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Development Loans for Immunization-Questions and
Answers1
This paper was commissioned by the Financing
Task Force of the Global Alliance for Vaccines and Immunization
and was written by Peyvand Khaleghian. Over 30 individuals were
interviewed in the preparation of this document, representing development
banks, UN agencies, bilateral aid organizations, academic institutions
and government immunization programs. Much of the paper reflects
the input of these individuals, though the document does not reflect
the views of any particular agency or organization and is intended
as a discussion paper rather than a statement of policy or recommended
practice.
1
What is a development loan?
Development loans are loans from development banks such as the World
Bank, the Asian Development Bank, the Inter-American Development
Bank and the African Development Bank. They are called "development"
loans because they finance various aspects of a country's social
and economic development such as roads, energy, health and education,
and they are mostly disbursed to a country's central government
rather than to districts, provinces or the private sector. Loan
amounts can vary from small (~US$5 million) to very large (more
than US$100 million), depending on the sector and the project in
question, and the disbursement period usually ranges from three
to eight years.
There are two broad categories of development
loan: investment loans,
which account for the majority (~75 to 80 percent) of development
loans and are typically focused on specific projects (such as establishing
rural clinics, training health workers, reintegrating soldiers into
communities, improving the efficiency of water systems, etc.); and
adjustment loans,
which account for 20 to 25 percent of development lending and are
designed to support broad policy and institutional changes (such
as privatization, public sector reform or judicial reform) rather
than specific projects. Each of these broad loan types has a number
of sub-types; these are described in Box 1.
The terms of a loan-interest rates, repayment
schedules etc.-depend on a country's income level, its size, and
the sector in question. Generally speaking, low-income countries
(with a per capita GNP of less than US$755 in 2000) are eligible
for zero-interest "soft loans" (also known as "credits")
which, in the case of the World Bank, have a 10 year grace period,
a small administrative charge (less than one percent of the total
loan amount) and a 40 year repayment period. While the principal
on these loans has to be paid back, their zero-interest rate and
long repayment period mean that around 65% of the loan amount is
effectively a grant-hence the term "credit"-and only 35%
has to be paid back. In other words, for every dollar repaid, the
country receives around two dollars for "free", depending
on inflation and commercial interest rates over the repayment period.
In middle-income countries (countries with a
per capita GNP between US$756 and US$9265 in 2000), loans are generally
made at market or near-market rates, though exceptions are occasionally
made for social sector loans (to health and education) and loans
to small countries (such as island-nations) with small economies.
In the case of the World Bank, the repayment period for these loans
is 15 to 20 years, and a five-year grace period usually applies.
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2
Why should countries have to take loans for
basic services such as immunization?
In principle, countries borrow for one of two reasons: either because
the government doesn't have enough resources itself to meet its
objectives, or because it believes that the return on its investment-whether
in immunization, airport construction, the energy sector or anything
else-is greater than the amount of interest (or inconvenience) it
incurs in taking a loan to finance it. If the Ministry of Finance
determines the country has enough money to fund its programs-and
if it gives priority to public financing of these programs-then
the country does not need to take a loan or seek other sources of
external financing. If, however, the Ministry of Finance decides
the country lacks sufficient domestic resources, or if it feels
that its domestic funds are better spent elsewhere, then it may
need to either scale back (or terminate) the programs in question
or to seek alternative sources of financing-such as loans, grants
or private funds-to meet the "financing gap".
This is not to say that loans and grants should only
be used as "methods of last resort" when domestic financing
fails. In some circumstances, there may be benefits to taking a
loan even when sufficient domestic resources seem to exist. These
are discussed further in Question 8.
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3
Is immunization a productive investment?
Immunization is one of the "best buys" among health interventions-and
possibly among a whole range of economic interventions as well.
It is a proven, low-cost and effective way of preventing death and
extending life. Immunizing children with the complete group of childhood
EPI vaccines (which includes vaccines against measles, pertussis,
diphtheria, tetanus, polio and childhood tuberculosis) costs between
$20 and $25 per child; this translates to a cost-effectiveness of
between $14 and $20 per year of healthy life gained, which in turn
compares with figures of $25 to $75 for other common preventive
interventions such as family planning and community distribution
of oral rehydration salts. Table 1 compares the cost-effectiveness
of immunization with other interventions that prevent death or extend
life. It should be noted that newer vaccines, such as those against
hepatitis B and Haemophilus influenzae type B, are also highly cost-effective:
a fact that is sometimes forgotten when the absolute cost of these
vaccines (which, for various reasons, is higher than that of the
EPI group) is considered in isolation, or when preventive services
are weighed against politically-popular treatment services.
As a rule of thumb, health interventions are considered
cost-effective in a given country if they cost less, per year of
life saved, than the GNP per capita. In low-income countries, the
average GNP per capita is around US$420. This contrasts with a cost
per year of healthy life gained for immunization of between $14
and $20, showing that even low-income countries-countries which
often face the hardest decisions about where to spend their limited
resources-can include immunization among their top-priority health
programs with the confidence of knowing that it represents a genuinely
"good buy".
These figures say nothing of the economic benefits
of immunization, however. Many economists and MOF officials are
more concerned about the cost-benefit
of immunization-i.e. the extent to which investments in immunization
lead to economic (as distinct from health) benefits, and whether
or not these exceed their costs-rather than its cost-effectiveness.
Retrospective studies have shown that around eight percent of increases
in national income can be explained by improvements in life expectancy,
and that a one-year increase in life expectancy can lead to a one
percent increase in a country's GDP within 15 years. Immunization
is one of the most effective ways of reducing childhood mortality
and increasing life expectancy. It prevents diseases that would
otherwise be fatal to a large proportion of those who contract them,
and it generally does so at a time-early childhood-that makes possible
a life-time of economic participation and productivity for those
who survive as a result. In the short run, immunization may result
in a need to increase government expenditures on education and primary
care, as more and more children survive through infancy; but in
the long run, the larger and healthier population that results will
live longer and reduce its fertility rates, and these in turn will
lead to higher incomes and standards of living-welcome news for
governments concerned with social and economic development.
Studies have also compared the cost of immunization
programs with the economic benefits to which they lead-including
cost savings from averted treatment costs, and the economic productivity
of individuals who survive as a result of being immunized. These
studies have consistently found positive-and often very large-returns
on investments in immunization, both for newer vaccines (such as
those against hepatitis B and Haemophilus influenzae type B, though
these results differ from country to country) and for the traditional
EPI group. In the case of the EPI antigens, most studies have estimated
economic returns of three to ten times
the program's cost-a benefit-to-cost
ratio that starkly illustrates the good economic sense behind investing
in immunization.
