This document outlines routes to sustainable immunization financing. It discusses the current global situation of immunization financing and legislation. Countries are transitioning from private to public health financing as their economies grow. While immunization costs are rising, many developing countries still rely heavily on external funding. The document proposes that countries could fully finance vaccination programs by 2016 through capturing 20% of new revenue from economic growth. It also discusses the need for stronger immunization legislation. The Sabin Vaccine Institute's Sustainable Immunization Financing Program works in 15 countries to promote institutional innovations like increased budget scrutiny and vaccine laws to gradually increase domestic ownership of immunization.

1. Routes to sustainable immunization
financing
Sabin Vaccine Institute
Sustainable Immunization Financing Program
9 May 2013

2. Outline
• Current global immunization situation
Financing
Legislation
• Institutional innovations
• Sabin SIF Program

3. Macroeconomics of health
• As their economies grow, countries spend
more on health
• The trend is to move from private (out-of-
pocket) to an increasing share of public
financing
• Developing countries are in transition,
increasing their public health investments

4. Source: WHO 2011
http://apps.who.int/nha/database/ScatterPlotPage.aspx

5. Vaccination financing
• Immunization costs are increasing
• The world’s 71 poorest countries depend
highly on external partners to finance their
national immunization (EPI) programs
• External funding has increased in recent
years but have governments kept pace?
• As of 2011, the pattern shows increasing
government investments but lingering
dependency

6. Vaccination financing

7. Vaccination financing

8. Vaccination financing
• A recent Sabin study found that, 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 20%
of new revenues coming from continued
economic growth over the 2013-16 period

9. Countries could increase funding for immunization
In the medium term

10. 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

11. Vaccination legislation

12. Change scenario
• How can we move from the current
dependent situation to sustainable country
ownership?
• Focus on the key public institutions: MoH,
MoF, parliament, subnational
governments
• Induce institutional changes through two
intertwined pathways
collective action
social learning

13. Change scenario
• Institutional change (innovation) means
developing new ways of working, ie new
best practices
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
Parliament scrutinizes the annual health and
EPI budgets, follows program execution
(technical and budgetary), helps mobilize
constituents, approves vaccine legislation

14. 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).

15. 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)

16. Sabin SIF Program
• First six-year grant (2008-2013), funded
by Bill & Melinda Gates Foundation
• Fifteen pilot countries chosen in
consultation with GAVI and partners
(WHO, UNICEF, World Bank), three more
added in 2012 with 2nd
grant (GAVI)
• Six Senior Program Officers based in
Africa (4), Asia (2) backed by three
Washington, DC-based Sabin staff

17. Sabin SIF Program
Strategies
• Change organizational environments by engaging new
stakeholders in immunization programs
 Elected officials
 Private firms
 Community service organizations
• Periodic parliamentary briefings, peer exchanges and
presentations at national and international meetings
• Support collective action through inter-country
meetings, a quarterly newsletter, an SIF Program blog

18. SIF Program inputs
Senior Program
Officer
Country
SIF Visits to
Target Countries
National
Briefing
Sub-national
Briefing
International
Partner Meeting
Peer exchangers
w/ SIF countries
2008 2009 2010 2011 2012
Total per
Country:
Sierra Leone 0 8 0 12 14 2 15 6 7 4 34
Liberia 11 1 0 0 5 1 2 5 4 5 17
Nigeria 1 0 0 0 1 0 1 0 0 1 2
Nepal 0 7 0 9 2 0 0 8 4 6 18
Cambodia 16 4 2 0 2 0 2 6 5 11 24
Sri Lanka 10 2 1 0 0 0 1 4 5 3 13
Uganda 1 5 1 13 4 1 5 6 5 7 24
Kenya 8 2 0 0 1 0 3 3 3 2 11
Ethiopia 3 1 0 0 0 0 3 0 1 0 4
DRCongo 0 5 0 18 6 0 6 8 9 6 29
RCongo (Brazza) 9 1 0 0 1 0 0 0 3 8 11
Madagascar 7 3 0 0 0 0 1 1 4 4 10
Cameroon 9 3 0 27 4 0 4 16 10 13 43
Mali 14 4 0 0 6 0 3 4 6 11 24
Senegal 10 1 1 0 3 0 4 1 1 9 15
99 47 5 79 49 4 50 68 67 90 279
Summary of Milestone Activities - From Reporting Period 2008-12
Total per Activity:
Cliffod Kamara
Devendra Gnawali
Diana Kizza
Helene Mambu
Jonas Mbwangue

19. SIF Program Results
• Government routine EPI expenditure
increases
5/10 reporting countries, 2009-10
7/9 reporting countries, 2010-11
• Government routine EPI budget increases
4/8 reporting countries, 2010-11
4/5 reporting countries, 2011-12
• Immunization legislation drafting underway
in 12 countries

20. Thank you for
your attention!