconsistent data

The analysis covers the period from 2010 to 2015. Countries started reporting JRF financing indicators

since 2000, however only in recent years the quality and accuracy of the reported data have progressively

improved. The GVAP set 2010 as the baseline year to monitor progress of the implementation of the global

plan. Despite the global emphasis on the importance of JRF financial indicators, many countries fail to fully

report them. WHO has made attempts to recover missing values and correct inconsistent data based on the

information collected since 2000 in order to increase the number of valid observations for more comprehensive

analysis.

Identification of inconsistent data and imputation is done according to guidelines and principles. The

following rules of internal validity were used to assess the consistency of the country reported data:

1. Total expenditure (from all sources) on routine immunization must be higher than total expenditure

(from all sources) on vaccines.

2. Total expenditure (from all sources) on routine immunization must higher than or equal to

government expenditure on routine immunization.

3. Total expenditure (from all sources) on vaccines must be higher than or equal to government

expenditure on vaccines.

4. Government expenditure on routine immunization must be higher than the government expenditures

on vaccines.

5. The reported percentage of government funding and the calculated percentage of government

funding (obtained by dividing the reported amount of government funding by the total expenditure for

both routine immunization and vaccine expenditures) must be equal.

In case one of the above criteria is not met for a reported value, the value is replaced by estimates based

on the following methods:

• Average of available data;

• Assumed continuation of time series trend;

• Data from comprehensive Multiyear Plans (cMYP) costing and financing tool when available

(mainly for GAVI eligible countries).

The following sections provide details on selection criteria and the trends of response rates from countries,

number of inconsistencies identified and estimates made by WHO.

9

2.4 Reporting Statistics

This section presents the statistics of reporting for each JRF financing indicator. The quality of country

reporting for the JRF financing indicators has been a critical issue since the beginning of the reporting.

Countries are facing many challenges in the quantification of immunization expenditure data. In response to

this, several initiatives have been undertaken by WHO and International Partners as a comprehensive effort

to strengthen local and regional capacity. In particular, active feedback between countries and WHO has been

intensified. In addition, immunization financing data has been disseminated and used for advocacy;

preparation and dissemination of a specific JRF guidance note by the Gavi Immunization and Financing

Sustainability (IF&S) Task Team4. The guidance note provides countries with comprehensive definitions for

each indicator as well as instructions on how to collect, estimate, validate and report the correct data.

The graph and tables below describe the reporting statistics for the JRF financing indicators over the period

2010 to 2015.

Figure 1. Reporting Statistics. Percentages of missing and inconsistencies

Table 1 – Reporting Statistics – All JRF financing indicators

All six JRF financing indicators

2010 2011 2012 2013 2014 2015

Missing 430 457 452 440 411 354

Inconsistencies 98 86 57 70 60 12

Estimations 231 228 198 167 99 78

4 http://www.who.int/immunization/programmes_systems/financing/data_indicators/JRF_guidance_note_march2015.pdf?ua=1

37% 39% 39% 38% 35%30%

8% 7% 5% 6% 5%1%0%

20%

40%

60%

80%

100%

2010 2011 2012 2013 2014 2015

JRF financing indicators of data quality

Missings inconsistencies

10

Figure 1 and Table 1 summarize reporting statistics for 194 countries, across all indicators between the

years 2010 and 2015. The number of missing indicators has decreased significantly during this period. The

sharpest decline is associated with year 2015, the number of missing values dropped from 411 in 2014 to 355

in 2015. Inconsistencies follow a similar pattern, a steady decline in 2010 to 2014 and a substantial fall in

2015.In 2015, only 12 inconsistencies are identified in JRF financial indicators across countries. As a result

of the reduction in missing and inconsistent values, the number of imputed estimations has also decreased. In

2010, 231 estimations have been calculated while this number was only 78 in 2015. This reporting statistics

clearly indicates that the initiatives and support from WHO and International Partners have impact on the

increasing response rate and data quality.

Table 2. Reporting Statistics. Details on each JRF financing indicator

Government expenditure on vaccines

2010 2011 2012 2013 2014 2015

Missing 46 56 56 49 52 52

Inconsistencies 17 13 8 12 12 _

Estimations 19 27 19 14 9 4

Total expenditure on vaccines

Missing 73 77 67 62 59 56


Estimations 40 41 29 24 12 14

Percentage of total expenditure on vaccines funded by government

Missing 59 59 61 60 60 48


Estimations 41 40 37 34 33 16

Government expenditure on routine immunization

Missing 86 95 93 96 84 73


Estimations 34 32 33 27 11 12

Total expenditure on routine immunization

Missing 97 100 98 99 85 74


Estimations 40 38 30 26 9 14

Percentage of total expenditure on routine immunization funded by government

Missing 69 70 77 74 71 57


Estimations 57 50 50 42 25 18

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As Tables 2 displays, despite the general increase in response rate in all indicators, there is a noticeable

difference between indicators reporting on vaccines and those reporting on routine immunization. For

instance, the number of missing data for the government vaccine expenditure is 52 in 2015, while this number

reaches to 73 for the government expenditure on routine immunization. This wide gap between two set of

indicators highlights challenges countries face in quantifying expenditure on routine immunization.

Lack of a well-established information management system in some countries makes it difficult to record

and track all the costs associated with routine immunization while vaccine expenditure information can be

identified easily. Moreover, quantifying the costs that are included in routine immunization is challenging as

health systems have many integrated services and shared costs are not easy to be distinguished and tracked

down (administrative cost, outreach…). Survey on the difficulties faced by countries in reporting JRF

financing indicators is available on the WHO website5.

2.5 Country Selection Criteria

To allow consistent time trend analyses, countries with completed time series of the following indicators

for the entire period 2010-2015 have been selected.

➢ Government expenditure on vaccines used in routine immunization.

➢ Total expenditure (from all sources) on vaccines used in routine immunization.

➢ Government expenditure on routine immunization, including vaccines.

➢ Total expenditure (from all sources) on routine immunization, including vaccines.

By selecting the countries with full six years observations on the main four indicators, the analysis reflects

the unbiased picture of existing expenditure trends in countries. Moreover, full time-series observations are

essential to calculate consistent and unbiased population weighted averages.

Table 3 provides the number of countries included in global and regional analyses.

5 Collection and reporting of immunization financing data for the WHO/UNICEF Joint Reporting Form - Results from country survey (2014):

http://www.who.int/immunization/programmes_systems/financing/data_indicators/report_jrf_survey_2014_draft.pdf?ua=1

http://www.who.int/immunization/programmes_systems/financing/data_indicators/report_jrf_survey_2014_draft.pdf?ua=1

12

Table 3. No. of countries selected in each analysis group

Regional classification

AFR AMR EMR EUR SEAR WPR Global

20 25 7 8 8 9 77

Inco

me

cla

ssif

ica

tio

n

LIC 12 0 0 0 1 0 13

LMIC 6 5 3 2 5 5 26

UMIC 1 16 4 3 2 2 28

HIC 1 4 0 3 0 2 10

of

wh

ich

are

Gavi6

eli

gib

le:

Initial Self-fin. 12 0 0 0 1 1 14

Phase 1 4 1 3 1 2 3 14

Phase 2 1 2 0 3 2 1 10

Phase 3 0 1 0 0 1 0 2

6 http://www.gavi.org/support/sustainability/transition-process/

http://www.gavi.org/support/sustainability/transition-process/

13

3. Global Analysis

The WHO-UNICEF joint reporting mechanism allows to monitor trends of key immunization financing

indicators. Countries which reported complete 6 years observations on four main indicators during the entire

period of 2010-2015 have been selected to ensure consistent and unbiased analyses: 77 countries fit the criteria

and their expenditure indicators have been expressed as population weighted averages and analyzed.

Table 4. Global Analysis. Countries by income classification and Gavi eligibility

Income Classification Group Total No. of

countries Gavi eligible

High Income 10 0

Upper Middle Income 27 4

Lower Middle income 27 23

Low Income 13 13

TOTAL 77 40

During the period 2010-2015, the number of countries reporting a specific line item in their national budget

for purchasing vaccines decreased from 73 to 63.

The level of consistency in reporting varies across regions, with large variations in the American and

African regions.

