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Taking care of tomorrow

Ruth Levine, Egleagh Mabuzane,  Amie Batson, Gina Tanbini, Pan American health organizatio
Working it out: Participants at the GAVI workshop discuss approaches to sustainable financing. Left to right: Ruth Levine, World Bank (foreground, top left); Egleagh Mabuzane, National Immunization Programme, Zimbabwe; Amie Batson, World Bank, and Gina Tanbini, Pan American health organization

Developing countries – and other GAVI partners – are starting to plan how immunization services should be financed beyond 2005. Along the way, they may even be triggering a rethink of the relationships between countries and donors, as Phyllida Brown reports

NOT so long ago, Zimbabwe’s immunization programme experienced some of the worst effects of an unsustainable financing scheme. Through a financial loophole in the then-closed economy, international corporations in Zimbabwe could donate money to a non-governmental organization, which increased the proportion of their profits that they could repatriate. For its part, the organization used the donations to buy hepatitis B vaccine for introduction into the national immunization programme. Vaccination began, but, soon after, the law changed and the scheme finished. Vaccine supplies stopped, babies could no longer be immunized against the virus, and many parents mistakenly assumed there was something wrong with the vaccine itself.

That was in 1994. Since 1999, Zimbabwe has successfully re-introduced hepatitis B vaccination as part of a properly planned, government-funded programme – helped by a major education campaign. But no one under-estimates the damage done seven years ago.

1: Steps to sustainability: how countries are preparing plans

Next year, the first countries will be asked to submit plans to GAVI showing how they will phase in money from other sources and how they will sustain their programmes after their five-year awards end. This month’s meeting was one of the first steps in preparing for those plans. The GAVI Financing Task Force (FTF) and others worked with teams from four countries – Bangladesh, Benin, Ukraine and Zimbabwe – to seek their views about what a sustainability plan should contain, and how sustainability should be measured. Unusually for a health meeting, officials from the finance ministries of several of the countries participated. Using the four teams’ input, the FTF will report to the GAVI Board and then develop guidelines by this winter for all countries to use in preparing their plans. Some of the countries’ suggestions for the content of a sustainability plan are shown in Box 4 .

Paulinus Sikosana, Secretary for Health and Child Welfare in Zimbabwe’s health ministry, told the GAVI partners this cautionary tale earlier this month at a meeting in Geneva (1) in which developing countries started to plan how they should pay for their immunization programmes from 2005 onwards (see Box 1 ). Although the circumstances of the incident are clearly different from the way GAVI works, the message was clear: once immunization starts, it must be sustained. Governments must take responsibility for ensuring their immunization programmes are stable, but donors and other partners must also act responsibly.

Paulinus Sikosana
Paulinus Sikosana: education and long-term planning are essential

No one should be more aware of this responsibility than GAVI and the Vaccine Fund. Their awards to countries are intended as catalysts.The awards last for five years, and the money can be spread over seven if a country chooses. But when the awards run out, countries will need different, sustainable sources of funds. If the GAVI partners – the countries themselves, plus donors, development banks and the international agencies – do not plan sustainable financing for the second half of this decade and beyond, those countries will be no better off – and possibly worse off – than before the awards were made. "If we fail, we will create a vacuum, by starting things and not following on in the longer term," says Steve Landry, from the US Agency for International Development (USAID) and co-chair of the GAVI Financing Task Force.

A widening gulf

Some developing countries are increasing their investment in health despite difficult economic conditions and severely limited resources (see Box 2 ). Immunization remains one of the most cost-effective health interventions, and accounts for no more than 5% of the health budget in those countries studied so far, and often much less. As a percentage of those countries’ gross national product, immunization accounts for no more than 0.1% (2) . But the costs – as well as the benefits – of immunization must be expected to grow as under-used vaccines and essential improvements, such as higher coverage, a better cold chain and the introduction of auto-disable syringes, are built into national programmes. The gap between what many governments pay for immunization now and what they will need to pay is large – and growing.