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4
What do immunization programs cost? How much
borrowing are we talking about?
The cost of an immunization program varies from country to country.
Determinants of cost include programmatic issues such as scale,
efficiency, service delivery strategies, the quality of existing
infrastructure, and whether or not newer (and more expensive) vaccines
(such as those against hepatitis B and HiB) are included; demographic
issues such as population density and distribution; and economic
issues such as labor costs and foreign exchange rates.
Recent studies have estimated the "cost per fully
immunized child" at around $US20 to $25. Of this cost, approximately
50-60% is for personnel costs (much of which are shared with other
programs such as PHC, maternal and child health, rural health extension
programs, etc.); 20-35% is for vaccines and supplies; and around
10% is for capital costs such as buildings, vehicles and equipment.
Viewed another way, the total cost of a national immunization
program-including allowances for shared costs (such as health workers
who combine immunization work with other duties) and depreciation
of capital equipment-translates to an average of 2-5% of government
health spending or roughly $US0.20 - $0.60 per capita for most countries.
This comes to roughly 0.03% to 0.10% of Gross National Product (GNP),
though the cost for the basic EPI group has been estimated at no
more than 0.01% of GNP for all but the poorest countries. Table
2 gives examples from recent cost studies in Morocco, Côte
d'Ivoire, Bangladesh and Ghana.
The amount of an immunization-specific loan would
seldom be as high, on an annual basis, as the total costs indicated
in these estimates. Borrowing for personnel costs is very limited,
tending only to support the incremental costs associated with the
project itself (and even then on a declining basis); and some costs
may be consistently met by a specific donor-such as UNICEF or a
bilateral agency-or by the government itself, in which case the
loan amount would be reduced even further (see Questions 5 and 7
for further comments). But even if a government were to borrow at
these levels, the total amount required to support an immunization
program would seldom account for more than 0.1% of the government's
total annual budget-a smaller figure than the amount which most
governments, including many of the poorest ones, will comfortably
borrow for other development projects such as roads, energy sector
reform, or other public works. In addition, the benefits of immunization
should be considered alongside the costs: and given the benefits
discussed in Question 3, even this level of borrowing may be associated
with a high enough rate of return to make it an economically-attractive
option. Since most countries borrow for immunization in the context
of loans for the health sector in general, these considerations
are somewhat hypothetical: but they highlight the fact that immunization,
in addition to being cost-effective, is also quite inexpensive in
absolute terms, especially by comparison with other projects for
which governments typically borrow.
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5
What about grants? Is there any point taking
a loan when grants are available?
Yes and no. Loans have some advantages over grants, so there may
be circumstances in which a loan makes sense even if grant funds
are available-notwithstanding the fact that loans, unlike grants,
have to be repaid. These include:
- Grant funds for immunization have been falling
since the early 1990s, partly because of declining development
assistance in general and partly because of a prevalent view by
donors that countries should become increasingly self-sufficient
in financing their immunization needs. As a result, many programs
are finding that even with grants, essential elements (such as
cold chain maintenance, training etc.) are inadequately funded-thus
raising the need for new financing sources, of which loans are
one.
- Grants often stipulate that a certain proportion
of the grant has to be spent on goods or services from the donor
country-so-called "tied" aid. This is not the case with
loans.
- Loans are developed through a process of negotiation
between country officials and a development bank, a process in
which country officials from the Ministry of Finance (MOF) and
Ministry of Health (MOH) have considerable influence over the
design of the final product. Grants are often designed to meet
a donor's requirements as much as those of the receiving country.
Grants may therefore be less receptive to a country's priority
requirements (and thus less likely to stimulate domestic "ownership")
than loans, over which country officials have greater control.
- Loans provide a secure source of financing over
a longer period (upwards of three to five years, and sometimes
as long as ten years or more) than most grants (which are typically
for one or two years at a time). This is especially important
for long-term planning and for ensuring the stability of population-based
programs such as immunization.
- Loans can provide substantially larger sums of
money than grants. For example, a recent immunization-strengthening
project in India was financed with a "soft" loan in
the amount of US $142 million-far more than could have been obtained
from grant funds alone.
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6
What is a "development credit"?
The term "credit" is used by development banks to refer
to "soft" loans-loans with an initial grace period, a
zero rate of interest, and a long repayment period-that are made
available to low-income (or, in some cases, to small middle-income)
countries. As explained in Question 1, the repayment amount for
these loans is often substantially less, in real terms, than the
amount originally borrowed, with one to three "free" dollars
for each dollar the government has to repay. The term "credit"
is used to capture this fact, and to distinguish these loans from
the other financial instruments (such as market-rate loans to middle-income
countries or private sector guarantees) which development banks
have at their disposal. The terms "credit" and "soft
loan" are therefore equivalent.
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7
What about other financing alternatives such
as user fees? Is there any alternative to public financing?
Trying to finance immunizations with user fees can be counterproductive.
Generally speaking, people are less likely to pay for preventive
services (such as immunization) for diseases which seem like a distant
threat when they are confronted by more pressing needs-such as the
need to care for a sick child-in the immediate present. As a result,
user fees for these services tend to reduce utilization and, in
the case of immunization, lower coverage rates. Not only does this
reduce the potential for cost recovery, it can also defeat one of
the essential aspects of an effective immunization program: high
coverage. Due to the phenomenon of "herd immunity", a
high coverage level can protect far more people than those actually
immunized, whereas a low coverage level can leave large parts of
the population-including part of the immunized population-at risk
of disease. This is the rationale for aiming for coverage levels
of about 80 to 90 percent. If user fees reduce coverage, then they
can threaten this essential aspect of an immunization program; and
given the relatively small amounts which people are typically prepared
to pay for preventive services, this may occur without much in the
way of compensating revenues. User fees are therefore discouraged
as a financing approach for essential vaccines in most programs.
Although user fees are discouraged as a financing approach, this
is not the same as discouraging the participation of private health
providers in the delivery of immunizations: which, in contrast to
user fees, is a way of increasing immunization coverage, and is
therefore useful to the immunization process as a whole. While the
bulk of immunizations are provided through public services, some
countries have had great success with sub-contracting immunization
delivery to NGOs.
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8
Is there any point in taking a loan if budgeted
domestic funds are available?
