Immunization Financing: A resource guide for advocates, policymakers, and program managers
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Introduction

Brief

Immunization is one of the best uses governments can make of limited public funds for health. Yet 1.5 million children under age 5 die from vaccine-preventable diseases every year and 19 million remain underimmunized."† This introduction notes some important developments in the global immunization environment that set the context for this resource guide and highlights some important themes in the document as a whole.

Trends

Several important trends have emerged or accelerated since the previous edition of this resource guide (titled Immunization Financing Toolkit) was published in 2010:

  • Countries and the international community have made powerful new commitments to immunization and immunization financing. Most importantly, the Global Vaccine Action Plan (GVAP) was endorsed in 2012 by all 194 member states at the World Health Assembly. This resource guide can help advance GVAP’s Strategic Objective 5, which calls for immunization programs to have “sustainable access to predictable funding.” In addition, at the Ministerial Conference on Immunization in Africa in 2016, African countries committed to increasing domestic financing for both vaccines and immunization service delivery.

  • Gavi, the Vaccine Alliance, the most important external source of funding for immunization programs in developing countries, revised its policies for eligibility and transition (formerly graduation) in 2009 and again in 2015. As a result, many countries whose economies have grown are in the process of phasing out Gavi support and preparing to assume full responsibility for financing their immunization programs.

  • The menu of new vaccines available to low- and middle-income countries has continued to expand. Since 2010, Gavi has added human papillomavirus (HPV), Japanese encephalitis, inactivated polio, and rubella vaccines to its portfolio, and a dengue vaccine has been licensed in some countries. These vaccines are powerful life-saving tools, but they also bring new financing challenges; many are substantially more expensive than the traditional vaccines that most countries have long paid for using their own resources. Non- Gavi-eligible countries must pay the full cost of new vaccines from the start, while Gavi-eligible and transitioning countries that receive Gavi support must plan for assuming these costs over the long term.

  • Interest in new or unconventional financing sources for immunization, and for health more broadly, has grown. These financing sources range from trust funds and endowment funds to new taxes and national lotteries. Many policymakers and other stakeholders have no experience with these mechanisms.

These trends are happening in the context of historic commitments by countries at all income levels to achieve universal health coverage (UHC)—access to necessary health care for all, regardless of the ability to pay and without financial hardship. This global commitment is embodied in a United Nations resolution and the 2030 Agenda for Sustainable Development, a global plan that includes a target to achieve UHC by 2030, along with access to safe, effective, quality, and affordable essential medicines and vaccines for all. Although countries are moving toward UHC on different paths, the process often requires broad changes in the way health services, including immunization, are financed and accessed. The implications of UHC-related reforms for immunization financing are an important theme of this edition of the resource guide.

Assessing Immunization Financing Options

This resource guide assesses financing mechanisms and financing sources for immunization using six main criteria: additional resources raised, cost, predictability, sustainability, flexibility, and equity. Not all of these criteria are relevant to every financing mechanism, however, and other considerations may be important in certain contexts. For example, particular financing mechanisms may promote transparency and accountability to a greater degree than others, and some new mechanisms may be useful in drawing attention to and building popular support for immunization.

In most cases, how a mechanism rates on a particular criterion depends on how it is implemented and on the country context. For this reason, the briefs in this resource guide focus less on definitive judgments about particular financing options and more on the conditions that affect whether a mechanism can be effective. For example, the predictability of financing from an earmarked tax depends on factors such as the nature of the tax, how consumption of the taxed good or service changes with economic conditions, and how easily the tax can be evaded.

Financing mechanisms can, of course, be assessed from different perspectives. The resource guide’s primary focus is on the needs of immunization programs, but it also views these needs within the broader context of health financing and notes when these perspectives may come into conflict. Policymakers must balance immunization against other health priorities, and they must balance spending on commodities (such as vaccines) against spending on other aspects of the basic service delivery platform on which all programs depend. Ultimately, advocating for larger health budgets is as important as advocating for immunization within health budgets.

Major Themes

Each brief in this resource guide can be read separately, but several themes emerge from the volume as a whole.