Table 5. Global Analysis.77 selected countries. Line item in national budget for vaccines

Countries with line item in national budget for

vaccines 2010 2011 2012 2013 2014 2015

Global (77)

73

95%

73 95%

73 95%

74 96%

72 94%

63 82%

AFR (20) 20

100%

20

100%

19

95%

20

100%

19

95%

18

90%

AMR (25) 24

96%

95%

23

92%

24

96%

23

92%

24

96%

19

76%

EMR (7) 6

86%

6

86%

6

86%

7

100%

6

86%

6

86%

EUR (8) 7

88%

7

88%

7

88%

7

88%

7

88%

7

88%

SEAR (8) 8

100%

8

8

8

6

8

100%

8

100%

8

100%

8

100%

6

75%

WPR (9) 8

89%

9

100%

9

100%

9

100%

8

89%

7

78%

Gavi (40) 38

95% 39

98% 38

95% 40

100%

37 93%

35 86%

14

Each of the four main JRF financial indicators- expressed as population weighted average per live birth-

followed an upward trend: in fact, their minimum level is at the baseline, while the respective peak is reached

in the last year, except the government expenditure on vaccines which shows a slightly lower figure in 2015

compared to the previous year (Table 6, Figure 2).

Table 6. Global Analysis. Indicator summary

(population weighted average, US$ per live birth in 77 selected countries) Indicators 2010 2011 2012 2013 2014 2015

Expenditures on Routine Immunization (RI)

Total RI expenditure per live birth $33.1 $36.1 $35.4 $36.9 $41.7 $43.2

Government RI expenditure per live birth $29.2 $31.2 $31.4 $30.6 $34.9 $36.9

% of total RI funded by government 88% 86% 89% 83% 84% 85%

Expenditures on Vaccines

Total vaccine expenditure per live birth $27.6 $30.5 $29.2 $31.5 $35.5 $35.9

Government vaccine expenditure per live birth $25.1 $27.0 $26.3 $26.2 $30.5 $30.0

% of total vaccine funded by government 91% 89% 90% 83% 86% 84%

The total expenditure grew more than the government expenditure:

- The total expenditure on routine immunization and the total expenditure on vaccines showed a

similar percentage increase throughout the period (approximately a 30% growth rate), peaking to US$

43.2 and US$ 35.9 in 2015 respectively;

- The government expenditure on routine immunization grew from US$ 25.1 in 2010 to US$

36.9 in 2015 (+26.4%), while the government expenditure on vaccines was US$ 25.1 at baseline and

reached US$ 35.9 in 2015 (+19.5%).

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The comparison between growth rates of the four different indicators leads to these remarks:

- The percentage of expenditures funded by governments is decreasing, due to other external

sources of funding, such as those provided by GAVI support (Table 6; figure 3);

- Since the government expenditure on routine immunization grew in percentage terms more than

the government expenditure on vaccines, a new allocation of resources occurred; indeed, throughout

the six-year period, the share of service delivery passed from 14% to 19% of the government

expenditure on routine immunization (Figure 4).

Figure 2. Global Analysis. JRF financial indicators

(population weighted average, US$ per live birth in 77 selected countries)

20

25

30

35

40

45

2010 2011 2012 2013 2014 2015

GLOBAL ANALYSISTotal and Government Expenditures on Routine Immunization and Vaccines

16

Figure 3. Global Analysis. Total Expenditure on Vaccines, by source of financing


Figure 4. Global Analysis. Composition of the Government Expenditure on Routine Immunization


91% 89% 90% 83%86% 84%

9%11% 10%

17%

14% 16%

0

5

10

15

20

25

30

35

40

2010 2011 2012 2013 2014 2015

$27,6 $30,5 $29,2 $31,5 $35,5 $35,9

GLOBAL ANALYSISTotal Expenditure on Vaccines

86% 87% 84% 86%87% 81%

14%13% 16% 14%

13% 19%

0

5

10

15

20

25

30

35

40

2010 2011 2012 2013 2014 2015

$29,2 $31,2 $31,4 $30,6 $34,9 $36,9

GLOBAL ANALYSISGovernment Expenditure on Routine Immunization

Vaccines Service delivery

17

4. Regional Analysis

WHO member states are grouped into six WHO regions: African region, region of the Americas, South-

East Asia region, European region, Eastern Mediterranean region, and Western Pacific region. The following

section describes and analyses JRF financial indicators according to WHO regions.

4.1. African Region

47 countries are in African Region (AFR). Twenty countries have complete 6 years observations on the

four financing indicators during the period of 2010-2015, 17 of them are Gavi eligible7. Table 7 provides

information of the selected countries, their income status and Gavi eligibility.

Table 7. AFR. Selected countries by income classification and Gavi eligibility



High Income 1 0



Low Income 12 12

TOTAL 20 17

All 20 selected countries in the African region reported to have line item in 2010, 2011 and 2013. In 2012,

Congo reported to drop the line item, and in the next year, reported to add the line item back. In 2015, Congo

dropped the line item again. At the end of the period, another country (Comoros) dropped the line item as

well, which resulted in 18 countries having line items in 2015 (Table 8).

7 Of which: 12 countries are “Initial Self-financing”, 4 countries are in “Phase 1 – Preparatory transition”, 1 country is in “Phase 2 - Accelerated transition”.

18

Table 8. AFR. Indicator summary


Indicators 2010 2011 2012 2013 2014 2015


vaccines 20 20 19 20 19 18

Expenditures on Routine Immunization :

Total RI expenditure Per Live Birth $22.0 $26.7 $22.5 $28.0 $36.2 $28.8

Government RI expenditure Per Live Birth $6.4 $5.9 $5.9 $6.1 $6.7 $8.4


Expenditures on Vaccines:

Total vaccine expenditure Per Live Birth $12.7 $15.0 $14.7 $21.8 $24.9 $23.4

Government vaccine expenditure Per Live Birth $3.5 $2.9 $3.0 $3.7 $3.8 $4.0


Over the last six years, the African Region experienced an increase in all the JRF financing indicators

expressed as population weighted average per live birth. Even though each expenditure has evolved following

a different fluctuating trend, the peak is reached in 2015, with the exception of the total expenditure on

vaccines which shows a slight fall at the end of the period.

The expenditure on routine immunization has grown at rates different from those shown by the expenditure

on vaccines:

- The total and government expenditure on routine immunization have both experienced growth rates

consistent with the trend recorded globally (an increase of about 30% for the entire period; see

Chapter 3);

- The total expenditure on vaccines has almost doubled compared to baseline, while the expenditure

funded by government underwent a modest increase (+8.6%).

The significant increase in the externally funded expenditure on vaccines is clearly due to the GAVI

support over the years.

19

Figure 5. African Region. JRF financial indicators


Figure 6. African Region. Total Expenditure on Vaccines, by source of financing


0

5

10

15

20

25

30

35

40

2010 2011 2012 2013 2014 2015

AFRTotal and Government Expenditures on Routine Immunization and Vaccines

27% 19% 20% 17% 15% 17%

73% 81% 80%

83%85% 83%

0

5

10

15

20

25

30

2010 2011 2012 2013 2014 2015

$12,7 $15,0 $14,7 $21,8 $24,9 $23,4

AFRTotal Expenditure on Vaccines

20

Figure 7. African Region. Composition of the Government Expenditure on Routine Immunization


Table 9 provides information on the government routine immunization expenditure per live birth for the 20

selected countries. The highest increase is in Congo with almost 300% increase from US$ 3.2 in 2010 to US$

11.4 in 2015. Ten countries showed upwards trends, while other 10 countries experienced a decrease in their

government expenditure on routine immunization. Gabon is the country with the most decline in the region.

Both Gavi and non-Gavi countries experienced fluctuating trends throughout the period.

Table 9. AFR. Government expenditure on routine immunization per live birth, US$. 20 selected countries

