SPECIAL FEATURE - July 2002
Sustainable financing: the pioneers tales
By late November this year, the first 13 countries to receive support from GAVI and the Vaccine Fund must have initiated their plans for sustained financing beyond the initial five-year support period. Cambodia and Ghana have made an early start. Phyllida Brown talks to the teams involved
HOW big will your countrys immunization financing gap be in 2007 or 2008? This is a question that many might prefer to ignore, but Dr Mercy Essel Ahun, manager of Ghanas Expanded Programme on Immunization, is not one of them. Together with her colleagues, the health and finance ministries and Ghanas partners, she has looked her programmes future funding gap squarely in the eye and has begun to work out how to deal with it.
No one pretends its an easy task. But the truth is, health ministries have never really been challenged to think in this way before. Data from countries indicate that from one year to the next, funding for direct immunization costs has varied considerably, suggesting that the development of long-term financing strategies has not been given high priority. "For us, as doctors, it was an eye-opener," says Ahun. "Until now we have just delivered the service. But now we have to get firm commitments from government and partners for a fairly long-term period." Particularly because, as the service expands to protect children against a wider range of diseases and to serve those who are hardest to reach, its costs are rising. When Ghanas routine immunization programme offered just the traditional vaccines such as diphtheria, tetanus and pertussis (DTP), polio and measles direct spending was about US$3.7 million a year (see Figure). With the introduction of new antigens against hepatitis B and Haemophilus influenzae type b (Hib) in a new combination vaccine (DTP+HepB+Hib), the cost of the new vaccine alone will be more than $7 million a year (1,1a) .
|Mercy Essel Ahun: "Ghanas partners must keep the immunization flag flying"
Support from GAVI and the Fund, which has paid for the new vaccines, is initially intended to last for five years and to act as a catalyst for other sources of finance. What will those sources be? "We have come up with a plan where increasingly, we are going to bear more and more of the costs," says Ahun. The government intends to take increasing responsibility for personnel and other recurrent costs and, depending on the amount of debt relief it secures, will pay an increasing share of the costs of the new vaccines. Several new ways to mobilize resources within the country have been suggested, including money from the decentralized health districts. But, as Ghana and its partners in the Alliance are agreed, external support will still be needed to help buy the vaccines themselves. That means donors, or international partners, must continue to play a key role.
Financial sustainability plans are required from all countries receiving support from the Alliance and the Vaccine Fund in the second year of their funding. The plan is intended to show how the country proposes to support its immunization programme after the end of the initial five-year award (see Box 1). But its much more than a document, says Ahun. Its creation requires a process that brings people together, sometimes for the first time, to agree on common objectives. By setting out clearly the immunization programmes current costs and its expected future costs, it forces all stakeholders to think about the options and choose how to move ahead.
1: Whats the financial sustainability plan for and when should it be ready?
All countries receiving support from GAVI and the Vaccine Fund have been asked to prepare a financial sustainability plan (FSP) in their second year of funding to indicate how they propose to support their immunization programme after the initial support ends. For the first 13 countries to receive awards, plans should be initiated by November 2002. The next round of countries will prepare plans in 2003. The first 13 countries will pilot the process; it may evolve as lessons are learnt.
To achieve financial sustainability, a country is not expected to become self-sufficient at least, not in the near- to medium term. While self-sufficiency is the ultimate goal, it is wholly unrealistic for most eligible countries for the foreseeable future. Instead, achieving sustainability is seen by GAVI as a responsibility that must be shared between countries and their development partners. Last year, the Alliance agreed a definition of financial sustainability as "the ability of a country to mobilize and efficiently use domestic and supplementary external resources on a reliable basis to achieve current and future target levels of immunization performance in terms of access, utilization, quality, safety and equity".
The GAVI Financing Task Force (FTF) has produced guidelines (2) for how to draw up the plans. These were developed in close consultation with stakeholders and revised multiple times, including a revision after Ghana and Cambodia had tested them. The FTF is helping to arrange technical support to individual countries in producing the plans, and is also holding two intensive training workshops in July, one in English, one in French, in Kenya and Senegal respectively, to help managers prepare.
More information, including reports from Cambodia and Ghana on the pre-tests of the guidelines, details of the July workshops, and other explanatory documents, are at www.vaccinealliance.org
Using the plan as a tool to advocate for immunization
Equally important, the plan provides vital ammunition for the immunization programme to argue its case both with its own government and with international partners, such as governments in industrialized countries.
"It is good to put something down on paper," says Ahun. "Its about getting a consensus and saying, this is what the programme has come up with." At the national level, the plan must be signed by the health and finance ministries, so that it commits both to a shared agreement and raises the profile of immunization across the government. "We have had these discussions with people right from the top, and everybody now knows about the financial sustainability plan," she says.