Immunization is a public responsibility. Immunization is in the public interest because its benefits extend beyond those who receive vaccines to the population as a whole, through the control of infectious diseases. Governments therefore have primary responsibility for overseeing and financing immunization programs, with assistance from international donors in the case of the poorest countries. Moreover, immunization should be free because even small costs to households can be a barrier to access. Thus, while the private sector may have important roles to play (for example, in vaccine manufacturing or service delivery) in some countries, governments retain overall responsibility for ensuring that vaccines in the national program are available and free to those who need them.

Ultimately, advocating for larger health budgets is as important as advocating for immunization within health budgets.

Immunization financing should be considered in the context of the movement toward UHC. Access to immunization—and investments in robust immunization services that can serve as a platform for delivering other vital health services— is central to the goal of achieving UHC. At the same time, immunization planning and budgeting must fit within each country’s health financing architecture as it evolves to meet the UHC goal. In the long run, immunization services will benefit from efforts to strengthen the capacity of health systems to deliver a full package of critical services. But the ongoing transformation of health systems can also pose risks to immunization programs. Countries must ensure that funding for the various components of immunization does not fall through the cracks as health financing systems evolve. Changes made to health financing and delivery as part of the move toward UHC can reduce access to immunization if the new UHC architecture covers less of the population than existing immunization programs do. Decentralization processes happening in parallel in many countries also pose challenges for immunization financing, and countries must think carefully about which essential functions and financing responsibilities should lie with which levels of government and plan to build needed capacity accordingly.

Regular health-sector budgets are likely to remain the main source of funds for immunization, although new sources of financing for immunization can play a complementary role. A wide variety of alternative financing mechanisms for immunization have been proposed, including trust funds, lotteries, and earmarked taxes, but few have been implemented. Briefs in this resource guide offer general assessments of several innovative funding sources, but countries should carry out their own assessments in light of their own circumstances.

General government revenues, supplemented where relevant by social insurance contributions and donor financing, will remain the financial backbone of most countries’ health and immunization programs. These traditional public financing systems are typically the most equitable and sustainable, and they are managed through existing public financial management systems. Pursuit of secondary funding sources should not distract governments and advocates from ensuring adequate and sustainable allocations from the general health budget both for immunization and for the broader health service delivery platform on which it depends.

Regular health-sector budgets are likely to remain the main source of funds for immunization.

The various components of immunization programs have different financing needs. The activities that make up immunization programs have different characteristics, which in turn have implications for financing. For example, vaccine procurement typically involves long lead times, requires assured and timely disbursement of funds, and is best carried out centrally to maximize economies of scale and predictability for suppliers. Vaccine delivery, on the other hand, is typically integrated with the delivery of other services in clinics and communities, so most costs are shared. Supply chains involve responsibilities at different levels of the health system. The characteristics and financing needs of these functions must be taken into account in weighing alternative approaches to immunization financing.

Raising resources for immunization is important, but how funds are spent can also make a big difference. By using funds more efficiently, countries can do more with limited immunization resources. In many cases, the greatest opportunities for gains may come from improved procurement of vaccines because vaccine purchases account for a large share of immunization expenditure and the prices paid by countries in similar circumstances can vary considerably. Improvements in the way health services, including vaccine delivery, are purchased can also increase the quality and reach of those services by creating a better balance of incentives. Strengthening processes and institutions for immunization decision-making, including by making greater use of economic analysis, can also help ensure that funds for immunization yield the greatest possible health and economic benefits. Finally, improvements in public financial management are critical to efficient and predictable financing of all health programs.

Gavi-eligible as well as transitioning countries must plan for life after Gavi. In the past 15 years, external financing through Gavi has given many countries an unprecedented opportunity to introduce important new vaccines and strengthen delivery systems and supply chains. However, countries must prepare to eventually assume full responsibility for financing their own growing immunization programs.

Sources and Further Reading

Addis Declaration on Immunization. Ministerial Conference on Immunization in Africa. Addis Ababa, Ethiopia; 2016 Feb 7. Available from: http://immunizationinafrica2016.org/ministerial-declaration-english

Brenzel L, Jones A. Immunization financing toolkit: a resource for policy-makers and program managers. World Bank and the GAVI Alliance; 2010. Archived at: https://perma.cc/2L2T-Z38V

GAVI Financing Task Force. Immunization financing options: a resource for policymakers. Archived at: https://perma.cc/C4D2-YV3H

World Health Organization. Global Vaccine Action Plan 2011–2020. Available from: http://www.who.int/immunization/global_vaccine_action_plan/en/

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