Overview of colloquium themes

1. Advocacy, sustainability and country
ownership
e McQuestion
Mike McQuestion
Director, Sustainable Immunization Financing
Third Colloquium
Kathmandu, Nepal
19-21 July 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
•Six Senior Program Officers based in Africa (3), Asia (2),
Europe (1) backed by three Washington, DC-based Sabin
staff

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

4. SIF Domains
• Financing Mechanisms
• Legislation
• Budget, Resource Tracking, Advocacy

5. Decade of Vaccines
• In 2011-12 the global immunization
community came together to chart the
Decade of Vaccines (2011-2020)
• In May 2012 the 65th
World Health Assembly
approved a Global Vaccine Action Plan to
implement the DoV vision
• Country ownership and sustainability are
two GVAP guiding principles

6. Global Vaccine
Action Plan
• “Country ownership: countries have
primary ownership and responsibility for
establishing good governance and for
providing effective and quality immunization
services for all” (Page 5)

7. • “Sustainability: informed decisions and
implementation strategies, appropriate
levels of financial investment, and
improved financial management and
oversight are critical to ensuring the
sustainability of immunization
programmes” (Page 6)
Global Vaccine
Action Plan

8. Spending trends

9. Spending trends

10. Routine Immunization Expenditures per surviving infant
(US$), SIF Program countries, 2010 and 2014

11. SIF countries catching up
1015202530
US$/infant
10 11 12 13 14
year
SIF Other Gavi
JRF Indicator 6730, SVI extract
Fig. 1. Govt routine immunization spending (lowess regression)

12. Problems and
opportunities
• Immunization costs rising faster than
government spending -> growing
dependency on external financing
• Self-financing uncharted territory for most
lower income countries

13. Problems and
opportunities
• Country ownership potential increasing
– Growing income, revenues
– Rising educational levels
– Improving technology, connectivity
– Increasing political expectations
• Timing: Immunization awareness, inputs,
demand increasing in recent years

14. 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

15. DoV Vision
By the end of the Decade:
 Managers will use financial data, just as they
now use coverage, surveillance data, to prepare,
follow, advocate for their budgets (“third leg on
the EPI stool”)
 Decisions will be based on national technical
expertise (NITAGs)
 Immunization will be part of social contracts
 Governments will allocate sufficient funds for
routine immunization, by law

16. 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

17. 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

18. 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)

19. • We are a community of practice

20. SIF Domains
• Financing Mechanisms
• Legislation
• Budget, Resource Tracking, Advocacy

22. SIF Domains
• Financing Mechanisms
• Legislation
• Budget, Resource Tracking, Advocacy

23. Estimated costs vs. expenditures
- Problem: cMYP costing tool, current budget documents do not
systematically capture actual expenditures
Accuracy

24. Budgetary Phase Description of Phase Amount in US$
Amount in local
currency
Percent of Budget within
each Phase (%)
Expanded Program on Immunization
sends proposal to Ministry of Health
38,681,307 35,586,802,440 100%
Ministry of Health adjusts the
proposed budget based on their
aggregated budget
5,820,519 5,354,877,480 15%
Parliament approves EPI budget
after review
3,288,837 3,025,730,040 9%
Amount made available to EPI by
Ministry of Finance after readjustment
by the Parliament
1,204,339 1,107,991,880 3%
Phase-III:
Disbursement
Amount disbursed by the MoH to EPI 388,364 357,294,880 1%
Phase-IV:
Expenditure
Amount spent by EPI
(calculated from receipts)
388,364 357,294,880 1%
Phase-I:
Proposed Budget
Phase-II:
Approved Budget
Routine Immunization Budget Flow, Country "X" - 2015

25. I. Empirical Budgeting

26. Empirical
Budgeting:
Vietnam &
Senegal
Health Minister
restores EPI budget
from $4.40/Surviving
Infant to $8.71/S.I.
Vietnam, FY2014
In late 2014, the Vietnamese
National Assembly & Health
Minister cut all MOH program
budgets by >40%
Senegal, FY2016
Gears
of
Collect
ive
Action
Sabin
M
onitoring
&
Feedback
SabinMonitoring&Feedback

27. Impact of Empirical Budgeting

28. SIF Domains
•Financing Mechanisms
•Legislation
•Budget, Resource Tracking, Advocacy

29. II. Advocacy
Coalitions

30. Advocacy Coalition: Democratic Republic of the Congo
Name: Parliamentary Support Network for Immunization.
Date Established: May 2012.
Leader: Hon. Gregoire Lusenge. President of the Subcommittee on Gender,
Women, Families, and Children.
Membership: 50 MPs + numerous EPI staff, private health professionals, MOF &
MOB officials, development partners, and CSO representatives.
Legislative Status: Formalized by National Assembly President.
Constitutive Text: Charter
Funding: Publicly financed, September 2014
Impacts to-date:
1. Immunization credit line in national budget act
2. 8 provinces committed to insert immunization credit line in provincial budget
act & to increase operational cost budget
3. 66% EPI budget increase in Maniema province, 2014.
4. Prime Minister disbursed remaining amount to EPI, 2015.
Short-Term Goals:
• Organize evaluation workshop among Coalition’s satellites to assess execution
of commitments

31. Advocacy Coalition: Mali
 Name: Parliamentary Immunization Network
 Date Established: August 2015
 Leader: Hon. Abdoulaye Dembele, Member of the National Assembly Health Committee
 Membership: 60 MPs
 Legislative Status: Formalized by National Assembly President.
 Constitutive Text: None as of yet
 Funding: Unknown
 Impacts to-date:
• Compelled EPI team to allow Coalition MPs to participate in the FY2016 EPI budget
preparations, October 2015.
Short-Term Goals:
• Insert separate credit lines for vaccine purchase & vaccine administration into the national
budget act
• Organize briefing with fellow MPs to persuade them to support the allocation of an adequate
immunization budget for FY2016, November 2015.

32. • Legislation

33. Legislative Process of SIF Pilot Countries
SIF Countries
Phase I Phase II Phase III Phase IV Phase V Phase VI
Background
Legislative
Research
Legislative
Strategy
Selected
Drafting of Bill/
Amendments
Stakeholder
Consultation
Bill Submitted
to Parliament
Passage of Bill
Cambodia Phase III
Cameroon Phase IV
Congo (Brazzaville) Phase III
DR Congo Phase IV
Indonesia *
Kenya Phase II
Liberia Phase IV
Madagascar Phase IV
Mali Phase III
Mongolia *
Nepal Phase V**
Nigeria Phase I
Senegal Phase III
Sierra Leone Phase I
Sri Lanka Phase II
Uganda Phase V
Vietnam *
* Laws passed prior to joining the Sabin-SIF Program.
**Nepal is located between Phases IV and V. The bill was approved by the Council of Ministers and will shortly be submitted to parliament.

34. Country ownership
indicators
• Full domestic financing for routine
immunization program
• Legislation assures public financing
• Program technically sound
• Transparent, accountable financial
management
• Parliamentary engagement
• Public aware, educated

35. 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

36. 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

37. 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

38. 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

39. • 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

40. 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

41. 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

42. • 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

44. Thank you!