For Ghana, the timing of the plan has been perfect, as it has coincided with the formulation of the wider health systems current 5-year plan. So its goals and targets are being integrated into the wider plan. Indeed, says Ahun, the idea of financial sustainability plans could catch on in other areas of the health system: two other programmes have expressed interest in doing their own.
Abroad, meanwhile, the plan provides the country with a stronger basis for attracting new funds from partners. Local staff of the major partners will have a case to put to their headquarters, Ahun hopes, while at international level, the Alliance can keep up the political pressure.
"Beyond what we can do in our country, the partners need to keep flying the immunization flag very high," says Ahun.
2: Putting the plan together
Each countrys plan must include:
- Information about the current immunization programme, its costs and the sources of its funds.
- A statement about the programmes key objectives for expanding and improving its services.
- Figures and a graph (see Figure) showing the increase in estimated projected costs from the first year of funding for eight years, expected income, and the gap between what is expected and what is needed. As all players recognise that it will be difficult to get long-term commitments from either a national government or its partners, the Alliance has agreed that the plan should show what proportion of the expected funds is secure, what proportion is probable, and what proportion is possible. Tables allow for itemising of all components of the programme such as vaccines, personnel, supplies, transport, training, vehicles and cold chain equipment.
- An outline of the strategic priorities for financial sustainability: for example, an indication of the main constraints and the approaches being taken to close the financing gap.
- A description of actions that can be taken to address the problems, who will take these actions and when.
- A set of indicators to monitor progress: for example, whether a plan of action is in place to generate demand among families for childrens immunization, or whether there is a budget line item for immunization.
- The signature of the Minister of Health.
- The signature of the Minister of Finance.
- The signatures of key members of the immunization coordinating committee, including leading financing partners, indicating that they have reviewed the document; and
- Comments on the plan by leading financing partners.
Political support and public demand
She recognises the scale of the challenge, but is optimistic that resources for Ghanas immunization programme will continue to flow. Her reasoning is twofold: first, because the government is committed to immunization. The evidence in its favour is direct and strong. Ahun points to the success of the measles immunization campaign organized in the Central region of Ghana last year. The peak month for transmission of the measles virus in Ghana has just passed and cases in the Central region are down by 90%. "So the programme has visible effects," she says.
Second, and just as important, people in Ghana want and demand immunization for their children. "the way the mothers descended on the stadium at the launch of the new vaccine showed the faith that people have in immunization."
Lessons for the Alliance
Ghanas test of the process also gave GAVI some important information. First, that the guidelines needed to be simplified (4) . Second, significant time and resources are needed for preparing the plans, and these may have to be boosted with outside help for specific technical tasks. Ghana had support from external consultants who helped to cost the existing services, for example. Despite having an exceptionally high level of training and specialist knowledge, and an efficient and strong immunization service, Ahun believes that her country would have "struggled" to produce the plan if it had not had help with the cost assessments.
Does she have any worries? Ahun is aware that in some countries, health ministries could see the demand for a financial sustainability plan for the immunization service alone as a threat to the health sector as a whole. However, if the plan is integrated into the overall health plan, as in Ghana, this need not be a problem, she believes. Ahun and her colleague Dr George Amofah have also warned of the challenges for their government in addressing competing health priorities and new single-issue initiatives, as well as the need to beat down the cost of new vaccines.
Tough questions for donors
The planning process raises a challenge for development partners. This goes beyond Ghana, and affects all countries. In essence, countries are being asked to change their behaviour and make long-term commitments to immunization, but development partners are not yet ready to do the same. Despite proposals last year that the financial sustainability plans should include firm commitments of 5 or 7 years money from partners (3) , in reality those partners have been unwilling or unable in law to commit themselves more than a year or two ahead.
It can also be difficult for local staff of a development partner, far from their HQ, to take such responsibility, and awkward for countries to have to ask them in the first place. The current guidelines do require signed comments from partners, but this stops short of a hard financial commitment. Can partners really expect countries to make long-term plans and commitments if they themselves are unwilling to do so? "The new definition of financial sustainability (see Box 1 ) puts the onus on the international partners as well as the countries," says Vio Mitchell, the coordinator of the GAVI Financing Task Force. In that case, doesnt the development partners unwillingness to commit themselves so far amount to a cop-out? Like Ahun and her colleagues in Ghana, Mitchell believes that the only way to resolve this issue will be through high-level advocacy, with Alliance partners continuing to argue the case for stable financing for immunization with ministers of health and international development.
"The commitment of the GAVI partners to improve immunization has always been a long-range proposal," says Dr Tore Godal, GAVIs executive Secretary. "We know that all issues will not be solved overnight, in five years, or even ten. But we are an initiative that is learning and evolving as we go. We must use the lessons we learn through experience today before we consider what we do in year six and beyond." Godal explains that the Fund may be directed in future to different purposes, such as health system infrastructure, other under-used vaccines, or new approaches to reaching children with essential health care.
