Advocacy, sustainability and country ownership

e McQuestionMike McQuestion

Director, Sustainable Immunization FinancingThird Colloquium Kathmandu, Nepal

19-21 July 2016

Introduction

Sabin SIF Program:

•Funded by Bill & Melinda Gates Foundation (2008-present) and GAVI Alliance (2012-present)•Fifteen pilot countries chosen in 2008 in consultation with GAVI partners, seven more (GAVI-graduating) countries in 2012 •Six Senior Program Officers based in Africa (3), Asia (2), Europe (1) backed by three Washington, DC-based Sabin staff

The Sustainable Immunization Financing Program

The SIF Program works with twenty-one lower and lower middle income countries to secure sustainable funding for their immunization programsSIF Senior Program Officers work directly with counterparts in government ministries and parliaments, subnational decision makers and the private sector to develop innovative financing solutions

SIF Domains

• Financing Mechanisms• Legislation• Budget, Resource Tracking, Advocacy

Decade of Vaccines

• In 2011-12 the global immunization community came together to chart the Decade of Vaccines (2011-2020)

• In May 2012 the 65th World Health Assembly approved a Global Vaccine Action Plan to implement the DoV vision

• Country ownership and sustainability are two GVAP guiding principles

Global Vaccine Action Plan

• “Country ownership: countries have primary ownership and responsibility for establishing good governance and for providing effective and quality immunization services for all” (Page 5)

• “Sustainability: informed decisions and implementation strategies, appropriate levels of financial investment, and improved financial management and oversight are critical to ensuring the sustainability of immunization programmes” (Page 6)

Global Vaccine Action Plan

Spending trends

Spending trends

Routine Immunization Expenditures per surviving infant (US$), SIF Program countries, 2010 and 2014

SIF countries catching up

1015

2025

30U

S$/

infa

nt

10 11 12 13 14year

SIF Other Gavi

JRF Indicator 6730, SVI extract

Fig. 1. Govt routine immunization spending (lowess regression)

Problems and opportunities

• Immunization costs rising faster than government spending -> growing dependency on external financing

• Self-financing uncharted territory for most lower income countries

Problems and opportunities

• Country ownership potential increasing– Growing income, revenues– Rising educational levels– Improving technology, connectivity– Increasing political expectations

• Timing: Immunization awareness, inputs, demand increasing in recent years

Change scenario• How can we move from the current

dependent situation, where countries rely on outside funding for immunization, to the goal of sustainable country ownership?

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

• Induce institutional changes through targeted advocacy efforts

DoV VisionBy the end of the Decade:

Managers will use financial data, just as they now use coverage, surveillance data, to prepare, follow, advocate for their budgets (“third leg on the EPI stool”)

Decisions will be based on national technical expertise (NITAGs)

Immunization will be part of social contracts

Governments will allocate sufficient funds for routine immunization, by law

Change scenario• Institutional change (innovation) means

developing new ways of working, ie new best practices

• Each institution must innovateMinistry of health begins to monitor and report

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

Change scenarioMinistry of finance considers these efficiency

estimates when it recommends and follows the execution of the immunization budget

Subnational governments, elected bodies form realistic immunization budgets, actively follow EPI performance

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

Government, parliament write or update laws

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)

• We are a community of practice

SIF Domains

• Financing Mechanisms• Legislation• Budget, Resource Tracking, Advocacy

SIF Domains

• Financing Mechanisms• Legislation• Budget, Resource Tracking, Advocacy

Estimated costs vs. expenditures- Problem: cMYP costing tool, current budget documents do not systematically capture actual expenditures

Accuracy

Budgetary Phase Description of Phase Amount in US$ Amount in local currency

Percent of Budget within each Phase (%)

Expanded Program on Immunization sends proposal to Ministry of Health

38,681,307 35,586,802,440 100%

Ministry of Health adjusts the proposed budget based on their

aggregated budget 5,820,519 5,354,877,480 15%

Parliament approves EPI budget after review

3,288,837 3,025,730,040 9%

Amount made available to EPI by Ministry of Finance after readjustment

by the Parliament 1,204,339 1,107,991,880 3%

Phase-III:Disbursement

Amount disbursed by the MoH to EPI 388,364 357,294,880 1%

Phase-IV:Expenditure

Amount spent by EPI(calculated from receipts)

388,364 357,294,880 1%

Phase-I:Proposed Budget

Phase-II:Approved Budget

Routine Immunization Budget Flow, Country "X" - 2015

I. Empirical Budgeting

Empirical Budgeting: Vietnam & Senegal

Health Minister restores EPI budget

from $4.40/Surviving Infant to $8.71/S.I.