54% 50% 50% 60% 56% 47%

46%50% 50%

40% 44%53%

0

1

2

3

4

5

6

7

8

9

2010 2011 2012 2013 2014 2015

6,4 5,9 5,9 6,1 6,7 8,4

AFRGovernment Expenditure on Routine Immunization

Vaccines Service Delivery

Congo (The) LMIC Phase 2 3.2 4.9 9.5 10.5 15.5 11.4 Increasing 257%

Guinea LIC Initial 0.8 4.1 3.0 3.6 6.7 2.3 Increasing 204%

Tanzania LIC Initial 4.3 5.4 3.0 2.8 7.6 11.6 Increasing 167%

Rwanda LIC Initial 5.9 6.4 6.9 7.1 6.8 14.0 Increasing 137%

Seychelles HIC 27.2 20.7 44.2 131.6 222.2 49.5 Increasing 82%

Swaziland LMIC 53.9 67.9 58.1 55.0 48.7 91.0 Increasing 69%

Mali LIC Initial 9.7 6.3 3.0 5.2 7.4 13.7 Increasing 42%

Mozambique LIC Initial 3.7 4.1 4.6 5.8 5.1 4.4 Increasing 18%

Eritrea LIC Intial 2.5 2.5 2.6 2.7 2.6 2.7 Increasing 10%

Côte d'Ivoire LMIC Phase 1 7.2 4.8 13.1 11.2 7.6 7.4 Increasing 3%

Togo LIC Initial 18.1 19.5 22.7 21.4 3.6 17.5 Decreasing -3%

Mauritania LMIC Phase 1 6.5 3.9 3.2 3.2 12.9 6.2 Decreasing -4%

Burkina Faso LIC Initial 5.8 6.0 5.3 4.6 5.0 5.4 Decreasing -7%

Benin LIC Initial 6.5 5.4 5.5 5.6 5.5 5.5 Decreasing -16%

Cameroon LMIC Phase 1 6.8 7.8 3.5 5.3 5.9 5.6 Decreasing -17%

CAR LIC Initial 0.5 1.1 0.4 0.9 1.0 0.4 Decreasing -17%

Sao Tome and P. LMIC Phase 1 74.2 66.0 102.8 122.2 93.5 58.2 Decreasing -22%

Chad LIC Initial 7.0 0.6 6.1 5.1 3.4 4.5 Decreasing -35%

Comoros LIC Initial 16.2 12.3 8.7 4.2 2.0 7.6 Decreasing -53%

Gabon UMIC 65.4 30.5 32.5 33.2 26.0 8.7 Decreasing -87%

$6.4 $5.9 $5.9 $6.1 $6.7 $8.4 Increasing 32%

2014 2015Trend between

2010 and 2015

Percentage

change

Population Weighted Average

CountryIncome

classification

Gavi

grouping 2010 2011 2012 2013

21

4.2. Region of the Americas

Thirty-five countries are in the Region of Americas (AMR). Twenty-five of them have six years

observations and fit the selection criteria. Table 10 provides information on the countries selected in this

region, their income and Gavi eligibility.

Table 10. AMR. Selected countries by income classification and Gavi eligibility



High Income 4 0



Low Income 0 0

TOTAL 25 5

Out of the 25 selected countries in the region of Americas, most of the countries have been reporting line

item in national budget for vaccine purchase over the period of 2010-2015. The number of countries reported

to have line item at the beginning of period was 24, and it stayed fairly stable until 2014. In 2015, the number

dropped substantially to 19 countries having the line item for vaccine procurement.

Grenada, Jamaica, Saint Vincent and The Grenadines and Venezuela are the member states that were

constantly reported to have a line item in period of 2010 to 2014, while in 2015 they reported to drop line item

in national budgets for vaccine purchase. This issue seems to be due to reporting errors.

22

Table 11. AMR. Indicator summary


Indicators 2010 2011 2012 2013 2014 2015


vaccines

24 23 24 23 24 19

Expenditures on Routine Immunization







% of total vaccine funded by government 99% 97% 98% 92% 96% ~100%

The number of AMR selected countries accounts for almost a third of the total number of member states

considered in the global analysis. Since the JRF financial indicators of each country have varied over 6 years,

the four indicators expressed as population weighted average per newborn have experienced some fluctuations

during the period as well. The indicators showed their minimum level in 2012 and reached the peak in 2014,

except the government expenditure on routine immunization which exhibits the bounds of the time series

delayed by one year.

At the baseline, the indicators in the Region of Americas were between 4 and 5 times higher than the global

population weighted averages and, over years, they increased at rates even higher than those observed in the

global analysis. The government expenditure on routine immunization shows high percentage increase:

starting from US$ 141.7 in 2010, it reached US$ 187.5 in 2015 (+ 32.3%).

In 2015 both routine immunization and vaccines are almost exclusively funded by domestic resources.

The significant decrease in external funding is clearly justifiable by observing the characteristics of the sample:

out of 25 countries, there are no low income countries, 16 of them are classified as “upper middle income”

and only 5 countries are GAVI eligible (mainly in Phase 2 and 3): in accordance with the dynamics of the

GAVI co-financing policy, they all increased the government expenditure over time, moving towards self-

sufficiency. Finally, it is noted that the composition of government spending has been stable, recording only

an increase in the share of service delivery at the end of the period (Figure 10).

23

Figure 8. Region of the Americas. JRF financial indicators


Figure 9. Region of the Americas. Total Expenditure on Vaccines, by source of financing


120

130

140

150

160

170

180

190

200

2010 2011 2012 2013 2014 2015

AMRTotal and Government Expenditures on Routine Immunization and Vaccines

99% 97% 98% 92%

96% ~100%

1%3%

2%8%

4%

0

20

40

60

80

100

120

140

160

180

200

2010 2011 2012 2013 2014 2015

$132,3 $142,0 $130,9 $143,0 $181,2 $168,3

AMRTotal Expenditure on Vaccines

24

Figure 10. Region of the Americas. Composition of the Government Expenditure on Routine Immunization


Table 12 shows data on the government routine immunization expenditure per live birth for 25 the countries

with full six years of observations. During this period, 23 countries have a substantial to moderate increase in

their expenditure on routine immunization. These growths vary from 1.7% to 360%.

Table 12. AMR. Government expenditure on routine immunization per live birth, US$. 25 selected countries

92% 92% 91% 94%

93% 89%

8% 8%9% 6%

7% 11%

0

20

40

60

80

100

120

140

160

180

2010 2011 2012 2013 2014 2015

$141,7 $149,0 $141,5 $140,3 $186,0 $187,5

AMRGovernment Expenditure on Routine Immunization


CountryIncome

classifificationGavi 2010 2011 2012 2013 2014 2015

Trend between

2010 and 2015

Percentage

change

Argentina HIC 74.7 254.1 209.2 155 244.2 343 Increasing 359%

Dominica UMIC 16.1 53.6 58 50.4 43.1 60.8 Increasing 278%

Saint Lucia UMIC 26.9 19.5 29.6 39.9 27 95.2 Increasing 254%

Guatemala LMIC 30.7 31.4 70.4 51.8 60.6 91.2 Increasing 197%

Dominican

RepublicUMIC 14.1 19.5 27.3 82.6 37.2 37.4 Increasing 165%

Paraguay UMIC 58.2 134 243.8 178.2 112.6 103.3 Increasing 77%

Panama UMIC 249.7 357.9 319.3 320.3 342.1 420.2 Increasing 68%

Venezuela UMIC 51.6 76.8 80 72.7 86.8 81.1 Increasing 57%

Guyana UMIC Phase 2 82.5 61.6 108.5 133.5 129.7 127.6 Increasing 55%

Honduras LMIC Phase 3 58.5 70.8 49 56 63.2 81.4 Increasing 39%

Colombia UMIC 75 129.2 120.6 149.9 132.5 99.6 Increasing 33%

Bahamas HIC 128.7 105.3 130.7 123.7 161.5 168.8 Increasing 31%

Bolivia LMIC Phase 2 48.3 49.9 45.8 40.3 59.8 63 Increasing 30%

Cuba UMIC Phase 2 181.5 174.7 154.8 129.2 224.2 227.5 Increasing 25%

Uruguay HIC 149.9 172.5 167.2 161.8 207 185.3 Increasing 24%

El Salvador LMIC 113.9 138 93.9 105.7 94.4 139.6 Increasing 23%

St.Vincent and G. UMIC 26.2 17.5 22.3 24.4 37 30.8 Increasing 18%

Peru UMIC 220 146.1 198 97 114.9 257.6 Increasing 17%

Nicaragua LMIC Phase 1 85.4 64.5 66.4 84.8 90.2 96.2 Increasing 13%

Grenada UMIC 53.2 38.2 56.6 36.7 47.4 57.5 Increasing 8%

Ecuador UMIC 153.2 161.4 146.1 96 130.7 165.3 Increasing 8%

Brazil UMIC 214.7 180.1 157.9 189.9 279.3 226.2 Increasing 5%

Belize UMIC 54.9 66.8 37.4 41 47.8 55.8 Increasing 2%

St. Kitts and Nevis HIC 28.2 22.5 24.6 30.3 26.1 7.4 Decreasing -74%

Jamaica UMIC 182.7 69.7 71.2 70.2 33.4 36.7 Decreasing -80%

$141.7 $149.0 $141.5 $140.3 $186.0 $187.5 Increasing 32%Population Weighted Average

25

4.3 Eastern Mediterranean Region

21 countries are in the Eastern Mediterranean Region (EMR). Seven of them have six years observations

and are included into the analysis. Table 13 provides information on the selected countries, their income and

Gavi eligibility.

