Country ownership of African immunization programs

1. Financing ownership
An international perspective:
Immunization and broader
issues in health
Mike McQuestion PhD
Sabin Vaccine Institute
Washington, DC USA
AMASA-10
Entebbe, Uganda
10-12 November 2014

3. $8
$6
$4
$11 $12 $11
$5
$7
$16
$21
$17
$35 $34
$21
$19
678
785
646
1116
1274
764 739
805
$0
$10
$20
$30
$40
$50
$60
$70
$80
$90
$100
$0
$250
$500
$750
$1,000
$1,250
$1,500
2006
n=27
2007
n=34
2008
n=27
2009
n=29
2010
n=30
2011
n=28
2012
n=27
2013
n=33
Lesdépensesdugouvernement(US$)
Lerevenunationalbrut(RNB)parhabitantUS$
Les Dépenses du Gouvernement sur la Vaccination de Routine, sur la Santé, et le Revenu
National Brut par Habitant du Pays Africains
dépenses pour la vaccination de routine par nourrissons survivants
dépenses pour la santé par habitant
RNB (US$) par habitant
Tous les valeurs sont exprimées en dollars constants et sont pondérées selon la population. Les dépenses publiques pour la vaccination
de routine ont été extraites de la base des donnés sur le financement de la Vaccination de l'Organisation Mondiale de la Santé -
formulaire conjoint, indicateur 6500. Les dépenses ont été énoncées en dollars américains ou en monnaie locale. Celles qui étaient
énoncées en monnaie locale ont été converties en utilisant le taux établi au 30 de Juin de l'année du rapport. La population des
nourrissons survivants est prise de la base de données en ligne de la Division des Nations Unies pour la population et a été ajustée en
prenant en compte la mortalité infantile. Le revenu national brut par habitant, exprimé par la méthode Atlas en dollars américains
provient de la Banque mondiale. Les dépenses de santé des gouvernements ont été obtenues de la base de données des Comptes
nationaux de la santé de l’OMS.

4. Dependency
• In the current, dependent equilibrium
Work is done through patron-client relationships, not institutional
engagement
Technical decisions such as new vaccine introduction are based on external
expertise
External financing dominates and is generally off-budget
Governments underinvest (substitution effect)
Public does not credit government

5. 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

6. Change scenario
• Institutional change (innovation) means developing
new ways of working, ie new best practices
• Each institution must innovate
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

7. Change scenarioMinistry 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

8. 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)

9. Institutional logics
• The state institutions- government and parliament-
must work together
• But these institutional actors follow different logics
• For those who follow a welfare logic, one might argue
that immunization is a basic human right

10. Institutional logics
• According to the logic of medicine and public health,
no one should be left unvaccinated
• Economic logic holds that immunizations are a
justifiable investment provided the data show they
are cost effective or cost savings

11. Institutional logics
• According to the logic of public finance, the EPI
program deserves a bigger budget provided there is
unmet need, adequate revenues and the program
meets three criteria: absorptive capacity, allocative
efficiency and value for money

12. Institutional logics
• Political logic maintains that inmunizations are part of the social
contract, something the state should provide as a public good
• In addition, to assure a well functioning EPI program is to deserve
more votes!

13. Institutional innovation
• Innovation comes through advocates (champions)
who do the necessary institutional work
• They explain their case in rational terms
• They use different techniques
Mimicry: associate the change with other, existing practices
Theorize: elaborate causal arguments
Educate: impart the new skills needed (Lawrence and
Suddaby 2006)

14. Institutional innovation
• These are observable processes
Champions and those they engage produce texts- written,
spoken, symbolic- for or against the innovation
Connecting these texts, actors construct the innovation,
arriving at a common understanding of the meaning of the
new idea or practice (Phillips and Malhotra 2008)

15. Thank you!