The standard response to this question is "no". That is,
if domestic funds are available, then there is no need to seek external
financing of any sort-much less loans, which must eventually be
repaid. If budgeted funds are available on a reliable
basis, with little fluctuation from year to year, and if they are
sufficient to meet the full costs
of supplies, training, operations and maintenance for all aspects
of the immunization program, then loans are not needed.
This is seldom the case, however. Funds are often
insufficient, sometimes extending only to personnel, vaccines and
essential supplies but not to equally-important components such
as cold chain maintenance (to keep vaccines at their optimal cold
storage temperature) or information systems; and the quantity of
budgeted funds may be unstable, fluctuating from year to year with
changes in the economy, the government, or the government's priorities.
Loans can provide one part of a strategy to deal with these problems.
Loan funds can be used to fill the financing gap between budgeted
allocations and the amount required for an effective immunization
program, and they can provide a consistent and predictable source
of financing over an extended period of time-both of which can,
in turn, improve the efficiency and effectiveness with which immunization
activities are carried out. Loans also have their disadvantages,
as summarized in Question 19; but in circumstances where funds for
immunization are either insufficient or unreliable-whether these
are from domestic or external sources-then loan funds may be a useful
complement to other sources of immunization financing.
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9
What are the macroeconomic consequences of
taking a loan? Isn't the point to get out of debt, not into more
of it?
The macroeconomic consequences of borrowing vary from country to
country. In some countries, borrowing has led to unsustainable debts
that burden current and future generations; in other countries however,
borrowing has been a means to improving social conditions and economic
development, with a consequent increase in the standard of living
and future possibilities. Generally, if a country takes a loan for
sound reasons and uses the money to further its social or economic
development, then it can expect a positive return on its decision
to borrow; but if a country adopts a borrowing pattern that backs
ill-conceived or poorly-executed projects, then it can find itself
in a spiral of worsening debt with little in the way of benefits
to show for it. In the latter case, development banks may actually
suspend lending to a country until it demonstrates a change of direction
and improves its performance in areas such as economic management,
policies for social inclusion and equity, and management of loan-financed
projects-though existing projects are generally permitted to continue.
Every country will have to decide on the merits of borrowing on
the basis of its own macroeconomic circumstances. If a country is
heavily indebted, or if there is concern about its ability to pay
back a loan, then it may wish to look at other financing alternatives
such as grants or GAVI funds (if eligible) instead. However, given
the importance and value of immunization, the relatively small amounts
required to sustain an effective program, and the availability of
"soft" loans for such countries, even these countries
may wish to consider the benefits of borrowing-as discussed in Question
18-as one potential financing alternative.
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10
What about other health programs that are
under-funded? Would it be better to spend loan proceeds on something
other than immunization?
Immunization is a fundamental part of any country's public health
program. It is highly cost-effective, benefits society over a long
period, and helps to prevent diseases which would otherwise have
harmful effects on a country's economy and health. Nevertheless,
immunization still has to compete with other health programs (such
as malaria control or hospital rehabilitation) for funds. Many of
these programs are just as important as immunization and may in
some cases be considerably more "visible" to policy makers
or the general public. Advocates for these programs may argue that
loan proceeds-or any other source of financing for that matter-should
be directed to these programs instead. This may explain why immunization-related
lending usually occurs in the context of loans to broader areas
such as primary health care, child health and communicable disease
control, rather than in the form of stand-alone, immunization-specific
loans.
The issue of prioritizing health programs is one for each government
to decide. In doing so, governments frequently consider issues such
as economic cost-benefit (does the program have medium- or long-term
economic benefits that exceed its costs?), cost-effectiveness (does
immunization "purchase" more health per dollar than other
health interventions?), the viability of alternative financing sources
(can user fees or grants be used to recover costs without compromising
program effectiveness or equity?) and the political consequences
of funding-or not funding-the program in question (is the program
considered important by professional groups, citizens groups and
the general public?). Immunization scores very highly on all these
criteria. While the outward appearance of certain health problems
may seem greater than that of immunization (which, as a preventive
service, becomes more "invisible" the more effective it
becomes), the unique benefits and characteristics of immunization
make it a high priority for government attention in all countries.
Questions 2, 3 and 8 discuss other issues related to this subject.
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11
Can existing loans be reallocated to support
immunization?
Generally speaking, loans are flexible. Unused amounts can be cancelled,
bought-down, or reallocated to other programs consistent with the
loan's objectives. Lending organizations are usually quite flexible
when it comes to such adjustments, and the legal documentation of
most loans is usually framed in very general terms so that adjustments,
extensions and reallocations can be accommodated without undue difficulty.
Thus, an existing loan to support child health services could be
adjusted to support upgrading the immunization cold chain, or a
loan to strengthen primary health care might be extended to include
immunization.
Policy-based loans or loans for general budget support may have
even more flexibility, as they can be allocated at the discretion
of the government (so long as any core macroeconomic or other conditions
have been met), and investing in immunization is a widely-recognized
way of demonstrating a government's commitment to effective social
policies.
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12
Who decides what a loan should focus on?
Obtaining a development loan requires the coordinated efforts of
a line ministry (such as the Ministry of Health), the Ministry of
Finance, and a development bank. The Ministry of Finance plays an
important role in this process, first deciding whether or not the
country should be borrowing at all, and then deciding where the
loan funds (if any) should be allocated. Line ministries that want
a loan usually begin by making their case to the MOF-which, depending
on the strength of their arguments, the needs or priorities in other
sectors and the country's macroeconomic circumstances, will decide
whether or not to proceed with a loan for that ministry. The MOH
can therefore take certain steps to strengthen its case with the
MOF when asking for a loan, including:
- Reviewing and explaining the economic benefits
associated with immunization, as summarized in Question 3 and
available in greater detail (and for specific vaccines) from a
wide variety of published sources;
- Summarizing the current sources and uses of financing
for the immunization program, and explaining why these are insufficient
or too unreliable to meet the program's needs;
- Summarizing the immunization program's long-term
strategy (including its long-term financing strategy and its links
with other parts of the health system) and illustrating how loan
funds could strengthen this program-particularly with regards
to financial sustainability and the program's long-term financial
footing;
- Illustrating the health and personal benefits that
flow from an effective immunization program-and the losses associated
with a weak program-using case studies, comparisons with neighboring
countries or other examples;
- Demonstrating that the present immunization program
is reasonably efficient and is getting the most out of resources
currently available;
- Illustrating how the long term sustainability of
the immunization program will be assured after the loan is finished.
- Demonstrating that the MOH has a proven track-record
of fiscal responsibility and effective project management.