Table 13. EMR. Selected countries by income classification and Gavi eligibility



High Income 0 0



Low Income 0 0

TOTAL 7 3

Six out of the seven selected countries in the Eastern Mediterranean region have been reporting a line item

in national budgets for vaccine purchase over the period of 2010-2015. The number of countries reported to

have a line item at the beginning of period was 6 and it stayed stable until 2012. In 2013, Djibouti which never

report a line item, reported it and the number increased to 7. However, the following year, Djibouti dropped

the line item so that in 2015, 6 countries reported to have the line item for vaccine procurement.

Table 14. EMR. Indicator summary


Indicators 2010 2011 2012 2013 2014 2015

Countries with line item for vaccines in national

budget 6 6 6 7 6 6









26

The four financing indicators- expressed as population weighted average per newborn grew at rates higher

than those noticed in the global analysis (see Chapter 3). The total and government expenditure on vaccines

has increased more than the expenditure on routine immunization, meaning that resources have been allocated

between vaccines and service delivery differently compared to 2010 (Figure 13 shows the composition of the

government expenditure on routine immunization over the period).

The total expenditure on routine immunization and the government expenditure on vaccines reached their

maximum level in 2015, peaking to US$ 39.6 and US$ 18.0 respectively.

The total expenditure on vaccines shows the biggest percentage increase among the 4 indicators (+100%),

but -as the deployment of domestic resources increased as well- in 2015 the share of externally funded

expenditure on vaccines is steady compared to baseline (Figure 12).

It is worth noting that, 4 countries out of 7 EMR selected countries, are classified as “upper-middle

income”, while the remaining countries are classified as “Phase 1” of GAVI support.

Figure 11. Eastern Mediterranean Region. JRF financial indicators


0

5

10

15

20

25

30

35

40

45

2010 2011 2012 2013 2014 2015

EMRTotal and Government Expenditures on Routine Immunization and Vaccines

27

Figure 12. Eastern Mediterranean Region. Total Expenditure on Vaccines, by source of financing


Figure 13. Eastern Mediterranean Region. Composition of the Government Expenditure on Routine Immunization


57% 41%50% 44%

55% 57%

43%

59%

50%

56% 45%43%

0

5

10

15

20

25

30

35

2010 2011 2012 2013 2014 2015

$15,9 $23,9 $26,5 $32,2 $30,8 $31,9

EMR Total Expenditure on Vaccines

78% 81%80% 82%

80% 86%22% 19%

20%18%

20% 14%

0

5

10

15

20

2010 2011 2012 2013 2014 2015

$11,7 $12,2 $16,6 $17,3 $21,1 $20,9

EMRGovernment Expenditure on Routine Immunization


28

Table 15 provides information on the government expenditure on routine immunization per live birth for

7 selected countries. During the period, Djibouti experienced the highest increase from US$ 36.4 to US$ 82.1.

The second country with the highest increase is Iran with a 108% increase. Overall, 6 countries showed upward

trends and directed more resources to immunization since 2010. These increases vary from 125% to 23%.

In contrast to the regional trend, Yemen underwent a substantial decline during this period since the

expenditure on routine immunization decreased from US$ 4.9 in 2010 to US$ 1.3 at the end of the period.

This drop is mainly due to conflict and crisis in Yemen, which has contributed to weakening the financial

situation of the country.

Table15. EMR. Government expenditure on routine immunization per live birth, US$. 7 selected countries

CountryIncome

classificationGavi 2010 2011 2012 2013 2014 2015

Trend between

2010 and 2015

Percentage

change

Djibouti LMIC Phase 1 36.4 31.4 64.6 73.7 78.4 82.1 Increasing 126%

Iran UMIC 12.5 12.3 18.1 18.1 29.2 25.9 Increasing 108%

Lebanon UMIC 44.2 37.1 45.5 55.4 61.4 86.4 Increasing 96%

Tunisia LMIC 14.4 30.8 29.1 29.0 29.2 27.4 Increasing 90%

Jordan UMIC 76.2 74.3 87.3 100.3 99.4 141.4 Increasing 86%

Sudan LMIC Phase 1 3.2 2.8 6.4 5.5 4.7 4.0 Increasing 23%

Yemen LMIC Phase 1 4.9 5.1 7.0 7.1 7.5 1.3 Decreasing -74%


29

4.4. European Region

53 countries are part of the European Region (EUR). Only 8 countries fit the selection criteria of complete

6 years observations of the four financing indicators and are included in the analysis. Four of them are eligible

for receiving Gavi fund, in different phases of Gavi co-financing arrangement. Table 16 provides summary

information on the number of selected countries, their income status and Gavi eligibility.

Table 16. EUR. Selected countries by income classification and Gavi eligibility



High Income 3 0



Low Income 0 0

TOTAL 8 4

From the 8 selected countries in the European region, 7 of them have been reporting line items in national

budgets for vaccine purchase over the period of 2010-2015. Bulgaria is the country that always reported no

line item for vaccine purchase during this period. (Table 17).

Table 17. EUR. Indicator summary


Indicators 2010 2011 2012 2013 2014 2015


budget

7 7 7 7 7 7









30

The European region shows a decrease in all four financial indicators calculated as population weighted

average per live birth. Contrary to what has been observed in the global analysis (see Chapter 3), the indicators-

after peaking in 2011- declined steadily and then reached their minimum level at the end of the period.

Even though the government expenditure on vaccines is still 3 times bigger than the global population

weighted average, it decreased from US$ 142.7 in 2010 to US$ 94.2 in 2015 (-34%), while the government

expenditure on routine immunization declined from US$ 187.2 in 2010 to US$ 155.8 in 2015 (-17%).

Since the government expenditure on vaccines decreased more than the government expenditure on routine

immunization, the latter reveals that service delivery received an ever larger share of domestic resources

during the six-year period.

As Figure 14 exhibits, the total and government expenditures evolved parallel over time, therefore the

percentage of the total routine immunization funded by government could remain constant, while the

percentage of vaccines funded by government fell slightly from 96% in 2010 to 94% in 2015 (see Figure 15).

Figure 14. European Region. JRF financial indicators


80

100

120

140

160

180

200

220

2010 2011 2012 2013 2014 2015

EURTotal and Government Expenditures on Routine Immunization and Vaccines

31

Figure 15. European Region. Total Expenditure on Vaccines, by source of financing


Figure 16. European Region. Composition of the Government Expenditure on Routine Immunization


96% 97%96% 95% 93%

94%

4% 3%

4%5%

7%

6%

0

20

40

60

80

100

120

140

160

180

2010 2011 2012 2013 2014 2015

$148,6 $153,2 $135,5 $127,5 $118,5 $100,1

EURTotal Expenditure on Vaccines

76% 73%69% 66% 63%

60%

24%27%

31%34%

37%

40%

0

20

40

60

80

100

120

140

160

180

200

2010 2011 2012 2013 2014 2015

$187,2 $202,1 $188,2 $183,4 $175,6 $155,8

EURGovernment Expenditure on Routine Immunization


32

Figure 16, shows the share of funding allocated to vaccine purchase and service delivery. In 2010, 76% of

the resources were directed to vaccine costs. This share declined throughout the period and reached to 60% in

2015. During the period, the share of service delivery varies from 24% to 40 %.

Table 18 provides data on the government routine immunization expenditure per live birth for 8 selected

countries that fit the analysis criteria. Two countries (Armenia and Georgia) have a substantial increase in

their routine immunization expenditure. Both of them are middle income countries and in phase 2 of Gavi

support. The data reveals that Gavi policies have helped them to re-direct their domestic fund to immunization.

The other 6 countries showed declining trends. This decrease ranges from -6.3 % to -53.6 %. The country with

the major decline is Azerbaijan, although it is in phase 2 Gavi and an upper-middle income country.

The 3 high income countries in our list also experienced moderate to a considerable drop. Iceland, The

Netherlands and Andorra decreased their government expenditure on routine immunization by -8.9%, -17.8%

and -31.4% respectively.

Table 18. EUR. Government expenditure on routine immunization per live birth, US$. 8 selected countries

CountryIncome


Trend between

2010 and 2015

Percentage

change

Armenia LMIC Phase 2 15.3 20.4 25.6 56.6 88.1 98.5 Increasing 544%

Georgia UMIC Phase 2 35.5 49.5 18.6 41.2 62.9 60.1 Increasing 69%

Bulgaria UMIC 254.4 435.1 347 211.1 311.5 238.3 Decreasing -6%

Tajikistan LMIC Phase 1 5.2 6.2 3.6 4 4.4 4.9 Decreasing -6%

Iceland HIC 269.8 386.5 441 383.9 325 245.7 Decreasing -9%

Netherlands HIC 649.1 647.2 642.9 665.9 600.4 533.8 Decreasing -18%

Andorra HIC 806.4 869.1 808 849.3 743.1 553.3 Decreasing -31%

Azerbaijan UMIC Phase 2 32.5 30.4 28.6 28.6 10.9 15.1 Decreasing -54%

$187.2 $202.1 $188.2 $183.4 $175.6 $155.8 Decreasing -17%Population Weighted Average

33

4.5. South East Asia Region

11 countries are in South East Asia Region (SEAR), 8 countries have full six years observations and are

included into the analysis. 6 of them are eligible for receiving Gavi support, in different phases of Gavi co-

financing arrangement. Table 19 provides information on the number of countries, their income status and

Gavi eligibility.

