Routes to sustainable immunization financing Sabin Vaccine Institute Sustainable Immunization Financing Program 9 May 2013
Outline • Current global immunization situation Financing Legislation • 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 2011 http://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 Alternative Investment Functions Based on the Regression of 2011 Government Expenditure for Routine Immunization per Surviving Infant on Gross National Income, 37 Phase II GAVI-eligible 50 countries Government Expenditure on Routine Immunization (US$) 45 43 US$ 40 US$ 40 35 34 US$ 30 per Surviving Infant 26 US$ 25 23 US$ 20 20 US$ 18 US$ 15 10 Required Expenditure per Infant Assumes elasticity = 30% 5 Assumes elasticity = 20% 0 2011 2012 2013 2014 2015 2016 Reference Year Projected Years *Based on a 2011 elasticity of 5.9% and an annual 5% increase in Gross National Income US$ (GNI) per Capita (Atlas Method)
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 pathways collective action social learning
Change scenario • Institutional change (innovation) means developing new ways of working, ie new best practices Ministry 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 2 nd grant (GAVI) • Six Senior Program Officers based in Africa (4), Asia (2) backed by three Washington, DC-based Sabin staff
Sabin SIF Program Strategies • 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 Summary of Milestone Activities - From Reporting Period 2008-12 Senior Program Total per SIF Visits to National Sub-national International Peer exchangers Country 2008 2009 2010 2011 2012 Officer Target Countries Briefing Briefing Partner Meeting w/ SIF countries Country: 34 0 8 0 12 14 2 15 6 7 4 Sierra Leone Cliffod Kamara 11 1 0 0 5 1 2 5 4 5 17 Liberia 2 1 0 0 0 1 0 1 0 0 1 Nigeria 0 7 0 9 2 0 0 8 4 6 18 Nepal Devendra Gnawali 24 16 4 2 0 2 0 2 6 5 11 Cambodia 10 2 1 0 0 0 1 4 5 3 13 Sri Lanka 24 1 5 1 13 4 1 5 6 5 7 Uganda Diana Kizza 8 2 0 0 1 0 3 3 3 2 11 Kenya 3 1 0 0 0 0 3 0 1 0 4 Ethiopia 29 0 5 0 18 6 0 6 8 9 6 DR Congo Helene Mambu 11 9 1 0 0 1 0 0 0 3 8 R Congo (Brazza) 10 7 3 0 0 0 0 1 1 4 4 Madagascar 43 9 3 0 27 4 0 4 16 10 13 Cameroon Jonas Mbwangue 14 4 0 0 6 0 3 4 6 11 24 Mali 15 10 1 1 0 3 0 4 1 1 9 Senegal Total per Activity: 99 47 5 79 49 4 50 68 67 90 279
SIF Program Results • Government routine EPI expenditure increases 5/10 reporting countries, 2009-10 7/9 reporting countries, 2010-11 • Government routine EPI budget increases 4/8 reporting countries, 2010-11 4/5 reporting countries, 2011-12 • Immunization legislation drafting underway in 12 countries
Thank you for your attention!
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