The MOH can also engage in high-level advocacy efforts
with senior officials in the MOF, ensuring that immunization is
placed on the agenda at meetings between these officials and their
development bank counterparts. In some cases, such as countries
where the MOH has an existing relationship with a development bank
through recent or current projects, the MOH may raise the subject
of an immunization-related loan directly with development bank staff;
but since the final approval for a loan must come from the MOF,
and given the importance of the MOF's long-term commitment to immunization
in securing the program's long-term health, the MOF should be included
in these discussions from a very early stage.
If the idea of a loan for immunization is accepted
by the MOF and the development bank, project development proceeds
with various contributions from the MOH, the development bank, and
from other organizations-including international organizations such
as UNICEF or WHO, and domestic groups such as NGOs or academic institutions-that
are active or interested in immunization. Assessment activities
(such as procurement evaluations, financing assessments, infrastructure
reviews, etc.) are also part of this process, providing information
about the current system and informing the design of the final project.
The main participants at this stage are government officials and
development bank staff. On the government side, these representatives
usually include officials from the MOF (who review the rationale,
appropriateness and country-readiness for a loan) and the MOH (who
provide the technical and financial justifications for the loan);
while on the development bank side, participants include staff members
from various disciplines (including finance, economics and public
health) who review the technical and financial aspects of the loan
proposal and may suggest changes based on their knowledge of the
country, the project or policy changes in question, and the bank's
policies and procedures.
The final stage of approving a loan involves high-level
negotiations between government representatives and development
bank staff. The negotiation process continues until an agreement
is reached on what areas a loan should support and how this support
should be structured, and no commitments are made until both parties-the
government and the development bank-are satisfied with the outcome.
Government officials play a large part in this process, and they
usually have considerable leverage in determining the structure
and terms of a loan: though the final product is always a negotiated
agreement, and compromises are often made on both sides. In this
respect, however, loans tend to be more country-owned than grants-which
often reflect the donor's priorities as much as those of the recipient-and
this may be an important benefit for countries looking to improve
the sustainability of their immunization programs.
Once an agreement is reached on the final product
and the project is approved by the development bank, loan funds
are disbursed-usually on a predetermined schedule, and seldom all
at once-to the Ministry of Finance (acting, in this context, as
a representative of the government as a whole: referred to in the
loan contract as the "borrower"), and the MOF in turn
passes them on to the line ministry responsible for executing the
project (referred to in the loan contract as the "executing
agency").
From this point onward, the role of the MOH (the "executing
agency") is to oversee project implementation and periodically
report to the MOF and the development bank; while the role of the
MOF (the "borrower") is to monitor the financial aspects
of the loan (such as preventing corruption, ensuring accountability
and preparing for the loan's eventual repayment-even if this may
be a distant event, as with "soft loans"/credits) and
to provide a more general oversight of the project and its implementation.
Development bank staff provide technical assistance
and support at all stages of this process, and they periodically
undertake project implementation reviews of their own, liaising
with both MOH and MOF officials in doing so. The outcome of these
reviews may, in some situations, lead to changes in the project's
design or objectives, especially in response to learning or changed
circumstances as the project unfolds: though any such changes would
usually be discussed with MOH and/or MOF officials before being
made.
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13
If we take a loan, won't the Ministry of
Finance just reduce the regular budget allocation to health; and
if so, what's the point of borrowing?
This is possible, but there are some ways around it. Fundamentally,
the consultative process involved in taking a loan for immunization
should ensure that all participants-including those from the Ministry
of Finance-are fully apprised of the importance and benefits of
an effective immunization program and therefore committed to providing
adequate funds irrespective of whether or not a loan (or any other
new source of financing) enters the picture. To solidify these commitments,
some countries have experimented with immunization-specific line-items
in their national budgets, while others have contemplated the use
of "supra-budgetary funds"-funds that are pre-allocated
to immunization and can't be easily modified through budget debates
or shifts in government policy-to protect the stability of immunization
financing. Sometimes a loan itself can be designed to protect domestic
funds. For example, a loan agreement can specify how much the government
should contribute to the immunization program (as distinct from
how much the loan will provide), or it can set performance targets
that can only be achieved if current funding levels are maintained.
At a more personal level, development bank staff often have strong
working relationships with officials in the Ministry of Finance,
so the very involvement of these individuals in the consultative
process can sometimes help ipso facto to make long-term financing
for immunization more secure.
Even if these strategies fail, and if the government
decides to reallocate existing commitments away from immunization
because of an immunization-supporting loan, the reliability and
predictability of loan funds-which typically extend over a period
of five years or longer-may, in and of itself, be a worthwhile and
adequate benefit, especially in settings where the irregularity
or unpredictability of immunization financing is having an adverse
impact on service delivery.
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14
Don't loan finances have the potential for
misuse and corruption?
In some countries, corruption and misuse of public money are a significant
problem for all funding including development loans. In view of
this, development banks have developed various safeguards-from strict
procurement procedures to a variety of accounting and auditing requirements-to
prevent loan funds from being misused or misappropriated. While
these safeguards can be effective in limiting corruption and misuse,
their price for doing so is the increased administrative burden
associated with inflexible (and sometimes complicated) procurement
procedures and accounting requirements, all of which are inseparable
parts of the loan itself.
Projects can be designed to limit corruption in other
ways, too. For example, complicated projects-such as those involving
multiple departments or numerous concurrent lines of action-present
more opportunities for corruption than simple projects, whereas
projects that build on established priorities and strengthen existing
programs tend to fare better in this regard. In the final analysis,
loans are only as effective as the government that takes them; and
no matter how many safeguards are put in place, the best defense
against corruption is a government that is actively committed to
stamping it out.
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15
What can loans be used for? What should they
be used for?
Loans are flexible and can be used in a variety of ways. In most
cases, they are used to support specific parts of a given program:
which, in the case of immunization, could include vaccines, materials,
capital equipment and training, among others. They can also be used
in more unusual ways-capitalizing a trust fund to meet the recurring
cost of vaccines, for example-provided these meet the needs of the
country and are approved by the lending organization. These approaches
are known as "investment" or "project-based"
lending; non-project ("adjustment") loans are less common
in the health sector, though immunization may also be an indirect
component of these loans (as a performance indicator of social protection
in a public sector reform loan, say) even if not directly financed
by them.