2: A tale of two countries

Jacques Hassan
Jacques Hassan

Benin: political commitment and practical schemes to guarantee funds

Jacques Hassan, director of research and development in Benin’s health ministry, is hopeful. Although income per head is just $325 a year, the country’s immunization budget has increased by an amount exceptional for any country – almost 30-fold – since 1996. Back in 1982, just 12% of children were routinely immunized; today, the reported figure is 85% and Benin has received an international award for its programme’s success. Immunization has high-level political support; the president immunizes children himself on polio days. Equally important, the health budget contains a line item for immunization so that the programme is always allocated a minimum sum.

But there are acute strains. Many health threats compete for resources. As in other developing countries, trained personnel are scarce and the international brain drain keeps taking them away. Staff are overstretched, and there is a risk that coverage will fall. Benin has applied to GAVI and the Vaccine Fund for awards to introduce additional vaccines and to improve its existing services.

Already, the government has taken steps to mobilize new and sustainable resources at home. It has set up an EPI Foundation, to collect private donations and use them to help purchase vaccines. It is also developing health insurance schemes that will give people incentives to prevent ill health in their families, and creating income within communities to pay for some costs of the immunization programme, such as fuel and vehicle maintenance. Nonetheless, Dr Hassan is under no illusions about the gap between what the government can raise and what it needs. "We must be realistic," he says. "With the best will in the world, the government cannot do everything alone. We need help from external contributors and from the private sector."

Siddiqur Choudhury
Siddiqur Choudhury

Bangladesh: popular demand for immunization will ensure the future of the service

For the government of Bangladesh, there’s no question that immunization must be assured for the long term, says Siddiqur Rahman Choudhury, a senior official in Bangladesh’s finance ministry who attended the Geneva meeting. A key step, he says, is to educate and inform people, and especially girls, so that demand for immunization grows and remains high. Mothers who have received education are more likely to protect their infants’ health than those who are uneducated. "Once you popularize immunization, the government cannot stop providing it," he says. "That’s the way to build financial sustainability."

Bangladesh’s overall health budget has increased from 4.7% of the total government budget in the mid-1980s to 7.5% of the total today. Within the immunization programme, a World Bank loan pays much of the cost of vaccines, and only 22% of the programme is currently funded by the government’s own direct resources. Before applying to GAVI and the Vaccine Fund for support, Bangladesh committed itself to sustaining the programme after the awards run out. "We will have to, not because GAVI has asked for it, but because there is a need for it, a demand for it," says Mr Choudhury. "A good programme is useless unless we sustain it." And, because that cannot be done by Bangladesh alone at present, it is up to the government, donors and lenders to work together, he says. "Sustainability should be a joint responsibility of national governments and donors."

In Côte d’Ivoire, for example, a recent study suggested that, by 2003, improvements to the existing national programme and the addition of hepatitis B vaccine would more than double the annual cost of the programme, from under US $4 million to about $9 million (2) (see Figure 1).

Given the many competing demands on the health purse, the idea that cash-strapped governments in the poorest countries will be able to finance such services entirely by themselves in the foreseeable future looks increasingly unrealistic. Indeed, the experience of the 1990s had already shown, says Tore Godal, executive secretary of GAVI, that some programmes from which donor support was withdrawn were not sustained. Despite this, some donors and analysts have continued to argue the philosophy that developing countries should move swiftly to achieve self-sufficiency because dependency on donors is undesirable.

