Final Summary of Main Outcomes
vaccines are a good 'buy' is not in question. But would immunization still be
a good buy if vaccines cost dollars instead of pennies, if reaching the most inaccessible
communities would cost the system $50 per immunized child, instead of $20? How
much are governments and donors willing to commit to long-term investments in
vaccines and immunization? What about other preventive health services?
GAVI Financing Task Force (FTF) has been exploring these questions, with two major
efforts scheduled to elicit results in the next few months. An immunization financing
database is being developed to document funding flows from both internal and external
sources to low-income countries' immunization programs, and the health systems
in which they operate. Financial Sustainability Plans, a requirement for countries
to continue receiving Vaccine Fund resources, will be prepared by November 2002
in the first 13 countries that received GAVI awards.
efforts will bring valuable information. But with the environment for aid funding
growing increasingly outcome-oriented, and the aid funding picture more complex,
more information is clearly needed. And at its June meeting in Paris, the GAVI
Board emphasized the need for more solid data demonstrating the link between immunization
and better health and economic outcomes in developing countries.
To complement the efforts of the FTF, the GAVI Secretariat
organized Economics and Immunization, a small workshop held in Oslo on
22 and 23 August, with developing country health and finance officials, health
economists, public health experts, and bilateral donors and foundations (see Participants'
List attached). The meeting was organized by ECON1 .
The group was asked to consider and provide input to help shape
a research agenda to:
a. quantify the link between
investing in immunization and prospects for economic development;
clarify the information that decision makers need to justify increased investments
in immunization, and to identify the sources from which such investments must
be met; and
c. explore different mechanisms to increase equitable
access to immunization.
group agreed on the following main points:
programs is doable Improving immunization programs to increase access
in most developing countries today is doable and affordable. According to preliminary
estimates, significantly more children could be reached in the next five years
with incremental increases in spending of less than $100 million per year. Ghana
has shown that increases in immunization coverage can be achieved, in a health
system basket funding approach, through deliberate policy decisions. Further analysis
is needed to determine the cost-effectiveness of different strategies for reaching
Vaccines contribute to the MDGs
Immunization against childhood killers is an example of an essential health
service that will contribute to reducing child mortality, one of the Millennium
Development Goals (MDGs) - the guiding targets for the development community.
The two-way health/poverty link: the case still needs to
be made The causal relationship between improved health outcomes and
economic growth has been widely accepted within the health policy community. Outside
this community, however, the causal link has not been as universally accepted,
including among some of those with fiscal responsibility in developing and donor
countries, and in multilateral agencies and development banks. It will be important
to determine whether this is due to a lack of awareness of the data that exist
or a rejection of these data. Depending on the outcome of this analysis, the most
appropriate response may be better communication, more data, or a combination
Macroeconomic conditions-- It is clear that
the economic benefits of improved health can only be attained in countries that
also have sound economic policies that provide for economic stability. However,
in some countries, the economic indicators may not tell the whole story. There
are reports that the IMF has constrained donor spending on health in certain countries
for fear of destabilizing longer term capacity for government spending. Immunization
may be a good case study to examine this dilemma and determine the limitations
of such defined constraints and whether they harm a countries' ability to improve
the health of its population.
Diversity of countries--
Even a cursory review of data reveals wide disparity in country situations. A
'one size fits all' approach to improving access to immunization or securing long-term
financial sustainability for immunization programs will not work.
predictable donor commitments In order to succeed at long-term financial
planning, developing countries will need longer-term and more reliable commitments
of support from donors. This is especially true for the poorest countries, and
for those whose health budgets rely upon significant external support. Donor commitments
to these countries should be untied to provide the country with decision-making
power, and include an exit strategy if a country rises above a certain income.
Performance targets could be agreed upon and monitored.
vs. external funding While increasing self-sufficiency will always
be the ultimate goal, a new definition of financial sustainability has been adopted
by the GAVI Board, as a country's ability to mobilize and efficiently use domestic
and supplementary external resources on a reliable basis. Countries' internal
allocation of commitments to immunization need to be based on country situations;
initial analysis of commitments within countries shows wide variance. In many
countries, increased financial commitments from the national budgets could in
fact be made a condition for further donor funding, but where external support
is pooled (e.g. sector support and general budget support) increased fungibility
makes the distinction between internal and external support for immunization less
The importance of health system, development
and poverty reduction strategies At the country level, decisions on
financing for immunization are not made in isolation but within the wider context
of funding for the health system and public spending in general. Immunization
coverage is included in many PRSPs as an indicator of health system performance.
The challenge for GAVI is to help secure increased flows of resources for health
by demonstrating results, rather than to focus too narrowly on immunization in
As a result of
the discussions, the GAVI Secretariat will ask partners to consider funding for
three research projects. Considering the need to have rapid results and minimize
burdens on under-staffed and over-burdened developing country health ministries,
the researchers will probe existing data sources instead of launching new investigations.
1. Immunization and Development
Bloom and Canning2 will be commissioned to analyze
the economic benefits of increasing investment to expand immunization coverage,
especially as compared to investing in other interventions including new
vaccines and other poverty alleviation efforts such as education, malaria control
and family planning programs. The analysis should include:
distinction between the cost/benefits of increasing coverage of:
basic 6 vaccines,
- the above plus the additional antigens
against hepB and Hib,
- the above plus future new vaccines
(against pneumo and rota, for example)
and Donor Behavior
ECON will be commissioned to undertake a
project to identify appropriate donor and developing country commitments to immunization
programs in health systems. The project will aim to produce an information-based
advocacy strategy to secure high-level political commitment. Components will include:
- A grouping of countries based on their current macroeconomic,
health and budgetary situations.
- In collaboration with the
FTF, an in-depth analysis of data from one representative country from each of
the above groups. Analysis will include:
- donor contribution
to health system,
- government spending on health as a proportion
of GDP and budget, and the nature of spending
- overall MTEF
and PRSP priorities and commitments
- predicted costs of expanding
coverage with basic vaccines; with hep B; Hib; and adding new vaccines
health outcome indicators
- Based on the above analysis,
assessment of the prospects for investments from internal budgets versus external
3. A Strategic Framework for Increasing Access
access team has been identified from within the GAVI Implementation Task Force.
To complement the team's efforts, the GAVI Secretariat and partners will work
further with McKinsey Consulting to develop a strategic framework for how the
Alliance can support countries to increase access not only to immunization but
to other essential health services as well. The project, which will be conducted
in close collaboration with the GAVI Implementation and Financing Task Forces
and health system experts, will include the following:
of countries based on their current DTP3 coverage and future targets
of possible incentive schemes at the district level.
of important district-level tools 'best practices' that could be
shared with other countries to improve the quality of all primary health care.
- Analysis of the roles of the different actors government
officials, national, regional and global representatives of GAVI partners, and
The Partners Meeting in Dakar from
20-22 November will provide an important opportunity to continue the discussions
launched in Oslo and review the progress to date on the activities stemming from
the meeting. By February/March of 2003, the work on the projects will be near
completion and brought together with the work of the FTF on financial sustainability
plans and the immunization financing database.
ECON Centre for economic analysis, Oslo, Norway.
David Bloom, professor of economics and demography; and David Canning, professor
of economics, both at Harvard University's School of Public Health.