Table 19. SEAR. Selected countries by income classification and Gavi eligibility



High Income 0 0



Low Income 1 1

TOTAL 8 6

From the 8 selected countries in South East Asia region, all of them have been reporting line items in

national budgets for vaccine purchase over the period of 2010-2014. However, the number of countries that

reported to have a line item decreased to 6 at the end of period. Two countries, Timor-Lest and Maldives,

dropped the line item in 2015 while they had reported it in previous years.

The selected countries represent most of the region, therefore the main JRF financial indicators listed

below – computed as population weighted averages per newborn- are supposed to be representative of the

totality of SEAR values. However, it should be noted that India, accounting for 70% of the total number of

live births, greatly affects the population weighted averages.

Table 20. SEAR. Indicator summary


Indicators 2010 2011 2012 2013 2014 2015


budget

8 8 8 8 8 6





34





The government expenditure on routine immunization, after reaching US$ 8.4 per live birth in 2012,

decreased to US$ 7.1 in 2015, but still could show a percentage increase of 16% compared to baseline.

The government expenditure on vaccines started at US$3.6 in 2010, then experienced a modest increase

and grew to US$ 4.6 in 2012. It reached a peak of US$ 5.4 in 2014.

In 2015 the total expenditure on vaccines and the total expenditure on routine immunization showed a

significant increase compared to the previous year, mainly due to external sources of funding and the Gavi

co-financing arrangement.

Figure 17. South East Asia Region. JRF financial indicators


0

2

4

6

8

10

12

14

2010 2011 2012 2013 2014 2015

SEARTotal and Government Expenditures on Routine Immunization and Vaccines

35

Figure 18. South East Asia Region. Total Expenditure on Vaccines, by source of financing


Figure 19. South East Asia Region. Composition of the Government Expenditure on Routine Immunization


72% 75%85%

65%78%

47%

28% 25%15% 35%

22%

53%

0

2

4

6

8

10

12

2010 2011 2012 2013 2014 2015

$5,0 $5,2 $5,4 $5,8 $6,9 $9,9

SEARTotal Expenditure on vaccines

59% 61%55%

61%

85%66%

41% 39%

45%

39%

15% 34%

0

2

4

6

8

10

$6,1 $6,5 $8,4 $6,2 $6,3 $7,1

2010 2011 2012 2013 2014 2015

SEARGovernment Expenditure on Routine Immunization


36

Figure 19 displays the share of funding allocated to vaccine purchase and service delivery. During the first

four years of our analysis, the government resource allocation had been divided between vaccines and service

delivery cost on an approximate ratio of 60:40%. In 2014, vaccines received a substantially great share of

funds and reached to 85%. This peak in vaccine expenditure might be due to the Gavi co-financing which re-

directed most of the domestic funds to vaccines. The share was reduced to 66% in 2015.

Table 21 provides information on the government routine immunization expenditure per live birth for 8

selected countries that met our criteria. Five countries followed an upward trend in their routine immunization

expenditure. Three out of these 5 countries are Gavi countries: Nepal with 53%, Bangladesh with 26 % and

Indonesia with 3.31% increase. On the other hand, the other 3 Gavi countries (India, Timor-Leste, Sri Lanka)

showed declining trends. This decrease ranges from -1.95% to -57.72 %. The country with the major decline

is Sri Lanka, a lower middle income country in phase 3 of Gavi support.

Table 21. SEAR. Government expenditure on routine immunization per live birth, US$. 8 selected countries.

CountryIncome


Trend between

2010 and 2015

Percentage

change

Thailand UMIC 32.2 28.2 53.4 36.2 62.2 81.8 Increasing 154%

Nepal LIC Initial 8.1 4.8 33.6 7.9 3.6 12.4 Increasing 53%

Maldives UMIC 22.4 20.0 20.0 31.1 31.4 30.0 Increasing 34%

Bangladesh LMIC Phase 1 7.8 7.4 6.2 5.2 7.6 9.8 Increasing 26%

Indonesia LMIC Phase 2 10.8 13.0 12.9 12.8 9.4 11.2 Increasing 3%

India LMIC Phase 1 3.7 4.1 5.7 3.6 3.9 3.6 Decreasing -2%

Timor-Leste LMIC Phase 2 21.8 3.7 5.2 8.1 16.0 15.6 Decreasing -28%

Sri Lanka LMIC Phase 3 35.1 36.4 25.9 41.6 18.7 14.8 Decreasing -58%


37

4.6 Western Pacific Region

27 countries are in the Western Pacific Region (WPR), 9 of them have full 6 years observations and are

included into analysis. Table 22 provides information on the number of selected countries, their Gavi

eligibility and income status.

Table 22. WPR. Selected countries by income classification and Gavi eligibility



High Income 2 0



Low Income 0 0

TOTAL 9 5

In 2010, 8 countries of the Western Pacific region reported having a line item in the national budget for

vaccine procurement. The number of countries reporting the line item remained stable over the period 2011

to 2013, with 9 countries indicating to have line item. However, this number dropped to 7 in 2015, with a few

countries reporting potentially inconsistent data: Solomon Islands shows an irregular reporting pattern, it

reported no line item in 2010, then it was added to their national budget in 2011 and kept in 2012 and 2013 as

well; the line item was dropped in 2014 and 2015. Similarly, New Zealand reported to have a line item from

2010 to 2014, and dropped it in 2015.

Table 23. WPR. Indicator summary


Indicators 2010 2011 2012 2013 2014 2015


budget

8 9 9 9 8 7





38





In the Western Pacific region, the four JRF financial indicators- computed as population weighted average

per live birth- followed an upward trend during 6 years. The initial level of the government expenditure on

routine immunization was US$ 34.1 in 2010. It increased moderately and reached US$ 39.2 in 2015, showing

a variation of about +15% for the entire period. The government vaccine expenditure was US$ 30.5 at baseline,

grew to US$33.9 in 2012 before decreasing to US$ 33.0 in 2015: compared to baseline, a growth of 8.2%

occurred.

In percentage terms, the expenditure on routine immunization grew more than the expenditure on vaccines,

which means that the share of funding allocated to service delivery increased over years (Figure 22). The total

expenditure grew at rates similar to those experienced by the government expenditure, the percentage of the

total expenditure on vaccines funded by government remained stable accordingly (Figure 21). It’s worth

noting that, in West Pacific region, the selected countries differ greatly each other in terms of income level,

number of live births and level of expenditure. Therefore, the population weighted average could hide the

variability of JRF financial indicators among countries.

Figure 20. Western Pacific Region. JRF financial indicators


29

31

33

35

37

39

41

43

45

2010 2011 2012 2013 2014 2015

WPRTotal and Government Expenditures on Routine Immunization and Vaccines

39

Figure 21. Western Pacific Region. Total Expenditure on Vaccines, by source of financing


Figure 22. Western Pacific Region. Composition of the Government Expenditure on Routine Immunization


97%97% 97% 97%

97% 96%

3%

3% 3% 3%3%

4%

0

5

10

15

20

25

30

35

40

2010 2011 2012 2013 2014 2015

$31,5 $35,4 $35,0 $34,3 $31,9 $34,3

WPRTotal Expenditure on vaccines

89%91% 90% 86% 84% 84%

11%

9% 19% 14%16%

16%

0

5

10

15

20

25

30

35

40

2010 2011 2012 2013 2014 2015

$34,1 $37,8 $37,6 $38,7 $36,5 $39,2

WPRGovernment Expenditure on Routine Immunization


40

Table 24 provides details on the government routine immunization expenditure per live birth for the 9

selected countries. Lao People's Democratic Republic is the country with the highest increase. Its routine

immunization expenditure increased from US$ 1.8 in 2010 to US$ 37.7 in 2015. Vietnam and Marshall Islands

have 70% and 62% increase respectively. 3 countries are Gavi eligible: Lao People's Democratic Republic,

Vietnam and Papa New Guinea. Three countries showed declining trends. This decrease ranges from -4% to

-81%. The country with the major decline is Solomon Islands, a lower-middle income country in phase 1 of

Gavi support.