Loans are best used for long-term, sustainable improvements
to a country's immunization system-not for activities or adjustments
that are short-lived or otherwise unsustainable. Possible uses include:
Financing capital or recurrent
expenditures. Development loans have traditionally been
used as a source of financing for capital expenditures, with very
limited support for recurrent costs. In the case of immunization,
however, the distinction between capital and recurrent costs may
not be so clear. Immunization has some "pure" capital
costs such as the cold chain, vehicles and so on; but as a whole,
it represents a recurrent investment in human capital. Each vaccinated
child represents a long-term human capital benefit to the country
as a whole, and this in itself may justify borrowing to meet the
cost of vaccines or supplies-provided these do not become a permanent
substitute for domestic funds.
Upgrading infrastructure.
Loans can finance projects to replace, upgrade or purchase
"pure" capital items such as cold chain equipment or
vehicles, and to spread the cost of repayment for these items
over a longer period than would otherwise be possible. Investing
in capital items has some disadvantages, however. First, such
investments nearly always increase the recurrent cost burden for
recipient governments, yet experience shows that governments seldom
make adequate arrangements for the recurring costs (of maintenance,
for example) that ensue; and second, investing in capital may
reduce governments' motivation to look for more innovative, cost-effective
and sustainable solutions such as outsourcing of fleet management
or equipment maintenance.
Long term vs. short term
investments. Many development agencies focus on short-term
goals (which tend to be easier to "see" and monitor)
rather than activities whose public health dividend may be longer
in coming. Loans can be especially suitable for investments in
the latter category. They are long-term in nature and can therefore
be integrated within (and designed to support) a program's long-term
strategy-a benefit which may be less easy to obtain with other
sources of development financing. Of particular value are interventions
that will survive beyond the end of the loan period itself, such
as improvements in procurement processes, financing strategies,
distribution systems and local capacities for IEC or monitoring
and evaluation, all of which can continue to benefit the immunization
program well after the loan period comes to an end.
Introducing new technologies.
Loans can be used as a source of medium-term "seed
financing" to introduce new technologies (such as new vaccines,
auto-destruct syringes etc.), giving countries a bridge period
in which to secure domestic financing for the continued support
of these technologies: a similar approach to the use of GAVI funds
to introduce new vaccines, for example.
Strengthening intra-sectoral
linkages. Since most immunization-related lending occurs
in the context of loans to broader areas such as PHC or maternal
and child health, the opportunity arises for loans to strengthen
linkages between the immunization system and other areas of the
health system. Disease surveillance, health information systems,
improvements in the primary care system-all of these are aspects
of the health system to which immunization is closely related,
so loans that improve any of these areas can be used to benefit
the immunization system as well.
Financing accelerated activities
or program extensions. Loans can provide the financial
support necessary to speed up the pace of activities such as disease
eradication programs (where these are relevant to the country
in question) or to reach geographic areas or population groups
with low immunization coverage.
Creative approaches.
In small countries with predictable vaccine requirements and a
strong commitment to immunization, loans can be used to capitalize
the recurrent cost of vaccines by establishing an immunization-specific
trust fund, the interest on which is used to finance the program's
vaccine requirements (or other recurrent costs) for an extended
period. This approach has been used in other sectors such as environmental
protection and rural microcredit: but only one country, Bhutan,
has taken this approach to financing its vaccine costs, with others
such as Armenia contemplating similar moves in the near future.
Loans funds could also be used to negotiate multi-year purchase
agreements (between the government and a vaccine supplier, for
example) and thus to argue for reduced prices for vaccines, syringes
or other essential supplies.
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16
Can loans be used for procurement of vaccines?
If so, what are the implications for existing procurement processes?
Will they have to change?
Most development loans come with specific conditions regarding acceptable
methods of procurement. While the purpose of these conditions is
to ensure transparency and reduce costs-and while they are frequently
successful in doing just this-the down-side of these requirements
is that countries may have to adjust their existing procurement
practices to fit in with those of the lending agency. The complexity
of this adjustment can range from minimal (if government officials
are already experienced with the agency's procurement requirements)
to moderate (if officials have to learn the new procurement procedures
from scratch) to substantial (if politically-important local suppliers
are unwilling to participate in the procurement process or fail
to make a successful bid).
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17
Will taking a loan impact our existing donor
relationships?
The use of loan funds to support immunization should present few
complications for existing donor relationships. If donors are funding
specific parts of a country's immunization system, then this can
continue; and if technical assistance is being received from donors
or other international agencies, then this remains a valuable contribution
and can actually enhance the loan/project development process.
However, development loans are not just about money.
The involvement of bank staff, in both technical and managerial
capacities, is part-and-parcel of all loans, so an immunization-related
loan inevitably brings an additional "player" to the table
of government officials, donors and other agencies involved in a
country's immunization program. The process of adjusting to these
new circumstances can be substantially eased if a well-functioning
Inter-Agency Coordinating Committee (IACC) is in place, especially
if the IACC and its members are involved or consulted in the loan/project
development process. Also, as discussed in Questions 14 and 16,
loan finances are usually accompanied by specific procurement and
accounting requirements which may differ from those used by the
government or other donors. For example, if a country wants to use
loan funds to buy its vaccines, the lending agency may require a
process of International Competitive Bidding (ICB) before permitting
its funds to be used in this way. This may cause difficulties if
the country has an existing commitment to purchase vaccines from
a specific supplier or through a specific financing intermediary
(such as a revolving fund). However, these circumstances can usually
be resolved by consultation between the involved parties, especially
if anticipated early in the project development process.
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18
What are some of the benefits of development
loans?
Loans have a number of financial and non-financial benefits. These
include:
- A long-term, secure source of financing. Loans
are typically made for periods of five years or more, in contrast
to grants (which are usually for one or two years at a time) and
domestic funds (which may fluctuate from year to year with changes
in the government, the economy, or the government's priorities).
- Large sums of money. Loans provide access to far
larger sums of money (from ~US$ 1 million to US$ 100 million or
more) than can be obtained from grants; and they do so on terms
that are substantially more favorable than loans from commercial
lenders, especially in the case of "soft loans"/credits.
- In-built flexibility. Unwanted loan amounts can
be cancelled or bought-down if not required, or can be reallocated
to other programs if circumstances change before the loan period
ends. Given the flexible legal foundation of development loans
(see Question 21), this is usually a fairly uncomplicated procedure.
- Untied money. Countries can use loan funds to purchase
goods or services from any source, provided the procurement requirements
of the lending agency (which are designed to maximize transparency,
prevent corruption, and obtain products and services at the lowest
cost) are met. Grant funds often come with the condition that
goods and services must be purchased from the donor country, or
may include "in-kind" items such as their staff members'
time, travel expenses etc.
