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"ECONOMICS OF IMMUNIZATION"
Oslo Workshop
22-23 August 2002
Final Summary of Main Outcomes
Background
That vaccines are a good 'buy' is not in question. But would
immunization still be a good buy if vaccines cost dollars instead of
pennies, if reaching the most inaccessible communities would cost the
system $50 per immunized child, instead of $20? How much are governments
and donors willing to commit to long-term investments in vaccines and
immunization? What about other preventive health services?
The GAVI Financing Task Force (FTF) has been exploring these questions,
with two major efforts scheduled to elicit results in the next few
months. An immunization financing database is being developed to
document funding flows from both internal and external sources to
low-income countries' immunization programs, and the health systems in
which they operate. Financial Sustainability Plans, a requirement for
countries to continue receiving Vaccine Fund resources, will be prepared
by November 2002 in the first 13 countries that received GAVI awards.
These efforts will bring valuable information. But with the environment
for aid funding growing increasingly outcome-oriented, and the aid
funding picture more complex, more information is clearly needed. And at
its June meeting in Paris, the GAVI Board emphasized the need for more
solid data demonstrating the link between immunization and better health
and economic outcomes in developing countries.
The Workshop
To complement the efforts of the FTF, the GAVI Secretariat organized
Economics and Immunization, a small workshop held in Oslo on 22 and
23 August, with developing country health and finance officials, health
economists, public health experts, and bilateral donors and foundations
(see Participants' List attached). The meeting was organized by ECON
1 .
The group was asked to consider and provide input to help shape a
research agenda to:
a. quantify the link between investing in immunization and prospects
for economic development;
b. clarify the information that decision makers need to justify
increased investments in immunization, and to identify the sources
from which such investments must be met; and
c. explore different mechanisms to increase equitable access to
immunization.
The Discussion
The group agreed on the following main points:
Improving immunization programs is doable – Improving
immunization programs to increase access in most developing countries
today is doable and affordable. According to preliminary estimates,
significantly more children could be reached in the next five years with
incremental increases in spending of less than $100 million per year.
Ghana has shown that increases in immunization coverage can be achieved,
in a health system basket funding approach, through deliberate policy
decisions. Further analysis is needed to determine the
cost-effectiveness of different strategies for reaching remote
populations.
Vaccines contribute to the MDGs – Immunization against childhood
killers is an example of an essential health service that will
contribute to reducing child mortality, one of the Millennium
Development Goals (MDGs) - the guiding targets for the development
community.
The two-way health/poverty link: the case still needs to be made
– The causal relationship between improved health outcomes and economic
growth has been widely accepted within the health policy community.
Outside this community, however, the causal link has not been as
universally accepted, including among some of those with fiscal
responsibility in developing and donor countries, and in multilateral
agencies and development banks. It will be important to determine
whether this is due to a lack of awareness of the data that exist or a
rejection of these data. Depending on the outcome of this analysis, the
most appropriate response may be better communication, more data, or a
combination thereof.
Macroeconomic conditions-- It is clear that the economic benefits
of improved health can only be attained in countries that also have
sound economic policies that provide for economic stability. However, in
some countries, the economic indicators may not tell the whole story.
There are reports that the IMF has constrained donor spending on health
in certain countries for fear of destabilizing longer term capacity for
government spending. Immunization may be a good case study to examine
this dilemma and determine the limitations of such defined constraints
and whether they harm a countries' ability to improve the health of its
population.
Diversity of countries-- Even a cursory review of data reveals
wide disparity in country situations. A 'one size fits all' approach to
improving access to immunization or securing long-term financial
sustainability for immunization programs will not work.
Long-term, predictable donor commitments – In order to succeed at
long-term financial planning, developing countries will need longer-term
and more reliable commitments of support from donors. This is especially
true for the poorest countries, and for those whose health budgets rely
upon significant external support. Donor commitments to these countries
should be untied to provide the country with decision-making power, and
include an exit strategy if a country rises above a certain income.