Practical ways to move toward sustainable financing

For governments:

Use existing resources more efficiently

  • Identify main inefficiencies, including wastage, and correct
  • Reduce barriers to children’s access to immunization through new approaches to service delivery
  • Educate people to increase demand for immunization, and keep demand high
  • Buy vaccines efficiently (through international or national mechanisms)

Mobilize resources

  • Get a mandate for base line funding such as
    • a budget line item (this already in place in many countries)
    • a law to protect a minimum budget for immunization (Ukraine, for example, has this)
    • A memorandum of understanding between the government and the Interagency Coordinating Committee (Bolivia, for example, has this)
  • Push for the allocation of resources to immunization on the grounds that it is cost-effective and benefits society at large, not just individuals
  • Commission and disseminate cost-effectiveness studies
  • Earmark funds and establish performance targets for regions
  • Engage development partner in an informed discussion of resource needs, and seek structured commitment to fill key funding gaps

For donors/development partners:

  • Engage in collaborative way, as true partners in a shared challenge
  • Within the health sector, promote the use of resources for cost-effective intervention such as immunization
  • Move towards multi-year commitments
  • Structure grants and loans to promote sustainability (for example, using performance-based criteria)
  • Consider developing new funding instrument that are buffered from the impact of the donor countries’ domestic political changes.

Source: adapted from Levin et al (3)

In the near term, sustainability need not mean self-sufficiency

Now, however, fresh thinking has produced proposals for a more realistic way forward. In an analysis (3) commissioned by the GAVI Financing Task Force, Ruth Levine, a health economist at the World Bank, and others, call for a new definition of financial sustainability for developing countries’ immunization programmes. No longer, they argue, need sustainability be considered to be synonymous with self-sufficiency. In current conditions, after all, progress towards self-sufficiency would mean, in effect, a growing “health gap” between rich and poor nations. At this month’s GAVI meeting in Geneva, the participants discussed and endorsed the ideas put forward by Dr Levine and her colleagues. The participants proposed that: “Although self-sufficiency is the ultimate goal, in the nearer term sustainable financing is the ability of a country to mobilize and effective use domestic and supplementary external resources on a reliable basis to achieve target levels of immunization performance*.”

This definition emphasizes a government’s skills in planning and securing stable funding for immunization , and making good use of its resources, rather than its ability to pay for everything itself. Under this definition, the spectre of “donor dependency” becomes less threatening, because the national government is taking responsibility, and negotiating with its partners on what it need to achieve its goals.

The definition also means that a government is responsible for using its resources as efficiently as possible, while at the same time meeting standards for quality and safety, and reaching increasing number of hard-to-reach children. Programme costs can be kept in check, for example, by using the best value vaccines and the most cost-effective means to immunize children. For the new approach to sustainability to work, it’s essential that the government should have a strong commitment to immunization, and evidence at its fingertips - such as estimate of the cost-effectiveness of vaccines - to argue its case with external and private domestic investors. “The challenge is fundamentally a political one,” says Dr Levine. For, despite the growing costs of wider immunization, the absolute amounts of money involved are small relative to other health interventions. “The resources are there,” says Dr Levine, “both in countries and in the international community. Compared with many other health interventions, arguing the case for immunization is really easy- - even when you add the new vaccines such as hepatitis B and Hib, this is not actually a lot of money.” Dr Levine points to countries such as Honduras, and Bolivia (Box 3), whose political commitment to immunization can only be envied by most industrialized countries.

3: Sweet victory: how Bolivia put performance into its programme

In 1999, faced with falling vaccination coverage, Bolivia set about revamping its immunization programme, with the World Bank and the Pan American Health Organization as partners and co-financers of the initiative. As well as improving the service by adding new antigens, implementing safe injection practices, and improving surveillance, the initiative strengthened the political and financial stability of the programme. Among other actions, the government:

  • More than doubled its own spending between 1999 and 2001, from US $1.15 M to an estimated US $3.5 M;
  • Committed itself to increasing its support to the programme by $500,000 a year progressively as external agencies reduce theirs;
  • Introduced a line item for immunization into the budget;
  • Imposed a tax on the national Social Security Agency with the proceeds earmarked for vaccine purchase;
  • Introduced performance-based contracts with local governments to encourage competition between areas for the highest coverage rates;
  • Signed a memorandum of understanding with the Interagency Coordinating Committee for the next phase of the initiative, up to 2005.

By 2000, coverage for three doses of diphtheria, tetanus and pertussis (DTP) was up from 75% in 1997 to 89%. Combination vaccine including DTP, Hep B and Hib now reaches 75% of the population. And the number of municipalities with low coverage has dropped by two-thirds.