- Domestic ownership and responsiveness to country
needs. Government officials play a large part in designing loan-financed
projects, and development banks frequently make large concessions
to get a loan through. As a result, loan-financed projects may
be more responsive to a country's needs than grants-which, in
many cases, are designed to meet the donor country's requirements
as much as those of the recipient-and they may also stimulate
greater domestic "ownership" of the resulting product.
- Amplification of domestic resources. Countries
that are eligible for "soft loans"/credits can use the
favorable terms on which these loans are made (i.e. no interest,
initial grace period, long repayment periods etc.) to amplify
their own domestic resources-in effect, getting one to three dollars
"free" for every dollar they themselves spend, as explained
in Question 1.
- Strengthening political commitment. Taking a loan
represents de facto political commitment to the service in question-not
just from the MOH but also from the MOF and the government as
a whole. This is good for sustainability, as it improves the profile
of immunization and makes it less likely to be seen as a "weak"
budget item, even after the loan period ends.
- Policy conditions to support sustainability. The
disbursement of a loan is sometimes made conditional on specific
reforms or policy changes. These are generally considered a nuisance,
but they can actually be designed in a way that protects or even
strengthens key aspects of the immunization program: for example,
by mandating a specific annual budgetary commitment to the immunization
program, or by requiring the government to finance a particular
cost component (such as EPI vaccines) from domestic resources
rather than grants or loans. Carefully-designed conditions can
therefore reinforce other efforts to establish the immunization
program on a more sustainable footing.
- Transparency and accountability. The procurement
and accounting requirements that come with a loan can limit corruption
and misuse and therefore improve the likelihood that a loan-financed
project will achieve its intended outcomes-particularly in countries
where corruption, patronage or misuse are common.
- Procurement efficiencies. Procurement practices
such as International Competitive Bidding can result in impressive
cost reductions on vaccines, syringes and other essential program
components. Since these components typically account for around
30 percent of immunization program costs, savings here can have
a dramatic impact on the program's financial condition.
- Technical assistance and knowledge-sharing. Technical
assistance is an inseparable part of the loan process and usually
continues from project design to project implementation. The involvement
of bank staff also provides opportunities for knowledge-sharing
on country experiences, best practices and recent innovations
in the field, all of which can improve the outcome of loan-financed
projects. In addition, technical assistance can be supported through
the loan itself, though some governments are reluctant to use
loan funds for this purpose.
- Strengthening dialogue between the MOH and the
MOF. Health-related loans provide an opportunity to strengthen
relationships and promote increased dialogue between the MOH and
the MOF, and this in turn may enhance the MOH's profile among
all Ministries: an important benefit with long-term consequences
for the MOH's ability to advocate for funding and protect existing
programs. Since MOH and MOF staff often "speak a different
language" (the language of public health vs. the language
of finance), the participation of development bank staff-as facilitators,
interpreters and interlocutors-can help this process take shape
and proceed more smoothly.
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19
What are some of the shortcomings of loan
financing?
Loans also have a number of shortcomings. These include:
- Loans have to be repaid. Unlike grants, loans must
eventually be repaid-whether at a substantial discount (as in
the case of "soft loans"/credits) or at market rates
(as with loans to middle-income countries: see Question 1). This
may pose a problem for highly-indebted poor countries or countries
with severely limited prospects for economic growth or stability
(including currency stability); but for most countries, the loan
amounts are sufficiently small-and the corresponding benefits
sufficiently large-that this is not a problem. Questions 6 and
20 discuss the differences between grant and loan funds, and Question
3 reviews the long-term benefits of investing in immunization.
- Substitution effects. The receipt of a loan may
lead the MOF to reallocate existing budgeted commitments away
from immunization, in which case loan funds would be substituting
for domestic resources rather than supplementing them. Question
13 discusses this problem and ways to avoid it.
- Slow to process. Loans can be slower to process
than grants, though this may be compensated by the larger sums
available from loans.
- Complicated safeguards. Development loans typically
come with a range of procurement and accounting requirements designed
to prevent corruption, improve efficiency and ensure transparency.
For some countries, the need to adjust existing procedures may
be not be worth the effort, especially for small loans; while
in others, political consequences or other factors may make it
difficult to meet these requirements as expected. See also Question
14.
- Policy conditions. Loans sometimes come with specific
policy conditions that must be fulfilled if the loan is to be
granted. In some cases, these conditions may be unacceptable to
a borrowing country, and a loan may be refused on these grounds;
but in many cases, the conditions are developed in consultation
with government officials and can be designed to protect or even
strengthen aspects of the program in question. See also Question
18.
- Variable quality and effectiveness of loan-financed
projects. Not all loan-financed projects are successful. Development
bank and government officials frequently face pressure to develop
and approve projects quickly, and projects are sometimes designed
with flaws that make implementation difficult. In addition, loan-financed
projects are only ever as effective as the government that takes
them: in other words, if implementation capacity is weak, or if
there isn't a substantial level of shared political commitment
to the service that's being borrowed for, then a loan-even with
training, capacity-building, institutional strengthening, etc.-can
only improve affairs to a limited extent.
- Complications in decentralized settings. In large
or highly-decentralized countries, loans can be problematic for
center-state relations. Loans are almost always disbursed to the
central government, while program functions (such as procurement,
operations and maintenance) may be decentralized to sub-central
levels such as provinces or states. A bank can lend directly to
provinces or states, but the center has to guarantee these loans-and
in some countries, it may not be willing to do so.
- Not as flexible as domestic funds. Although loan-financed
projects generally reflect domestic needs and priorities better
than grants, they are still the product of a negotiated agreement
between the government and a development bank and may call for
compromises on both sides. Also, although there is usually considerable
room for flexibility in loan-financed projects (both intrinsically
and in contrast to grants: see Questions 11 and 20 for more),
they don't have the same flexibility as domestic funds-which,
typically, are completely at the discretion of the government
or a given ministry to allocate.
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20
What are the key differences between a grant
and a loan?
Grants and loans differ in a number of key respects. These include:
- The need for repayment. Loans, unlike grants, have
to be repaid, though the repayment amount for "soft loans"/credits
may be substantially less than the amount originally borrowed,
as explained in Question 1. Loans may also come with small grants,
administered and disbursed by the development bank but originating
(in most cases) from bilateral assistance agencies. These can
be used to finance project preparation studies or ancillary activities
such as small side-projects or operations research.
- Conditionalities and other "strings".
