1. Advocacy for Sustainable Immunization Financing Mike McQuestion Director Sustainable Immunization Financing Sabin Vaccine Institute 10 th Annual Measles Initiative Meeting Washington, DC USA September 2011

2. S USTAINABLE I MMUNIZATION F INANCING PROGRAM Outline Current equilibrium: dependency Way forward Sabin Sustainable Immunization Financing Program Next equilibrium: country ownership

3. Cost per child fully immunized- US$30- exceeds most governments’ total per capita public health expenditure Fiscal gaps in immunization budgets are growing rapidly  Countries are underinvesting  Chronic external donor dependency  Newer vaccines are driving up costs Current equilibrium

4. External partners often provide their funds as “project support”, not on the national budget  government 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

5. 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 incentives  Spending other peoples’ money  Clientelism

7. Way forward Making 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

8. 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

9. Expanding fiscal space for immunization Uses of financing Sources 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

11. 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

12. Pilot Countries Senegal, Mali, Cameroon* Liberia, Sierra Leone*, Nigeria Madagascar, DR Congo*, Rwanda Ethiopia, Uganda*, Kenya Cambodia, Nepal*, Sri Lanka * Resident SIF Program Officer S USTAINABLE I MMUNIZATION F INANCING PROGRAM

13. 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 S USTAINABLE I MMUNIZATION F INANCING P ROGRAM

14. Program theory: Institutional innovation To reach financial sustainability, key national institutions must invest more in immunization, thereby reducing external donor dependency  MoH: 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)

15. 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, conditions  Agency: Champions within convince others

16. Program theory: Institutional innovation Every innovation needs to be legitimized  Legitimacy: Other options less appropriate How is the innovation legitimized?  Institutional entrepreneurs  Professional associations Once legitimized, the new practices diffuse across the organizational field (institutionalization) (Source: Dacsin et al 2002)

17. S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Methods Sabin catalyzes institutional innovations by engaging new stakeholders in immunization programs  Elected officials  Private firms  Community 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

18. S USTAINABLE I MMUNIZATION F INANCING P ROGRAM 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)

19. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Sources: WHO/UNICEF JRF, cMYPs, FSPs, country EPI manager reports. http://www.who.int/immunization_financing/data/en/

21. 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 costs  a weaker definition is self determination: country may not finance 100% but makes all allocative and programmatic decisions

22. 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

23. Sustainable funding sources are mobilized  Bigger national routine EPI budgets  States, regions, provinces also contribute  Debt relief funds o Earmarked for anti-poverty spending  Innovations o National insurance schemes o Special levies and taxes o Non-state actors contribute »Private sector providers, firms o National immunization trust funds

25. S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Thank You for Your Attention!