Table 24. WPR. Government expenditure on routine immunization per live birth, US$. 9 selected countries

CountryIncome


Trend between

2010 and 2015

Percentage

change

Lao PDR LMIC Phase 1 1.8 1.6 1.4 1.4 25.0 37.7 Increasing 1971%

Vietnam LMIC Phase 2 5.6 6.8 7.3 7.1 8.3 9.7 Increasing 71%

Marshall Islands UMIC 14.4 19.2 20.1 21.1 22.1 23.2 Increasing 62%

New Zealand HIC 890.5 876.7 915.8 1108.6 1296.5 1334.7 Increasing 50%

China UMIC 18.1 18.8 19.1 18.5 18.8 21.9 Increasing 21%

Papa New Guinea LMIC Phase 1 5.3 8.1 15.1 10.0 15.5 5.8 Increasing 10%

Australia HIC 948.3 1135.3 1084.3 1152.8 933.2 908.3 Decreasing -4%

Cambodia LMIC Initial 7.6 8.3 7.2 6.2 6.3 6.5 Decreasing -14%

Solomon Islands LMIC Phase 1 59.7 59.6 70.0 44.7 19.3 11.5 Decreasing -81%


41

5. Analysis for Gavi eligible countries

In January 2000, the Global Alliance for Vaccines and Immunization (Gavi) was established as a private-

public partnership of all the immunization filed actors (UN agencies, donors, vaccines manufacturers,...) with

the following four major objectives: 1) improving access to immunization services 2) expanding the use of all

existing safe and cost-effective vaccines 3) accelerating the development and introduction of new vaccines in

developing countries and 4) accelerating the research and development efforts for vaccines by developing

countries.

The immediate priority for Gavi was the provision of more recent vaccines to the low and lower-middle

income countries especially hepatitis B and Hib which had not been reached any low income country by that

time. The program initially targeted countries that meet the following criteria: gross national income (GNI)

per capita of less than US$ 1000 and a population of less than 150 million. After the program announcement,

76 countries were eligible. The eligibility threshold has been revised since the Gavi establishment according

to growth and inflation rate and currently countries are eligible to apply for Gavi support when their (GNI)

per capita is below or equal to US$ 1580. Based on this eligibility threshold, 73 countries were eligible to

receive Gavi funding in the period of 2010 to 2015. Realizing that fast increasing costs of immunization and

lack of countries’ sense of ownership would endanger the success of Gavi initiative, Gavi adopted the co-

financing strategy. Co-financing is designed to increase the predictability and sustainability of long-term

resources for national immunization programs. Table 25 provides information on different co-financing

arrangements according to income groups.

Table 25: Gavi. Co-financing arrangements

Country Group GNI per capita

threshold

Co-financing requirement

Low Income Countries

(Initial Self-financing)

GNI per capita at or below

the World Bank low-income

threshold

(currently ≤$ 1,045)

$ 0.20 per dose

(no annual increase)

Phase 1

(Preparatory Transition)

GNI per capita above the

World Bank low-income

threshold but at or below

the Gavi eligibility

threshold (currently

> $ 1,045 to ≤ $ 1,580)

Starts at $ 0.20 per dose and

increases 15% annually

Phase 2

(Accelerated Transition)

GNI per capita above the

Gavi eligibility threshold

(currently $ 1,580)

Starts at an additional 20% of

the difference between the

projected price of the vaccine in

42

the year Gavi support ends, and

increases over four years to

reach to that price

Phase 3

(Fully self-financing)

Country graduates from Gavi

support, and is fully financing

vaccine costs. Country still

have access to procure vaccines

through Gavi with lower prices.

Source: Gavi website8

Among the 73 Gavi eligible countries, 40 countries reported complete 6 years observations on four main

indicators during the period of 2010-2015 and thus are included into the analysis. Table 26 provides summary

information on the number of selected countries, their income status and Gavi co-financing phase.

Table 26. Gavi. 40 selected countries by income and Gavi phases

Income Classification Group Low

income Phase 1 Phase 2 Phase 3

High Income - - - -

Upper Middle Income - - 4 -

Lower Middle income 1 14 6 2

Low Income 13 - - -

TOTAL 14 14 10 2

40 Eligible countries

In this section the analysis according to different phases of Gavi co-financing is provided. Out of 40 Gavi

eligible countries that fit selection criteria, 14 are “low income” or “initial self-financing” phase, 14 are in

“phase 1 - preparatory transition” and 10 are in “phase - accelerated transition”. In addition, 2 countries are in

“phase 3 - fully self-financing”. Given the limited number of countries in phase 3, the analysis combines phase

2 with phase 3 countries. Table 27 provides the summary of the indicator analysis.

In the 14 selected countries in the initial self-financing phase, the average population weighted government

expenditure per live birth on routine immunization as well as the expenditure on vaccines have increased in

the last 6 years. Government expenditure on routine immunization was at US$ 5.9 in 2010, it experienced a

slight fall to US$ 5.4 in 2011, then it increased to US$ 7.1 in 2012 and declined to US$ 5.2 in 2013. At the

8 http://www.gavi.org/

43

end of the period, government expenditure on routine immunization reached US$ 8.6. The government vaccine

expenditure follows a similar pattern; it started at US$ 3.4 in 2010, experienced a downward trend to US$ 2.8

in 2011, then it grew steadily, ending at the US$ 3.5 in 2015.

The total expenditure on routine immunization (government and other sources) in countries in the low-

income phase of co-financing, follows an upwards but fluctuating trend. The population weighted average

total expenditure per live birth on routine immunization increased from US$ 20.6 in 2010 to US$ 26.9 in 2011,

then it declined to US$ 23.7 in 2012. This expenditure increased slightly in 2013 and more sharply in 2014 to

US$ 35.1. This major increase did not remain stable and the total expenditure per live birth decreased to US$

26.4 at the end of period. The total expenditure on vaccines (government and other sources) shows a constant

and steady increase in 6 years. The initial total expenditure on vaccine was US$ 13.9 per live birth in 2010.

The highest increase was in 2014, when the value reached US$ 23. Total expenditure on vaccines declined

marginally in the following year and reached to US$ 20.1 in 2015. (Table 27, Figure 23)

Table 27. Gavi countries. Indicator summary


Indicators 2010 2011 2012 2013 2014 2015

Expenditures on Routine Immunization (RI)

Government RI expenditure per live birth

Initial self-financing $5.9 $5.4 $7.1 $5.2 $5.8 $8.6

Phase 1 $4.6 $4.8 $6.3 $4.6 $5.1 $4.9

Phases 2-3 $16.5 $18.2 $16.8 $17.3 $16.5 $18.4

Gavi eligible countries

$6.7 $7.0 $8.1 $6.7 $7.1 $7.7

Total expenditure on RI per live birth


Phase 1

$8.6 $9.7 $9.9 $10.0 $10.3 $15.6

Phases 2-3 $21.0 $22.6 $23.0 $23.7 $23.5 $23.7

Gavi eligible countries $12.4 $14.4 $14.2 $14.9 $16.4 $18.7

% of total expenditure on RI funded by government

Initial self-financing 28% 20% 30% 19% 16% 32%

Phase 1 54% 49% 63% 46% 50% 31%

Phases 2-3 78% 81% 73% 73% 70% 77%

Gavi eligible countries

54% 49% 57% 45% 43% 41%


Government vaccine expenditure per live birth


Phase 1 $2.2 $2.1 $2.4 $2.4 $3.8 $3.3

Phases 2-3 $12.4 $13.9 $13.3 $11.8 $10.8 $12.7


44

Total vaccine expenditure per live birth


Phase 1 $4.7 $6.5 $5.8 $7.3 $8.1 $11.7

Phases 2-3

$15.7 $17.0 $17.2 $15.9 $14.9 $16.0


% of total vaccine expenditure funded by government

Initial self-financing 24% 19% 21% 15% 15% 18%

Phase 1 46% 32% 42% 33% 47% 28%

Phases 2-3 79% 82% 77% 74% 72% 80%

Gavi eligible countries 51% 44% 48% 38% 42% 35%

Countries with line item for

vaccines in national budget 38 39 38 40 37 35

In the 14 selected countries in phase 1 of Gavi co-financing (preparatory transition phase), the population

weighted average government expenditure per live birth on routine immunization has increased from 2010 to

2015. The government expenditure on routine immunization was at US$ 4.6 in 2010, it increased moderately

to US$ 4.8 in 2011 and more sharply to US$ 6.3 in 2012. However, this number decreased slightly to US$ 4.6

in 2013, with an increase in the following year to US$ 5.1. At the end of the period, the government

expenditure on routine immunization decreased marginally to US$ 4.9. the government vaccine expenditure

follows a similar pattern; it started at US$ 2.2 in 2010, then experienced a slight downward change to US$ 2.1

in 2011, then it grew steadily in 2013 and 2014, ending at the total of US$ 3.3 in 2015.