Performance targets could be agreed upon and monitored.
Internal vs. external funding – While increasing self-sufficiency
will always be the ultimate goal, a new definition of financial
sustainability has been adopted by the GAVI Board, as a country's
ability to mobilize and efficiently use domestic and supplementary
external resources on a reliable basis. Countries' internal allocation
of commitments to immunization need to be based on country situations;
initial analysis of commitments within countries shows wide variance. In
many countries, increased financial commitments from the national
budgets could in fact be made a condition for further donor funding, but
where external support is pooled (e.g. sector support and general budget
support) increased fungibility makes the distinction between internal
and external support for immunization less meaningful.
The importance of health system, development and poverty reduction
strategies – At the country level, decisions on financing for
immunization are not made in isolation but within the wider context of
funding for the health system and public spending in general.
Immunization coverage is included in many PRSPs as an indicator of
health system performance. The challenge for GAVI is to help secure
increased flows of resources for health by demonstrating results, rather
than to focus too narrowly on immunization in isolation.
Next Steps
As a result of the discussions, the GAVI Secretariat will ask partners
to consider funding for three research projects. Considering the need to
have rapid results and minimize burdens on under-staffed and
over-burdened developing country health ministries, the researchers will
probe existing data sources instead of launching new investigations.
1. Immunization and Development
Researchers Bloom and Canning2 will be
commissioned to analyze the economic benefits of increasing investment
to expand immunization coverage, especially as compared to investing in
other interventions – including new vaccines and other poverty
alleviation efforts such as education, malaria control and family
planning programs. The analysis should include:
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a distinction between the cost/benefits of increasing coverage of:
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the basic 6 vaccines,
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the above plus the additional antigens against hepB and Hib,
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the above plus future new vaccines (against pneumo and rota, for
example)
2. Immunization and Donor Behavior
ECON will be commissioned to undertake a project to identify appropriate
donor and developing country commitments to immunization programs in
health systems. The project will aim to produce an information-based
advocacy strategy to secure high-level political commitment. Components
will include:
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A grouping of countries based on their current macroeconomic, health
and budgetary situations.
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In collaboration with the FTF, an in-depth analysis of data from one
representative country from each of the above groups. Analysis will
include:
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donor contribution to health system,
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government spending on health as a proportion of GDP and budget, and
the nature of spending
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overall MTEF and PRSP priorities and commitments
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predicted costs of expanding coverage with basic vaccines; with hep
B; Hib; and adding new vaccines
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key health outcome indicators
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Based on the above analysis, assessment of the prospects for
investments from internal budgets versus external funding.
3. A Strategic Framework for Increasing Access to Immunization
An access team has been identified from within the GAVI Implementation
Task Force. To complement the team's efforts, the GAVI Secretariat and
partners will work further with McKinsey Consulting to develop a
strategic framework for how the Alliance can support countries to
increase access not only to immunization but to other essential health
services as well. The project, which will be conducted in close
collaboration with the GAVI Implementation and Financing Task Forces and
health system experts, will include the following:
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Grouping of countries based on their current DTP3 coverage and future
targets
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Exploration of possible incentive schemes at the district level.
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Identification of important district-level tools – 'best practices' –
that could be shared with other countries to improve the quality of
all primary health care.
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Analysis of the roles of the different actors – government officials,
national, regional and global representatives of GAVI partners, and
local communities.
The Partners Meeting in Dakar from 20-22 November will provide an
important opportunity to continue the discussions launched in Oslo and
review the progress to date on the activities stemming from the meeting.
By February/March of 2003, the work on the projects will be near
completion and brought together with the work of the FTF on financial
sustainability plans and the immunization financing database.
1 ECON Centre for economic analysis,
Oslo, Norway.
2 David Bloom, professor of economics
and demography; and David Canning, professor of economics, both at
Harvard University's School of Public Health.
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