Financial Sustainability of Childhood Immunization:
Issues and Options1
Dr. Ruth Levine, Dr. Magdalene Rosenmöller and
This paper, commissioned by the Financing Task
Force of the Global Alliance for Vaccines and Immunization (GAVI),
provides a framework for discussion of the financing of immunization
in developing countries. Narrowly, the paper is intended to contribute
to the development of a template for the preparation of the financial
sustainability plans required of countries receiving grants under
the Childrens Vaccine Fund. More broadly, the paper seeks
to help leaders in poor and wealthier nations think about specific
actions that can contribute toor conflict witha long-term
goal of stable and adequate financing for childhood immunization.
Childhood immunization represents one of the quintessential
best buys for the health sector, yielding tremendous
benefits for individuals and society. The intervention is most effective
when coverage is at 80 percent or higher, and when children are
immunized during a rather narrow age span. These characteristics
imply that the greatest health benefits are reaped when immunization
programs can depend on adequate levels of funding on a reliable
In developing and industrialized countries alike,
the financing of immunization is primarily a domestic and public
sector responsibility: a core public health function of the state.
However, the political nature of resource allocation decisions,
competition among health (and other) programs for very scarce resources,
large increases in funding requirements as coverage expands and
new vaccines become available all add up to the potential (and reality)
that dependence on domestic government resources alone will leave
poor countries falling further and further away from achieving the
benefits of immunization.
Out of both self-interest and a concern for social
welfare in poor nations, the international community may see some
level of financing of immunization services in developing countries
as a global responsibility. This perspective has been manifested
historically in grant support from wealthy countries to poor ones
for the development of basic childhood immunization programs (primarily
through the Expanded Program on Immunization). Currently, as significant
coverage gaps for routine immunizations are found, and as new and
more costly vaccines are added to immunization schedules, resource
transfers for immunization programs continue under the Childrens
Vaccine Fund and through GAVI partners. Over the foreseeable time
horizon, then, for many countries of the world, the financing of
immunization services will be a shared responsibility: national
governments have the primary role; and development partners have
a secondary but crucial role.
Broadening the Concept of
Financial Sustainability. Traditionally, financial sustainability
has been taken to mean the ability of a country to mobilize sufficient
domestic (public and private) resources to finance a given set of
goods and services, such as primary health care or family planning
services. Financial sustainability has been synonymous with self-sufficiency,
and often applied to situations where external financiers (aid agencies)
sought to induce developing country governments to mobilize domestic
resources for activities that previously had been donor-funded.
However, more than for many other health interventions, the nature
of immunization and the international interest in the future success
of immunization programs may require that the focus of financial
sustainability be shifted toward the ability of a country to
mobilize and allocate sufficient domestic and external resources
on a reliable basis to achieve target levels of immunization performance.
The emphasis turns away from single-minded attention to phasing-out
external funding, and toward the question of how to structure the
full financing packageand, importantly, how to use available
resources efficientlyso that sufficient funding is available
on a reliable basis. Specific actions can be taken by developing
country governments and development partners to promote this objective.
Dimensions of Financial Sustainability.
Financial sustainability is part and parcel of good management of
immunization programs, and of the health sector as a whole. Many
of the facets of financial sustainability overlap with sound program
We identify nine dimensions of financial sustainability
of immunization systems, falling into the categories of efficiency
in the supply chain, and appropriate funding structure. These are:
Lower Costs through Efficiency in the Supply Chain
- Sustained high demand
- Efficient vaccine procurement
- Efficient immunization services
Reliable and Sufficient Revenues through Appropriate
- Steady and sufficient funding for vaccines
- Steady and sufficient funding for labor and
other non-vaccine recurrent costs
- Steady and sufficient funding for investments
- Timely resource flows from source to service
- Balance between public and private financing
- Effective mobilization and management of supplementary,
external resources and long-term financing
Government Actions to Foster
Sustainable Financing. Among the many actions that national
governments can take to evolve toward higher and more stable levels
of funding for immunization systems, the following stand out as
the ones with the highest potential impact:
- Promote allocation of resources on the
basis of cost-effectiveness and public finance principles.
- Use international procurement mechanisms.
- Establish legal mandates for baseline funding
of national immunization programs.
- Develop and implement a targeted program to
reduce waste, with quantitative endpoints.
- Engage development partners in informed discussion
of resource requirements, and seek structured commitments to fill
in key funding gaps.
- Earmark funds and establish performance targets
for sub-national entities.
- Develop targeted program to reduce barriers
to access through new delivery strategies, including those that
involve the private sector.
Development Partner Actions
to Promote Sustainable Financing. As noted above, it is likely
that external aid will continue to play an important role in financing
immunization services in many developing countries, and development
partners are motivated to provide funding in a way that is reliable
and fosters high levels of immunization coverage.
There are actions that donor (and lending) agencies
can take within the constraints of existing funding instruments.
There are certainly ways in which standard funding mechanisms can
be made less detrimental to the cause of financial sustainability.
Key messages from an assessment of the advantages and disadvantages
of different instruments are:
- Restricting external funding to capital
investments does not contribute to reaching the objective of financial
- Sectoral (rather than immunization-specific)
programs have tremendous potential to contribute to sustainability,
but to date the experience has not been highly positive.
- Performance-based funding criteria can be strong
instruments to encourage governments to increase the efficiency
in the supply chain.
- Incorporating policy conditions related to immunization
system performance and/or financing can be a useful tool to promote
- Most existing instruments do not address the
fundamental international and domestic political risks to steady
funding for immunization programs. Mediating this risk would require
one or more new funding instruments that are designed to be buffered
from the political process.
Indicators of Financial Sustainability.
Indicators of financial sustainability should be selected based
on the criteria of: validity and reliability; availability of data
(without special collection procedures); relevance to worker and
ease of explanation; relevance in variety of country contexts; and
relationship to high priority policies and programmatic actions.
Applying these criteria, the Financing Task Force
may select among a large number of indicators of financial sustainability.
Section VI of the paper lists these possible indicators.
It is recommended that in establishing uniform indicators
and setting targets toward financial sustainability, GAVI:
- Establish a small, core set of indicators
of financial sustainability that would require information that
is available in most countries.
- Request of countries that in their financial
sustainability plans they propose an additional set of country-specific
indicators, tied to their proposed policy and programmatic actions.
- For both the core and the country-specific indicators,
set targets for financial sustainability in a participatory fashion,
with the full input of health financing specialists, immunization
program specialists, and policymakers in recipient countries.
- Tying together progress toward both institutional
and financial sustainability, encourage countries to engage in
a benchmarking process.
1 This paper was prepared by Ruth
Levine (World Bank), Magdalene Rosenmöller (World Bank) and
Peyvand Khaleghian (Consultant). Comments should be directed to:
Ruth Levine (firstname.lastname@example.org)
and Violaine Mitchell (email@example.com).
This paper is intended to promote discussion of issues, and does
not represent the views of the World Bank.