New thinking for donors, too

The new definition also challenges donors to update their roles. In a global economy, the benefits of immunization cross borders. So, out of self-interest as well as a concern for people’s welfare, it makes sense for richer countries to in vest in the health of poorer ones. Evidence is mounting that better health is a key step to reducing poverty in the poorest economies. To ensure sustainable support, donors could be asked to commit themselves in writing to a certain number of years. If there is to be genuine collaboration, donors who are used to setting targets for the countries they support could even agree to meet certain targets themselves so that responsibility is evenly shared.

But definitions are just definitions. What difference will a new definition make? Potentially, a lot. After delegates at the Geneva meeting support the broader definition of sustainability, it is now being put to the GAVI Board. If GAVI policy is built round the new definition, it could give governments in developing countries more flexibility about how to approach their plans for sustainable financing - and it could also mean that donors become more engaged in those plans. If all parties use the planning process as a real opportunity, rather than a bureaucratic exercise, says Dr Levine, real progress can be made.

4: What should be in a sustainability plan?

Suggestions from Bangladesh, Benin, Ukraine and Zimbabwe for the content of governments’ plans include:

  • An assessment of current conditions affecting the service
  • Projected resource needs for first 1-2 years after the Fund awards end
  • A plan for implementing the service in those first years
  • Statements of 5- to 7- year commitments from (a) government and (b) partners
  • An identification of potential problems ahead (such as devaluation)
  • Plans for different scenarios, based on different financial commitments by government and partners
  • Strategies for mobilizing fund from (a) external (b) domestic and (c) private sources
  • Measures for cost savings
  • Plans for staff training and capacity building at national and district levels
  • Endorsement by 8or memorandum of Understanding with) the Interagency Coordinating Committee

So what do the donors themselves think about the new thinking on sustainability? Immunization Focus approached officials in several donor agencies. Those who responded were generally positive. Norway, which last year committed $125 million to GAVI, has long believed in long-term investment in countries. Its programmes with countries typically last at least 10-15 years, says Rune Lea, health adviser in the Norwegian Agency for Development Cooperation. The aim is to invest in human capital, through health and education, as a way to build each country’s capacity towards eventual self-sufficiency. Dr Lea warns that a truly sustainable immunization programme will need to be planned within the overall health system’s framework, but is broadly supportive of the arguments put forward by Dr Levine and her colleagues.

For the US, too, there is increasing recognition that the long-haul approach makes sense, although no one imagines it will be easy to achieve. “We acknowledge that this is the way it is going to have to be, because there are no reasonable alternatives in the short term,” say Steve Landry at USAID. It will mean that donor agencies’ staff at country level, who serve on Interagency Coordination Committees, will engage more actively than before as real partners with the government. “The whole concept of the ICC is that now all the partners are sharing some responsibility for the function of the programme, in explicit terms, and they have to engage on a routine basis in working with the government to take this on.” In other words, the future of immunization is everyone’s responsibility.


(1) Immunization Finance Sustainability Plans. Workshop 4-6 June 2001, Geneva, hosted by WHO, cosponsored by USAISD and the Bill and Melinda Gates Children’s Vaccine Program at PATH.
(2) Kaddar, Miloud, Ann Levin, Leanne Dougherty and Daniel Maceira. May 2000. Costs and Financing of Immunization Programs: Finding of Four Case Studies. Special Initiatives Report 26. Bethesda, MD: Partnerships for Health Reforms Project, Abt Associates.
(3) Levine, Ruth, Magdalene Rosenmöller, and Peyvand Khaleghian. April 2001. Financial Sustainability of Childhood Immunization. Issues and Options. Commissioned by the GAVI Financing Task Force.
(4) Tambini, G. presentation at (1) and Annex, Project Appraisal Department, Phase II - Bolivia Health Sector Reform Project, World Bank; can be viewed on PAHO site.

Immunization Focus June 2001 - Contents

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