Loans and grants both come with a variety of conditionalities,
but grant conditions tend to be more restrictive-in terms of how
the money is used, where purchases are made, who can be involved,
etc.-than those of loans. Loan conditions are generally agreed
in advance with the borrowing country, and in some cases may actually
be requested by the government itself: to protect domestic funding
for immunization, for example, or to specify a policy change that
may be politically difficult to achieve without an external body
to hold responsible.
- Tied aid. Grants often stipulate that a certain
proportion of the grant has to be spent on goods or services (such
as supplies or project consultants) from the donor country-so-called
"tied" aid. This is not the case with loans.
- Country participation and ownership. Loans are
developed through a process of negotiation between country officials
and a development bank, a process in which country officials from
the MOF and MOH have considerable influence in designing the final
product. Grants are often designed to meet the donor's requirements
as much as those of the receiving country. As such, they are sometimes
less receptive to a country's priority requirements (and thus
less likely to stimulate domestic "ownership") than
loans, over which country officials have greater control.
- Period of support. Loans provide a secure source
of financing over a longer period (upwards of three to five years,
and sometimes as long as ten years or more) than most grants (which
are typically for one or two years at a time). This is especially
important for long-term planning and the stability of population-based
programs such as immunization.
- Amounts available. Loans can provide substantially
larger sums of money than grants. For example, a recent immunization-strengthening
project in India was financed with a "soft" loan in
the amount of US $142 million-far more than could have been obtained
from grant funds alone.
- Stability. Grants are more susceptible to geopolitical
influences than loans, which tend to be more neutral.
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21
What is the legal foundation of a development
loan?
Every development loan is based on a "Loan Contract" between
the borrowing government and the development bank providing the
loan. The purpose of this contract is to provide a legal foundation
for the loan and to specify, in very general terms, the loan's objectives,
activities and budget categories. Since these are specified in such
general terms, the loan contract leaves plenty of room for flexibility
and adjustment of the project in response to learning or changed
circumstances. This flexibility is not always obvious from project
design documents, which are typically very specific about the various
inputs, plans, timetables and indicators of a given project; but
since the loan contract is so general-and since it is this document
that forms the legal basis of the loan, not the project design documents-this
flexibility remains an essential and inherent part of virtually
all development loans.
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22
How sustainable is loan financing, especially
when compared with other options? Doesn't it just generate more
"donor dependence"?
If loans are used as a source of temporary funding, without attention
to long-term issues such as capacity building and ensuring a strong
immunization system for the future, then "donor dependence"
becomes a possibility. On the other hand loans, unlike grants, have
to be repaid (even if the repayment amount may be substantially
less, in real terms, than the amount initially borrowed), and this
in itself may bring about a higher level of domestic commitment
to the program-an important benefit that may help to make the program
more sustainable and secure in the long term. A related benefit
is that loans, unlike many grants, are typically developed through
an extensive process of negotiation between the lending agency and
government officials from the MOH and MOF. This helps to promote
domestic "ownership" of the resulting program and ensure
that it is consistent with the government's own priorities.
Even without these factors, many of the activities
that accompany a loan-such as data collection, operations research,
forecasting, financial projections, procurement reviews etc.-have
benefits that can outlast the loan itself. Overall, then, if borrower
countries use their loan proceeds to build a sustainable immunization
system, and if they take advantage of the loan's long maturity time
and inherent flexibility, the problems with sustainability and "donor
dependence" are not likely to materialize.
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23
If we decide to borrow for immunization,
what are some things we should look out for?
Countries that decide to use loan funds as part of their immunization-strengthening
strategy should bear in mind the strengths and weakness of loan
financing, as summarized in Questions 18 and 19. The following points
are also worth remembering throughout the loan/project-development
process:
Make sure the loan is being taken for the right reasons.
Loans that are taken for the sole purpose of meeting a financing
shortfall or a short-term target seldom work to stimulate long-term,
sustainable improvements in a country's immunization system. On
the other hand, loans that are used to strengthen the system through,
for example, improved planning and management, regeneration of an
aging cold chain, or the introduction of new technologies, can bring
about improvements in efficiency and equity that remain in force
until well after the loan period is over. Loans should be used to
improve the efficiency, effectiveness, equity and sustainability
of a program, not simply to meet a financing shortfall.
Make sure the loan is well-designed and suits the
needs of your program. Not all loan-financed projects are successful.
Development bank and government officials frequently face pressure
to develop and approve projects quickly, and projects are sometimes
designed with flaws that make implementation difficult. Both government
officials and development bank staff are responsible for ensuring
the quality, relevance and practicality of projects, but MOH and
MOF officials have considerable leverage in designing and setting
the terms of a loan-certainly more so than with grants, which are
often designed to meet the donor's requirements as much as those
of the receiving country.
Think through the implications for existing relationships.
Immunization programs are typically founded on strong relationships
between government officers and a wide variety of donors, suppliers,
interest groups and international organizations. Depending on the
circumstances, a loan may be associated with certain conditions
or expectations-about procurement procedures, for example-that can
affect these relationships. To avoid unexpected complications, these
effects should be thought through in advance, preferably through
having these groups participate in the loan/project development
process.
Use the project preparation process to conduct a comprehensive
review of the existing system. The project preparation process can
usually be used to conduct a thorough review of the existing immunization
system. Grant funds, often available through the development banks
themselves, can sometimes be used for this purpose.
Avoid being too complicated. The best projects are
often the simplest ones, while complicated projects-which typically
involve many agencies and a long list of objectives and recommended
actions-often face more difficulties. Immunization projects are,
by their nature, complex, and the temptation to squeeze too many
activities or objectives into a single project should be strongly
resisted. Start simply, be successful, and build upwards from there.
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24
Are there any circumstances in which a country
absolutely shouldn't take a loan?
In countries with overwhelming levels of public debt and few immediate
prospects for economic growth, extensive borrowing may not be a
prudent strategy. These countries have other avenues open to them,
including GAVI funds, bilateral grants and the possibility of debt
relief under the HIPC initiative, all of which can be used to good
effect-in both health and economic terms-by investing in the country's
immunization program. If the national budget and grant resources
are still inadequate to finance the highest priority programs, then
governments may need to engage in limited borrowing targeted toward
essential services or other high outcome interventions. Most countries
are not in this situation, however, and most MOFs are comfortable
with the concept of borrowing to make productive investments: especially
given the favorable terms of development credits and their large
grant component (which, as described in Question 1, provides governments
with around two dollars "free" for each dollar they themselves
spend). Given the cost-benefit and cost-effectiveness of immunization
programs, and in view of the relatively small amounts involved,
many countries-including many low-income countries-may be in a situation
to pursue loans as one way of strengthening their immunization programs.