The total expenditure on routine immunization (government and other sources) in countries in phase 1

follows an upward trend. The population weighted average total expenditure per live birth on routine

immunization increased from US$ 8.2 in 2010 to US$ 9.7 in 2011. This number continued to rise in the

following years and peaked at US$ 15.6 in 2015. Similarly, total expenditure on vaccines (government and

other sources) shows a constant and steady increase in 6 years. The initial total expenditure on vaccine was

US$ 4.7 per live birth in 2010. The highest rise is in 2013, when the value increased from US$ 5.8 in 2012 to

US$ 7.3. The total expenditure on vaccines increased sharply in the following years and reached to US$ 11.7

in 2015. (Table 27, Figure 23)

In the 12 selected countries in phases 2-3 (10 and 2 countries, respectively), the population weighted

average government expenditure per live birth on routine immunization shows a fluctuating trend. The initial

level of routine immunization expenditure was US$ 16.5 per live birth in 2010 and increased to US$ 18.2 in

2011. Routine immunization expenditure declined moderately in 2012, and then recovered to US$ 18.4 per

live birth in 2015. The population weighted average government expenditure on vaccines per live birth follows

a similar pattern, it started at US$ 12.4 in 2010, then experienced an increase and grew to US$ 13.9 in 2011.

The government vaccine expenditure declined moderately in following years to US$ 10.8 in 2014. In 2015

the expenditure increased to US$ 12.7.

45

Figure 23. GAVI. Government Expenditure on RI and Vaccines, by Different Phases of Gavi


5,95,4

7,1

5,25,8

8,6

3,42,8 2,9

3,2 3,4 3,5

0

1

2

3

4

5

6

7

8

9

2010 2011 2012 2013 2014 2015

GAVI Low Income Countries

4,6 4,8

6,3

4,65,1 4,9

2,2 2,12,4 2,4

3,83,3

0

1

2

3

4

5

6

7

8

2010 2011 2012 2013 2014 2015

GAVI Phase 1 Countries

16,5

18,216,8 17,3

16,5

18,4

12,413,9 13,3

11,810,8

12,7

0

5

10

15

20

2010 2011 2012 2013 2014 2015

GAVI Phase 2&3 Countries

46

Figure 24. GAVI. Vaccine Expenditure by source of funding, by Different Phases of Gavi


24% 19% 21% 15% 15% 18%

76% 81% 79%

85%85%

82%

0

5

10

15

20

25

30

2010 2011 2012 2013 2014 2015

$13,9 $14,3 $13,7 $20,8 $23,0 $20,1

GAVI Low Income Countries

46% 32% 42% 33% 47% 28%54% 68% 58% 67% 53%

72%

0

5

10

15

20

25

30

2010 2011 2012 2013 2014 2015

$4,7 $6,5 $5,8 $7,3 $8,1 $11,7

GAVI Phase 1 Countries

79% 82% 77% 74% 72% 80%

21%18% 23%

26% 28%20%

0

5

10

15

20

25

30

2010 2011 2012 2013 2014 2015

$15,7 $17,0 $17,2 $15,9 $14,9 $16,0

GAVI Phase 2&3 Countries

47

The total expenditure on routine immunization follows a steady and upward trend. This number grew from

US$ 21 in 2010 to US$ 23.7 at the end of the period. The total expenditure on vaccines increased from US$

15.6 to US$ 17.2 in 2010 to 2012, then it decreased slightly to US$ 15.9 in 2013 and to US$ 14.9 in 2014. At

the end of the period, total vaccine expenditure increased to US$ 16 (Table 27, Figure 23).

As illustrated in figure 24, the share of vaccine expenditure funded by government in Gavi low income

countries has undergone some fluctuations since the beginning of the period. It declined progressively from

24% to 15% over the period 2010 to 2014, then it increased to 18% at the end of the period. The share of

vaccine expenditure funded by government in Gavi phase 1 countries registered higher fluctuations, with

peaks of 46% and 47%, in 2010 and 2014, respectively. It dropped sharply to 28% at the end of period, in

2015.

Countries in phase 2 and phase 3 mainly relied on their domestic fund to finance the vaccine costs, the

share of government for vaccine purchases has been well above 70% during these years. The government

proportion was 79% at the beginning of the period, then increased to 82% in 2011 and declined progressively

until 2014, to 72%. The government’s share increased to 80% in 2015. (Table 27, Figure 24)

Overall, government expenditure on routine immunization as well as on vaccines show a slow increasing

trend in Gavi countries. However, Gavi eligible countries vary widely according to their income status and

co-financing arrangement.

The proportion of expenditures funded by government is relatively low in the low income group of

countries. This is not surprising, whilst new vaccines are being introduced, the total expenditure on vaccines

are escalating. However, these countries are only paying the minimum co-financing requirement of $0.20 per

dose thus reducing the overall share funded by the government.

The analysis confirms the anticipated effect of the phase 1 co-financing policy, with government

expenditures increasing in absolute terms. Comparing the phase 1 and low income country groups, it is evident

that the proportion of vaccines and routine immunization funded by government is higher. This indicates a

greater level of financial ownership in phase 1 countries.

Furthermore, the share of government expenditures in phases 2 - 3 of Gavi support is substantially higher

than countries in other phases of Gavi (over 70%), reflecting a greater level of financial ownership for

countries approaching the transition out of Gavi support.

48

6. Analysis by Income Classification

The World Bank categorizes countries into four income groups according to their economies and income

status: low income, lower middle income, upper middle income and high-income countries. Countries with

higher incomes have greater ability to mobilize resources for immunization programs. To understand the

possible effect of income on expenditure on immunization, the analysis by income classification has been

conducted. Table 28 provides the information on the selected countries and their income status.

Table 28 – Income Analysis – Selected countries by income classification

Income Classification Group No. of countries

Low Income 13

Lower Middle income 27

Upper Middle Income 27

High Income 10

TOTAL 77

Out of 77 countries selected by the criteria for the analysis, 13 are low income, 27 lower middle income, 27

upper middle and 10 high income countries.

In the 13 selected low-income countries, the population weighted average of government expenditure on

routine immunization per live birth- as well as the expenditure on vaccines- have increased in the last six

years. The government expenditure on routine immunization was at US$ 5.8 in 2010, it experienced a slight

fall to US$ 5.2 in 2011, then it increased to US$ 7.1 in 2012 and back to US$ 5.2 in 2013, and finally increased

sharply to US$ 8.7 in 2015. The government vaccine expenditure follows a similar pattern; it started at US$

3.4 in 2010, then experienced a downward change to US$ 2.7 in 2011, followed by progressive increase up to

US$ 3.5 in 2015. The total expenditure on routine immunization in low income countries follows an upwards

but fluctuating trend. The population weighted average total expenditure per live birth on routine

immunization increased from US$ 20.5 in 2010 to US$ 27.2 in 2011. This number declined in the following

year to US$ 23.9 and then increased slightly in 2013 and more sharply in 2014 with a peak at US$ 35.4. In

2015, total expenditure decreased to US$ 26. The total expenditure on vaccines (government and other

sources) shows an overall increase in the 6 years. The initial total expenditure on vaccine was US$ 14.2 per

49

live birth in 2010. The highest rise was in 2014 when the value reached US$ 23.4, then it declined to US$ 20.3

in 2015. (Table 29, Figure 25)

In the 27 lower-middle income countries, the population weighted average of the government expenditure

per live birth on routine immunization has increased in years 2010 to 2015. The government expenditure on

routine immunization was at US$ 6.8 in 2010; it increased moderately in the following years and reached to

US$ 8.7 in 2012, then it fell slightly to US$ 7.3 and US$ 7.5 in 2013 and 2014, respectively.

At the end of the period, the government expenditure on routine immunization reached to US$ 8.1, in 2015.