Vietnam, FY2014

In late 2014, the Vietnamese National Assembly & Health

Minister cut all MOH program budgets by >40%

Senegal, FY2016Gears

of Collective

Action

Sabin Monitoring

& Feedback

Sabin Monitoring &

Feedback

Impact of Empirical Budgeting

SIF Domains

•Financing Mechanisms•Legislation•Budget, Resource Tracking, Advocacy

II. Advocacy Coalitions

Advocacy Coalition: Democratic Republic of the CongoName: Parliamentary Support Network for Immunization.Date Established: May 2012. Leader: Hon. Gregoire Lusenge. President of the Subcommittee on Gender,

Women, Families, and Children.Membership: 50 MPs + numerous EPI staff, private health professionals, MOF &

MOB officials, development partners, and CSO representatives. Legislative Status: Formalized by National Assembly President.Constitutive Text: Charter Funding: Publicly financed, September 2014 Impacts to-date:

1. Immunization credit line in national budget act2. 8 provinces committed to insert immunization credit line in provincial budget act & to increase operational cost budget3. 66% EPI budget increase in Maniema province, 2014.4. Prime Minister disbursed remaining amount to EPI, 2015.Short-Term Goals:• Organize evaluation workshop among Coalition’s satellites to assess execution of commitments• Improve EPI budget disbursement rate

Advocacy Coalition: Mali Name: Parliamentary Immunization Network Date Established: August 2015 Leader: Hon. Abdoulaye Dembele, Member of the National Assembly Health Committee Membership: 60 MPs Legislative Status: Formalized by National Assembly President. Constitutive Text: None as of yet Funding: Unknown Impacts to-date:

• Compelled EPI team to allow Coalition MPs to participate in the FY2016 EPI budget preparations, October 2015.Short-Term Goals:• Insert separate credit lines for vaccine purchase & vaccine administration into the national budget act• Organize briefing with fellow MPs to persuade them to support the allocation of an adequate immunization budget for FY2016, November 2015.

• Legislation

Legislative Process of SIF Pilot Countries

SIF Countries

Phase I Phase II Phase III Phase IV Phase V Phase VI

Background Legislative Research

Legislative Strategy Selected

Drafting of Bill/ Amendments

Stakeholder Consultation

Bill Submitted to Parliament Passage of Bill

Cambodia Phase IIICameroon Phase IV

Congo (Brazzaville) Phase IIIDR Congo Phase IVIndonesia *

Kenya Phase IILiberia Phase IV

Madagascar Phase IVMali Phase III

Mongolia *Nepal Phase V**

Nigeria Phase ISenegal Phase III

Sierra Leone Phase ISri Lanka Phase IIUganda Phase V

Vietnam ** Laws passed prior to joining the Sabin-SIF Program.

**Nepal is located between Phases IV and V. The bill was approved by the Council of Ministers and will shortly be submitted to parliament.

Country ownership indicators

• Full domestic financing for routine immunization program

• Legislation assures public financing• Program technically sound• Transparent, accountable financial

management• Parliamentary engagement• Public aware, educated

SIF Graduation CriteriaFinancing Arrangements:•Self-sufficiency. Domestic financing covers all routine immunization functions except new vaccine introduction •Composition. Federal, provincial, and municipal governments jointly finance routine immunization•Sustainability. Financing is structured in a way that protects finance flows from economic, political, or institutional disruptions•Legislation. Public financing for immunization is guaranteed by law

SIF Graduation CriteriaBudget and oversight:•Method. Routine immunization budget is based on actual expenditures •Disbursement. Treasury disburses full approved immunization program budget to Ministry of Health•Allocation. Ministry of Health allocates full disbursed budget to immunization program•Resource tracking. In-year program expenditures are tracked at national and subnational levels•Absorptive capacity. Immunization program spends 90% or more of its allocated budget•Reporting. Allocated immunization budget and expenditures are reported to the finance office in the Ministry of Health•Oversight. Legislators oversee execution of approved immunization budget

SIF Graduation CriteriaPolicy and advocacy:•Policy. Routine immunization program explicitly supported in national health policy/plans/expenditure frameworks•Transparency. Federal and subnational officials, parliamentarians, the public are regularly informed about immunization outputs and expenditures (value for money) •Representation. Parliamentarians participate in immunization-related field activities

Public Goods• Public (collective) good: “The achievement of a common

goal, or satisfaction of a common interest” (Olson 1965)• Under certain conditions, actors in a collectivity will provide a

public good through collective action– Unattainable individually: can only be provided collectively– Jointness of supply: available to everyone if available to anyone– Non-excludability: cannot be feasibly withheld from any group member

• Examples: – A lighthouse, an army, a public education system, an immunized

society, a world without polio (Smith et al. 2007)– The SIF Program’s public good is a sustainably financed national

immunization program

• Necessary conditions for collective action Monitoring and feedback on the contributions

each actor makes toward the public goodMonitoring and feedback on progress being

made toward the goal (efficacy)Strategies change as neededActors learn from one anotherIndividual actors are publicly recognized for

their contributions

Collective action

Collective action• In practice, collective action is a process, a

series of individual decisions about whether to participate or not

• An actor decides, taking into account the decisions of nearby others (threshold effect) (Oliver et al 1985)

• If there is an organizing group, or a critical mass of committed actors, it is more probable the collective action will succeed

Examples of collective activities for sustainable immunization financing MoH, MoF and counterparts regularly analyze

expenditures and program outputs together to make the investment case for immunization

MoH, MoF and parliamentary counterparts meet regularly to discuss this updated information and follow immunization budget performance throughout the year

Parliament participates actively in formulating sector budget

Parliamentarians regularly visit, assess immunization performance in their constituent areas

SIF Program: Collective action

• Collective action ends when the country finds its particular sustainable financing solution Adequate, reliable funding External dependencies minimized or eliminated Supporting legislation enacted

SIF Program: Collective action

Thank you!