Questions 13 and 19 discuss issues to watch out for in doing so,
but these should not be taken as absolute contraindications-just
general cautions.
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Box 1-Categories of Development Loan
Most development banks use two basic types of lending
instrument: investment loans and adjustment loans. Investment loans
have a long-term focus (five to ten years) and finance goods, works
and services that support social and economic development in a broad
range of sectors. Originally focused on hardware, engineering and
bricks and mortar, investment loans now focus increasingly on institution-building
and social development. In the case of the World Bank, sub-categories
include: Specific Investment Loans (which support the creation,
rehabilitation and maintenance of specific infrastructure investments
such as hospitals and information systems); Sector Investment and
Maintenance Loans (which focus on the entire public expenditure
program of a given sector rather than on a specific project or program);
Adaptable Program Loans (which provide phased support for long-term
investment programs through a series of consecutive loans, each
building on the experiences of the previous one); Learning and Innovation
Loans (which support small pilot-type investment and capacity-building
projects and have a shorter time-frame than other investment loans,
of one to three years); Technical Assistance Loans (which are used
to build institutional capacity both in specific sectors and for
the preparation or implementation of investment or adjustment operations);
and Emergency Recovery Loans (which focus on the restoration of
key systems following extraordinary events such as war or natural
disaster, with a time-frame of two to three years).
Adjustment loans have a short-term focus (one to three
years) and provide quick-disbursing funds to support policy and
institutional reforms. Originally designed to provide support for
macroeconomic reforms, particularly in trade policy and agriculture,
adjustment loans now focus more on structural, financial sector
and social policy reforms and on improving public sector management.
Sub-categories include: Structural Adjustment Loans (which focus
on macroeconomic and structural issues that cut across sectors,
such as trade policy, public sector management and social safety
nets); Sector Adjustment Loans (which support policy changes and
institutional reforms in a specific sector, such as reforms in health
insurance); Programmatic Structural Adjustment Loans (which support
medium-term programs of policy and institutional reform by providing
a series of phased loans over three to five years, each building
on the lessons of the previous one); Special Structural Adjustment
Loans (which are designed to forestall or mitigate the structural
and social consequences of short-term financial crises, in tandem
with IMF operations); and Debt Reduction Loans (which help highly-indebted
countries to reduce their commercial debt, either by converting
it to lower-interest instruments or buying it back at a discount).
Source: World Bank (2000)
World Bank. 2000. "Lending Instruments:
Resources for Development Impact." World Bank Operations Policy
and Strategy Division, July 2000
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Table 1-Cost-Effectiveness of Immunization
vs. Other Interventions
Intervention |
Cost per year of healthy life
gained* |
Immunization with standard EPI antigens** |
$14 to $20 |
Immunization against hepatitis B |
$15 to $35 |
Immunization against HiB |
$20 to $150 |
Community distribution of ORS |
$25 to $75 |
Family planning promotion |
$25 to $75 |
Medical treatment of childhood infections |
$20 to $50 |
Clinical care for pregnancy/delivery |
$30 to $250 |
Curative care for injuries/minor
trauma |
$25 to $250 |
Medical treatment of tetanus |
$75 to $250 |
Medical management of diabetes |
$100 to $250 |
Surgery for cancers |
>$1000 |
Surgery for coronary artery disease |
>$1000 |
Medical treatment
of chronic lung disease |
>$1000 |
* Measured using disability-adjusted life-years
(DALYs).
** Measles, diphtheria, tetanus, pertussis, oral polio and BCG
Sources: Jamison et al. (1993), Peabody et
al. (1999), Miller and McCann (2000)
Peabody J et al. Policy
and Health-Implications for Development in Asia. New York: Cambridge
University Press, 1999
Jamison DT, Mosley WH, Measham AR, Bobadilla J-L (eds.). Disease
Control Priorities in Developing Countries. Washington DC: Oxford
University Press for the World Bank, 1993
Miller M, McCann L. "Policy analysis of the use of hepatitis
B, Haemophilus influenzae type B-, Streptococcus pneumoniae-conjugate
and rotavirus vaccines in national immunization schedules."
Health Economics 9: pp. 19-35, 2000
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Table 2-What Do National Immunization Programs
Cost?
|
Morocco
1997-98 |
Bangladesh
1997-98 |
Côte d'Ivoire
1998 |
Ghana
2000
|
Recurrent costs (% of total)
|
|
|
|
|
Personnel
|
42 |
47 |
54 |
20 |
Vaccines
|
11 |
23 |
13 |
12 |
Supplies
|
1 |
2 |
4 |
8 |
Transportation
|
* |
1 |
1 |
3 |
Short-term training
|
* |
* |
* |
* |
Social mobilization
|
* |
1 |
* |
1 |
Overhead/maintenance
|
2 |
1 |
2 |
1 |
Subtotal
|
57% |
75% |
74% |
45% |
Capital costs (% of total) |
|
|
|
|
Building
|
8 |
5 |
6 |
1 |
Vehicles
|
1 |
1 |
1 |
1 |
Equipment
|
3 |
3 |
2 |
1 |
Long-term training
|
* |
* |
0.00 |
* |
Subtotal
|
12% |
9% |
9% |
4% |
National Immunization Days (% of total) |
|
|
|
|
Subtotal
|
32% |
16% |
18% |
52% |
Total annual costs (US$ million) |
11.2 |
34.3 |
9.6 |
7.6 |
|
|
|
|
|
Total annual costs per capita (US$) |
0.41 |
0.28 |
0.67 |
0.40 |
Total annual costs as % of GDP |
0.03 |
0.08 |
0.09 |
0.11 |
|
|
|
|
|
Immunization coverage (DTP3,%) |
89 |
68 |
64 |
69 |
Sources: Kaddar et al. (2000), Levin et al.
(2001)
Note: Given the less than 80% coverage rate
observed in three of these countries, these costs are not necessarily
optimal and are included for illustrative purposes only.
* Less than 1%
Kaddar M, Levin A, Dougherty
L and Maceira D. "Costs and financing of immunization programs:
findings of four case studies." Special Initiatives Report
26. Bethesda, MD: Partnerships for Health Reform Project, Abt Associates
Inc., May 2000
Levin A, England S, Jorrisen J, Garshong B and Teprey J. "Case
study on the costs and financing of immunization services in Ghana."
Bethesda, MD: Partnerships for Health Reform Project, Abt Associates
Inc., September 2001
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|