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June 2001
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2001 contents page
SPECIAL FEATURE
Taking care of tomorrow
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, Zimbabwes 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.
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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 |
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.
Paulinus Sikosana, Secretary for
Health and Child Welfare in Zimbabwes 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.
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Paulinus Sikosana: education
and long-term planning are essential |
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 months
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.
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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
Benin: political commitment and practical
schemes to guarantee funds
Jacques Hassan, director
of research and development in Benins health ministry,
is hopeful. Although income per head is just $325 a
year, the countrys 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 programmes 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.
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Jacques
Hassan |
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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."
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Bangladesh: popular demand
for immunization will ensure the future of the service
For the government of Bangladesh,
theres no question that immunization must be assured
for the long term, says Siddiqur Rahman Choudhury, a
senior official in Bangladeshs 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. "Thats
the way to build financial sustainability."
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Siddiqur Choudhury |
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Bangladeshs 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 governments 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." |
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In Côte dIvoire, 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).
Figure 1: Closing the gap:
the costs of running Côte dIvoires immunization programme
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.
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 months
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 efficiently use domestic and supplementary external
resources on a reliable basis to achieve target levels of immunization
performance*."
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This definition emphasizes a governments
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 needs 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 numbers 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, its essential that the government should have
a strong commitment to immunization, and evidence at its fingertips
such as estimates of the cost-effectiveness of vaccines
to argue its case with external and private domestic
investors.
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Ruth Levine: "The
challenge is fundamentally a political one"
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"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.
Source: (4)
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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 peoples welfare, it makes sense for richer countries
to invest 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 a 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 supported 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 Vaccine 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 funds 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 (or Memorandum of Understanding
with) the Interagency Coordinating Committee
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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 countrys capacity
towards eventual self-sufficiency. Dr Lea warns that a truly sustainable
immunization programme will need to be planned within the overall
health systems 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," says Steve Landry at USAID. It
will mean that donor agencies staff at country level, who serve
on Interagency Coordinating 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 everyones
responsibility.
References:
(1) Immunization
Finance Sustainability Plans. Workshop 4-6 June 2001, Geneva, hosted
by WHO, cosponsored by USAID and the Bill and Melinda Gates Childrens
Vaccine Program at PATH.
(2) Kaddar, Miloud,
Ann Levin, Leanne Dougherty and Daniel Maceira. May 2000. Costs
and Financing of Immunization Programs: Findings of Four Case Studies.
Special Initiatives Report 26. Bethesda, MD: Partnerships for Health
Reform Project, Abt Associates www.VaccineAlliance.org/financing/pdf/
four_country.pdf
(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 www.VaccineAlliance.org/reference/fsci_execsumm.html
(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 in EPI Newsletter at www.paho.org/English/HVP/HVI/sne2302.pdf
*NOTE:
"Immunization performance" is defined in terms of current and future
goals for access, utilization, quality, safety and equity.
Phyllida Brown
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