Routes to sustainable immunization financing

Sabin Vaccine InstituteSustainable Immunization Financing Program

9 May 2013

Outline

• Current global immunization situationFinancingLegislation

• Institutional innovations

• Sabin SIF Program

Macroeconomics of health

• As their economies grow, countries spend more on health

• The trend is to move from private (out-of-pocket) to an increasing share of public financing

• Developing countries are in transition, increasing their public health investments

Source: WHO 2011http://apps.who.int/nha/database/ScatterPlotPage.aspx

Vaccination financing• Immunization costs are increasing• The world’s 71 poorest countries depend

highly on external partners to finance their national immunization (EPI) programs

• External funding has increased in recent years but have governments kept pace?

• As of 2011, the pattern shows increasing government investments but lingering dependency

Vaccination financing

Vaccination financing

Vaccination financing

• A recent Sabin study found that, given the political will, countries could fully finance their EPI programs by 2016 without taking funds away from other programs

• They would need to capture around 20% of new revenues coming from continued economic growth over the 2013-16 period

Countries could increase funding for immunization In the medium term

Vaccination legislation

• Even if political will exists, legislative guarantees of publicly provided vaccination are lacking or insufficient

• Few countries have up-to-date legislation

• Ideally, a vaccination law should contain a range of provisions, including means of EPI financing, vaccine procurement mechanisms, vaccination regulations

Vaccination legislation

Change scenario

• How can we move from the current dependent situation to sustainable country ownership?

• Focus on the key public institutions: MoH, MoF, parliament, subnational governments

• Induce institutional changes through two intertwined pathwayscollective action social learning

Change scenario• Institutional change (innovation) means

developing new ways of working, ie new best practicesMinistry of health begins to monitor and report

program efficiency (ie, expenditures per fully immunized child), allowing a stronger immunization investment case to be made

Parliament scrutinizes the annual health and EPI budgets, follows program execution (technical and budgetary), helps mobilize constituents, approves vaccine legislation

Institutional innovation

• “…organizational change is unplanned and goes on largely behind the backs of groups that wish to influence it” (DiMaggio and Powell 1983:157).

Institutional innovation

• Expected results of these innovations• Larger, more efficient immunization budgets• Up-to-date legislation guaranteeing those

budgets (earmarking) and providing for other aspects of vaccination

• More domestic stakeholders actively supporting immunization

• Public comes to expect a high-performing national immunization program provided by their government (public good)

Sabin SIF Program

• First six-year grant (2008-2013), funded by Bill & Melinda Gates Foundation

• Fifteen pilot countries chosen in consultation with GAVI and partners (WHO, UNICEF, World Bank), three more added in 2012 with 2nd grant (GAVI)

• Six Senior Program Officers based in Africa (4), Asia (2) backed by three Washington, DC-based Sabin staff

Sabin SIF ProgramStrategies

• Change organizational environments by engaging new stakeholders in immunization programs Elected officials Private firms Community service organizations

• Periodic parliamentary briefings, peer exchanges and presentations at national and international meetings

• Support collective action through inter-country meetings, a quarterly newsletter, an SIF Program blog

SIF Program inputs

Senior Program Officer

Country SIF Visits to Target Countries

National Briefing

Sub-national Briefing

International Partner Meeting

Peer exchangers w/ SIF countries 2008 2009 2010 2011 2012

Total per Country:

Sierra Leone 0 8 0 12 14 2 15 6 7 4 34

Liberia 11 1 0 0 5 1 2 5 4 5 17

Nigeria 1 0 0 0 1 0 1 0 0 1 2

Nepal 0 7 0 9 2 0 0 8 4 6 18

Cambodia 16 4 2 0 2 0 2 6 5 11 24

Sri Lanka 10 2 1 0 0 0 1 4 5 3 13

Uganda 1 5 1 13 4 1 5 6 5 7 24

Kenya 8 2 0 0 1 0 3 3 3 2 11

Ethiopia 3 1 0 0 0 0 3 0 1 0 4

DR Congo 0 5 0 18 6 0 6 8 9 6 29

R Congo (Brazza) 9 1 0 0 1 0 0 0 3 8 11

Madagascar 7 3 0 0 0 0 1 1 4 4 10

Cameroon 9 3 0 27 4 0 4 16 10 13 43

Mali 14 4 0 0 6 0 3 4 6 11 24

Senegal 10 1 1 0 3 0 4 1 1 9 15

99 47 5 79 49 4 50 68 67 90 279

Summary of Milestone Activities - From Reporting Period 2008-12

Total per Activity:

Cliffod Kamara

Devendra Gnawali

Diana Kizza

Helene Mambu

Jonas Mbwangue

SIF Program Results

• Government routine EPI expenditure increases

5/10 reporting countries, 2009-107/9 reporting countries, 2010-11

• Government routine EPI budget increases4/8 reporting countries, 2010-114/5 reporting countries, 2011-12

• Immunization legislation drafting underway in 12 countries

Thank you for your attention!