Cambodia: different needs
Ghana may be exceptional in that it has relatively strong expertise in planning its health service finances. Cambodia, which has also tested the FSP process, may be more typical of low-income countries; it has severely limited resources and few people with the relevant technical skills on whom to draw. Its immunization programme staff have not been specifically trained in financial management.
When a cost assessment was done in 2000, Cambodias projected health budget for 2001 was 1.1% of the countrys gross national product, although it is expected to double over the next 4 years. The immunization programme costs were about $2 million in 2001, with much of the funding coming from outside partners. Costs are expected to more than double by 2005 if all recommended programme improvements, including new vaccines are adopted (see Figure).
Cambodia is now putting together a plan to finance its immunization service into the medium term future. To start the process off, external helpers worked with the government to evaluate the guidelines in the test process, and to develop a timeline for completing the plan on target. Dr Sann Chan Soeung, the director of the national immunization programme, and his colleagues worked with Bryn Sakagawa, a health financing specialist with the consultancy firm Abt Associates in Bethesda, Maryland, and Mike Curtis of the Institute for Health Sector Development in London. A technical consultant, Susan Shin, from WHOs Western Pacific regional office, is now working with the immunization team to provide training in financial management skills.
In Cambodia, the test of the guidelines was the first opportunity that the hard-pressed health staff had had to discuss the broad concept of financial sustainability, says Sakagawa. Staff have many other preoccupations delivering the service, such as the replacement of the cold chain to combat vaccine wastage. With these problems, it is not surprising that financial management skills have been on the back burner till now.
Soeung reports that the initial support has been helpful. However, his team have encountered some of the most basic difficulties in developing financial sustainability plans. First, it has proved very difficult to schedule time to meet with staff from the ministry of finance. Second, much of the immunization teams time has been preoccupied with other meetings with donors on other topics. International partners, as well as national governments, need to set specific time aside for this process. The types of support that will be offered to Cambodia in the production of the plan range from clearing up confusion about the way the health system is financed currently, to training in accounting skills. The support team will also offer practical help, for example in the use of spreadsheet software. "We plan to work on the key analytical skills, too," says Sakagawa, "such as assessing how much the programme is going to cost, and identifying how big the gap will be between what the national programme and the donors are providing and what is needed."
As in Ghana, a key purpose of measuring the size of the gap is to enable the immunization programme to advocate for more support at home and with its development partners, and the team agreed that more training in advocacy would help the immunization staff to do this effectively.
What did Cambodia teach GAVI about the process? Importantly, it reinforced many of the findings from Ghana. It also highlighted that plenty of targeted technical support will be needed, especially where interpreters are required to translate complex sustainability ideas (5) . "All of these concepts are so new that if you work in another language, it will take a lot longer to develop the plan," says Sakagawa.
Power shift to countries
But often, people with the right skills will be at hand within the national government, says Ruth Levine, a health economist at the World Bank whose analysis led first to GAVIs new definition of sustainability and more recently to the development of the guidelines. "The guidelines are not complex for people who have any facility in dealing with financial concepts, and those people do exist in governments in every country in the world, although they are rarely in immunization teams," she says. A challenge for the team responsible for the plan is to find, wherever possible, those people within the country who can offer those skills.
Ultimately, both countries, Ghana and Cambodia, have gained from the testing of the planning guidelines and GAVI has also learnt lessons to help the remaining countries. Above all, the Financing Task Force hopes, key players have understood the need for mobilizing resources and forging new relationships between finance ministers, health ministers and international partners."At first," says Ruth Levine, "there was a perception that these plans would just be documents to feed some imagined bureaucratic beast in the GAVI secretariat." Now, she hopes, everyone understands that their real purpose is to make sure that the decision-makers are informed with the facts decision-makers who decide how the programme operates, those who hold the national purse strings, and, importantly, the development partners and that they are talking to each other about the major financial challenges and opportunities. The ultimate objective is to strengthen immunization services longterm. As Vio Mitchell puts it: "This is about a powershift to countries."
1. Country perspectives on financial sustainability: the Ghana experience. Ahun M. and Amofah G. Presentation to the Financing Task Force Forum January 2002. At www.vaccinealliance.org
1a. Case study on the costs and financing of immunization services in Ghana. Levin, A. et al. Sept. 2001. Partners for Health Reform Plus/Abt Associates. For more reports, check the Abt Associates website.
2. Guidelines for preparing a national immunization programme financial sustainability plan. GAVI Financing Task Force. April 2002. At www.vaccinealliance.org
3. Taking care of tomorrow. Immunization Focus, June 2001.
4. Ghana pre-test of the financial sustainability guidelines. GAVI FTF February 2002.
5. Pre-test of the financial sustainability guidelines in Cambodia. GAVI FTF March 2002.
Immunization Focus July 2002 - Contents