Advocacy for Sustainable Immunization Financing

Mike McQuestionDirector Sustainable Immunization Financing

Sabin Vaccine Institute10th Annual Measles Initiative Meeting

Washington, DC USASeptember 2011

SUSTAINABLE IMMUNIZATION FINANCING PROGRAM

Outline

• Current equilibrium: dependency

• Way forward

• Sabin Sustainable Immunization Financing Program

• Next equilibrium: country ownership

• Cost per child fully immunized- US$30- exceeds most governments’ total per capita public health expenditure

• Fiscal gaps in immunization budgets are growing rapidlyCountries are underinvestingChronic external donor dependencyNewer vaccines are driving up costs

Current equilibrium

• External partners often provide their funds as “project support”, not on the national budgetgovernment does not manage, parliament does not

oversee the funds Immunization managers spend too much time filling

out reports (fiscal burden)

time could be better used analyzing current data for decision-making

• Given the increased external funding governments often shift their funds elsewhere (substitution effect)

Current equilibrium

Current equilibrium• Public sector capacity is weak

Technical: budgeting, procurement, financial management, data analysis systems untested

Organizational: hierarchies, opacity, cronyism distort decision-making

Political: parliamentarians, other elected officials, the public are uninvolved

• Perverse incentivesSpending other peoples’ moneyClientelism

Way forwardMaking the domestic investment case

• Rather than framing immunization as a merit good (something all citizens are entitled to), subject the investment decision to standard public finance criteria Absorptive capacity: all currently available funds

and technologies are being used Allocative efficiency: funds are going to areas

according to need; all are being reached Value for money: maximum impacts are obtained,

linked to investments

Governments must find sustainable financing:« … the ability of a country to mobilize and

efficiently use domestic and supplementary external resources on a reliable basis to achieve current and future target levels of immunization performance in terms of access, utilization, quality, safety and equity« (GAVI)

Way forward

Expanding fiscal space for immunization

Uses of financingSources of financing

Government financing freed up from outside of health sector

Government financing freed up from other health interventions

New, fresh government financing from new revenue sources or from

increased revenues

New donor financing, from grants or loans

Program financing freed up from efficiency gains in immunization

programs

Maintaining and expanding traditional EPI immunization

efforts, including measles control activities

Paying for the incremental costs of new vaccine adoption

Reduced defense

spending

Hospital efficiency

Reduced loss, wastage

Examples

New earmarked taxes

GAVI, IFFImm,

new loans or grants

Source: Policy Forum and Workshop on Sustainable Immunization Financing: The World Bank and WHO/EURO, Istanbul, Turkey 13-17 November 2006

Sabin Sustainable Immunization Financing Program• $9.2 million USD, (2008-2013), funded by Bill & Melinda

Gates Foundation• Fifteen pilot countries chosen in consultation with GAVI

and partners (WHO, UNICEF, World Bank)• Five full-time Program Officers based in selected

countries• Innovation: rather than funding or technical assistance,

SIF Program acts as an agent to the principals, facilitating and connecting agendas

Pilot Countries

• Senegal, Mali, Cameroon*

• Liberia, Sierra Leone*, Nigeria

• Madagascar, DR Congo*, Rwanda

• Ethiopia, Uganda*, Kenya

• Cambodia, Nepal*, Sri Lanka

* Resident SIF Program Officer

SUSTAINABLE IMMUNIZATION FINANCING PROGRAM

Measurable Objectives

• Increase the proportion and amount of government financing for immunization

• Assure that countries find new, diversified, long-term financing for immunization

• Document innovative and effective financing strategies and mechanisms

SUSTAINABLE IMMUNIZATION FINANCING PROGRAM

SUSTAINABLE IMMUNIZATION FINANCING PROGRAM

Program theory: Institutional innovation• To reach financial sustainability, key national

institutions must invest more in immunization, thereby reducing external donor dependencyMoH: systematic advocacy (government budget cycle,

inter-agency coordinating committees, parliamentary committees, media, private sector)

MoF: link EPI disbursements to outputs (output-based budgeting)

Parliament: defend, follow EPI budget disbursement and EPI program performance (oversight)

Program theory: Institutional innovation• This appropriation process requires institutional

and organizational innovation- new collaborations, new rules, new business practices, shifts in decision-making powers- by both national and external partners

• Organizations innovate through:Structural change: New actors, conditionsAgency: Champions within convince others

Program theory: Institutional innovation• Every innovation needs to be legitimized

Legitimacy: Other options less appropriate

• How is the innovation legitimized?Institutional entrepreneursProfessional associations

• Once legitimized, the new practices diffuse across the organizational field (institutionalization) (Source: Dacsin et al 2002)

SUSTAINABLE IMMUNIZATION FINANCING PROGRAM

Methods• Sabin catalyzes institutional innovations by engaging

new stakeholders in immunization programsElected officialsPrivate firmsCommunity service organizations

• Engagement is through periodic parliamentary briefings, peer exchanges and presentations at national and international meetings

• Collaboration is supported through inter-country meetings, a quarterly newsletter, an SIF Program blog

SUSTAINABLE IMMUNIZATION FINANCING PROGRAM

Results to date• Collective action in 10/15 countries• Seven countries increased their routine

government 2010 EPI budgets (Cambodia, Cameroon, DR Congo, Mali, Nepal, Senegal, Sierra Leone)

• Six countries are drafting immunization financing legislation (Cameroon, DR Congo, Kenya, Liberia, Mali, Nepal)

CVEP Symposium: Global Vaccines 202X: Access, Equity,

Ethics2-4 May 2011

The Franklin Institute Science Museum. Philadelphia, USA

SUSTAINABLE IMMUNIZATION FINANCING PROGRAM

Sources:

WHO/UNICEF JRF, cMYPs, FSPs, country EPI manager reports.http://www.who.int/immunization_financing/data/en/

Next equilibrium

• External partners shift their investments “upstream”- more capacity building

• Countries own their immunization programs a strong definition is self reliance: country

finances 100% of the costsa weaker definition is self determination:

country may not finance 100% but makes all allocative and programmatic decisions

• Advocacy for key programs becomes a routine MoH function

• MoH, MoF and parliamentary counterparts provide regular briefings for non-state actors and the press

• Utilization, trust increase as the public credits the government for delivering high-quality immunization, other health programs

Next equilibrium

Next equilibrium

• Sustainable funding sources are mobilized Bigger national routine EPI budgets States, regions, provinces also contribute Debt relief funds

o Earmarked for anti-poverty spending

Innovationso National insurance schemeso Special levies and taxes o Non-state actors contribute

» Private sector providers, firmso National immunization trust funds

SUSTAINABLE IMMUNIZATION FINANCING PROGRAM

Thank You for Your Attention!