The government vaccine expenditure follows a constant and steady increasing trend. In 2010, government

vaccine expenditure was at US$ 4. In the following years, it increased moderately to an expenditure of US$

6.1 in 2015. The total expenditure on routine immunization in lower-middle income countries follows an

upward trend. The population weighted average total expenditure on routine immunization per live birth

increased from US$ 10.9 in 2010 to US$ 12.2 in 2011. This number continued to rise in the following years

and peaked at US$ 17.8 in 2015. Similarly, the total expenditure on vaccines shows a constant and steadily

increase over the period. The initial total expenditure on vaccine was US$ 6.6 per live birth in 2010. This

value increased moderately to US$ 9.9 in 2014 and more sharply in the following year until it reached US$

13.4 in 2015. (Table 29, Figure 25)

In the 27 upper middle-income countries, the population weighted average government expenditure on

routine immunization per live birth and on vaccines have experienced some fluctuations during the period of

2010 to 2015. The initial level of government expenditure on routine immunization was US$ 54.8 per live

birth and declined marginally to US$ 51.7 in 2012. The government expenditure on routine immunization

increased in the following years to US$ 64.6 and US$ 64.1 in 2014 and 2015, respectively. The government

expenditure on vaccines follows a similar pattern. From 2010 to 2012, a decrease occurred from US$ 50.3 to

US$ 48. Then the expenditure increased to US$ 60.3 and US$ 55.8 in 2014 and 2015, respectively.

In the 10 selected high-income countries, the population weighted average government expenditure on routine

immunization and vaccines per live birth are much higher than the expenditures in the other income groups.

The overall averages ranges from US$ 387.6 in 2010 to US$ 550.8 in 2013. The government expenditure on

vaccines follows a fluctuating pattern as well. During years of 2010 to 2012, vaccine expenditure increased

substantially from US$ 336.41 to US$ 471.24 per live birth. Then it followed some fluctuations before ending

up to US$ 444.2, in 2015.

50

Table 29. Income Classification. Indicator summary


Indicators 2010 2011 2012 2013 2014 2015


Total RI expenditure per live birth

Low income $20.5 $27.2 $23.9 $27.3 $35.4 $26.0

Lower middle income $10.9 $12.2 $12.8 $12.9 $13.0 $17.8

Upper middle income $55.1 $52.5 $51.9 $52.2 $64.9 $64.4

High income $387.7 $529.6 $495.4 $550.8 $534.5 $535.0

Government RI expenditure per live birth

Low income $5.8 $5.2 $7.1 $5.2 $5.7 $8.7



High income $387.6 $529.6 $495.4 $550.8 $534.5 $535.0

% of total RI funded by government

Low income 33% 21% 29% 22% 21% 35%

Lower middle income 83% 83% 83% 67% 69% 46%

Upper middle income 99% 99% 99% 99% 99% 99%

High income 100% 100% 100% 100%

%

100% 100%


Total vaccine expenditure per live birth

Low income $14.2 $14.3 $13.7 $21.1 $23.4 $20.3



High income $336.4

$471.2 $437.6 $464.0 $435.7 $444.2

Government vaccine expenditure per live birth

Low income $3.4 $2.8 $2.9 $3.1 $3.3 $3.5



High income $336.4 $471.2 $437.6 $464.0 $435.7 $444.2

% of total vaccine expenditure funded by government

Low income 24% 19% 21% 14% 14% 17%

Lower middle income 61% 52% 58% 50% 58% 45%

Upper middle income 100% 99% 100% 100% 100% 99%

High income 100% 100% 100% 100% 100% 100%

51

Figure 25. Income Classification. Government Expenditure on Routine Immunization and on Vaccines

(population weighted average, US$ per live birth)

3,42,8 2,9 3,1 3,3 3,5

5,85,2

7,1

5,25,7

8,7

0

2

4

6

8

10

2010 2011 2012 2013 2014 2015

Low Income CountriesGovernment Ependitures on Routine Immunization and Vaccines

4,14,5 4,7 4,6

5,76,1

6,87,4

8,7

7,3 7,58,1

0

2

4

6

8

10

2010 2011 2012 2013 2014 2015

Lower Middle Income CountriesGovernment Ependitures on Routine Immunization and Vaccines

50,3

48,047,0

48,5

60,3

55,854,8

52,1 51,7 51,9

64,6 64,1

40

45

50

55

60

65

70

2010 2011 2012 2013 2014 2015

Upper Middle Income CountriesGovernment Ependitures on Routine Immunization and Vaccines

52

The share of vaccine expenditure funded by the government in low income countries has undergone some

fluctuations since the beginning of the period. It slipped from 24% to 19% over the period 2010 to 2011. In

2012, it increased to 21% but decreased again to 14% in 2013 and 2014. At the end of the period, the share of

vaccine expenditure was 17%.

The share of vaccine expenditure funded by the government in lower-middle income countries follows a

similar pattern. It dropped from 61% to 50% over the period 2010 to 2013. In 2014, it reached a share of 58%

but then declined to 45% at the end of period.

In the upper middle and high-income countries the share of government expenditure for vaccine has been

100% throughout the period. These two income categories countries are self-sufficient in their vaccine

procurement and could allocate domestic resources to their immunization needs.

336,4

471,2

437,6

464,0

435,7444,2

387,6

529,6

495,4

550,8534,5 535,0

250

300

350

400

450

500

550

600

2010 2011 2012 2013 2014 2015

High Income CountriesGovernment Ependitures on Routine Immunization and Vaccines

53

Figure 26. Income Classification. Vaccine Expenditure by Source of Financing

(population weighted average, US$ per live birth)

24% 19% 21% 14% 14% 17%

76% 81% 79%

86%86%

83%

0

5

10

15

20

25

2010 2011 2012 2013 2014 2015

$14,2 $14,3 $13,7 $21,1 $23,4 $20,3

Low Income CountriesTotal Expenditure on Vaccines

61% 52% 58% 50%58% 45%

39%

48% 42%50%

42%

55%

0

2

4

6

8

10

12

14

16

2010 2011 2012 2013 2014 2015

$6,6 $8,6 $8,2 $9,3 $9,9 $13,4

Lower Middle Income CountriesTotal Expenditure on Vaccines

54

7. Discussion and Conclusions

WHO-UNICEF joint reporting mechanism has an important role in monitoring global, regional and

countries trends on immunization financing indicators and assisting countries in policy and decision making.

In 2015, the majority of the selected member states for this analysis, 63 out of 77 (82%), reported a specific

line item in their national budgets for purchasing vaccines. This number fluctuated during the year 2010 to

2015 with higher number of countries reporting on line item in previous years. Despite the concerns for the

quality of reported data, this high number of countries with a specific vaccine line item is evidence of priority

given to immunization and is the result of advocacy initiatives carried out at global and country levels.

The global analysis reveals that government expenditure on routine immunization as well as on vaccines

have increased over the six-year period. The population weighted average of expenditure on routine

immunization per live birth increased from US$ 29.2 in 2010 to US$ 36 in 2015 (+23%). During this period,

the expenditure on vaccines also increased by +20% from US$ 25 in 2010 to US$ 30 in 2015. However,

external funds and the introduction of new vaccines increased at a faster pace leading to a relatively decrease

in the percentage of total vaccine expenditure funded by government: from 84% in 2010 to 60% in 2015.

Similar trend is visible in government expenditures on routine immunization, which declined from 84% in

2010 to 63% in 2015.

The regional analysis of countries highlighted various expenditure trends in the regions. Selected countries

in the Americas and Western Pacific regions are fairly self-sufficient, with financing over 90% of total routine

immunization expenditure by domestic resources. The African region remains the most reliant on donor

support having 35% of total routine immunization expenditure funded by government in 2015.

The government expenditure on routine immunization has upwards and steady trends in all the regions

except Europe. However, out of 53 member states in Europe, only 8 fit the criteria for the selection, therefore

caution should be taken when generalizing this trend to the whole region. The highest increase is registered in

the Eastern Mediterranean region with a population weighted average expenditure on routine immunization

per live birth from US$ 11.6 in 2010 to US$ 20.9 in 2015 (+80%).

The analysis for Gavi eligible countries indicates that domestic funding and commitments to immunization

programs are increasing in those countries. However, external funds are growing in a faster rate leading to the

relative decline in the proportion of government fund. As result of the co-financing policy, countries with a

higher income (phases 2-3) are financing a greater share of their immunization expenditure over time.

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The analysis by income indicates large disparity among low and high-income countries, with high income

countries spending on average US$ 500 per live birth on their routine immunization and low-income countries

spending on average US$ 6.3. High and upper middle-income counties are fully funding their immunization

program and low-income countries rely on external funds to finance over 70% of their immunization costs.

Furthermore, prices of new vaccines are critical for middle income countries which are not Gavi eligible.

These countries are paying higher prices for vaccines than Gavi countries.

Despite the issues of missing and inconsistent data, the JRF remains a comprehensive source of reported

immunization financing data. Although the number of countries with full years report is 77, the majority of

the 194 member states have been increasingly reporting their data in the recent years. Furthermore, quality

analysis of data shows improvement in terms of reduction of inconsistencies and missing data. The JRF

financing indicators guidance note and support to countries seem to contribute to improve the overall quality.

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