1. Innovations for sustainable
immunization financing
Mike McQuestion, MPH, PhD
Sabin Vaccine Institute
Subnational SIF briefing
Sri Lanka

2. Outline
• SIF views of the current global
immunization situation
– Financing
– Legislation
• Institutional innovations
• Sri Lankan scenarios

3. Vaccination financing
• The world’s 71 poorest countries highly
dependent on external partners to finance
their national immunization (EPI) programs
• As external funding increased in recent
years, governments cut back their own
funding (substitution effect)
• This pattern shows increasing dependency
and reduced country ownership

8. Rank 2006 US$ 2007 US$ 2008 US$ 2009 US$ 2010 US$
1 Sri Lanka 24 Sri Lanka 26 Cameroon 21 Senegal 56 Ethiopia 17
2 Nigeria 17 Cameroon 18 Cambodia 7 Sri Lanka 10 Sri Lanka 12
3 Nepal 12 Senegal 13 Nepal 6 Ethiopia 6 Mali 9
4 Cameroon 6 Kenya 8 Kenya 5 Madagascar 4 Cameroon 7
5 Cambodia 5 Republic of Congo 5 Sierra Leone 5 Cameroon 4 Kenya 4
6 Kenya 4 Cambodia 5 Republic of Congo 4 Cambodia 4 Nigeria 4
7 Senegal 4 Mali 3 Senegal 4 Republic of Congo 4 Senegal 4
8 Republic of Congo 4 Nepal 3 Madagascar 2 Nepal 3 Nepal 1
9 Uganda 3 Uganda 2 Mali 2 Uganda 3 Republic of Congo 1
10 DR Congo 1 Madagascar 2 Liberia 2 DR Congo 1 Cambodia 1
11 Madagascar 1 Liberia 1 Uganda 1 Mali <1 Madagascar 1
12 Liberia 1 Sierra Leone 0 DR of Congo 0 Liberia - DR Congo 0
13 Mali <1 Ethiopia - Nigeria - Kenya - Liberia -
14 Sierra Leone - Nigeria - Ethiopia - Sierra Leone - Uganda -
15 Ethiopia - DR of Congo - Sri Lanka - Nigeria - Sierra Leone -
SIF Pilot Countries Ranked on the Amount of Government Funds Spent on Routine Immunization
1
per Surviving Infant2
1
WHO/UNICEF JRF Indicator 6730 (http://www.who.int/immunization_financing/data/en/)
2
UN Population Division Online Database (http://esa.un.org/unpd/wpp/unpp/panel_indicators.htm)

9. Vaccination financing
• 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 40%
of new revenues coming from continued
economic growth over the 2013-16 period

11. 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

12. Model vaccine law
(Source: Trumbo et al (forthcoming))
Declarative Criteria
Free Vaccination Free and universal provision of vaccines by the government for all citizens; vaccination as a free
public good, guaranteed by the state.
Compulsory Vaccination Mandatory vaccination of all citizens
Financial Criteria
Budget Line Required line item in national budget for vaccine purchase and immunization program
Tax Exemptions Guaranteed tax exemptions for the importation of vaccines, vaccine-related supplies, and cold
chain materials
Supply Mechanism Identification of specific procurements mechanism (e.g. Revolving Fund) to guarantee a safe,
efficient and reliable supply of vaccines and vaccine-related supplies
Operational Criteria
Regulatory Oversight Established regulations on vaccination program to ensure safe, efficacious vaccines are
administered
Immunization Schedule Required definition of a national immunization schedule
Enforceability Established sanctions for failing to comply with provisions of law (fines, restrictions on school
entry, etc.)
Existence of NITAG Legally chartered National Immunization Technical Advisory Group

13. Institutional innovation
• Through Sabin’s SIF Program, we are
observing countries innovating to solve
these problems, thereby increasing
ownership
• Key public institutions (ministry of health,
ministry of finance, parliament, provincial
councils) are developing new collaborative
ties, as we see here today

14. Institutional innovation
How do innovations happen? Four distinct
mechanisms have been identified
• Mechanism 1: Top -> down
• Champions at national level conceive and
initiate the changes
Example: Sri Lanka, where the MoH organized
one symposium on SIF for subnational
stakeholders in August 2011 and now a second
Example: Nepal, where parliament has requested
government to draft a new vaccination law

15. Institutional innovation
• Mechanism 2: Collaboration among
institutions
• Institutions innovate together
 Intergovernmental: national + subnational
Example: Cameroon, where federal government and
eleven provinces are defining how provinces can co-
finance routine immunization (part of a decentralization
program)
Intersectoral: government + private sector
Example: Rotary PolioPlus Program, which has led to
lasting collaboration of Rotary clubs with ministries of
health to eradicate polio

16. Institutional innovation
• Mechanism 3: Bottom -> up
• Champions at subnational or organizational
levels conceive, disseminate the changes
Example: Uganda, where 112 districts, through
their organization (Uganda Local Government
Association), are learning how to properly structure
their routine immunization budgets and write their
own vaccination by-laws
Example: DR Congo, where four of eleven
provinces have begun financing their routine
immunization services with local revenues

17. Institutional innovation
• Mechanism 4: Third parties
• Champions in the institutions or organizations
bring in help from the outside
 Example: In Kenya, where government is divided
and political tensions are high, the Kenyan
Pediatric Association brings together
parliamentarians with key government officials to
discuss immunization financing and legislation
Example: Nepal, where Rotary and Lions clubs
have teamed up to form a private sector fund to
co-finance routine immunization

18. Institutional innovation
• In each case, individuals in these
institutions have acted to produce the
change
• Others are trying but have yet to succeed
• Let us find these champions and help
them succeed
• But let us also remember that institutional
innovations are unpredictable

19. 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).

20. 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)

21. Thank you for
your attention!