institutional perspectives on country ownership of immunization programs

1. Advocacy and political will for
sustainability
e McQuestion
Sabin Vaccine Institute
Mike McQuestion
Meeting of the Regional Working Group on
Immunization for Gavi-supported countries in the
Western Pacific
WHO/WPRO Manila, Philippines
19 January 2016

2. 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
•Seven Senior Program Officers based in Africa (4), Asia
(2), Europe (1) backed by three Washington, DC-based
Sabin staff

3. The Sustainable Immunization
Financing Program
The SIF Program facilitates and catalyzes efforts to
secure sustainable funding for immunization
programs in twenty-two lower and middle income
countries
SIF Senior Program Officers coordinate directly with
counterparts in government ministries and
parliaments, subnational decision makers and the
private sector to develop innovative financing
solutions

4. Outline
• Advocacy and institutional change
• Case studies

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. Case studies
• The art of advocacy is knowing how to
formulate messages that fit into each
particular institution’s logic and how to
deliver them effectively
• Some examples:
– EPI manager makes investment case to MPs
– Finance officer convinces health director to
cross analyze data, report expenditure per
fully immunized child

16. Case studies
• Advocacy examples, continued
– Rotary and Lions clubs convince Government
of Nepal to create an immunization trust fund
– MPs from National Assembly convince
provincial MPs to join national MP
immunization network
– EPI team analyzes provincial immunization
expenditures, demonstrates program
efficiency, avoids mandated budget cut

17. 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).

18. Thank you!

19. SIF Domains
• Legislation
• Advocacy Coalitions
• Financing Mechanisms
• Budget, resource Tracking

20. SIF Graduation Criteria
Financing 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

21. SIF Graduation Criteria
Budget 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

22. SIF Graduation Criteria
Policy 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

23. 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

24. • Necessary conditions for collective action
Monitoring and feedback on the contributions
each actor makes toward the public good
Monitoring and feedback on progress being
made toward the goal (efficacy)
Strategies change as needed
Actors learn from one another
Individual actors are publicly recognized for
their contributions
Collective action

25. 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

26. 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

27. • 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

28. Thank you!