GAVI and Financing Expanded Immunization Programs

1
GAVI and Financing Expanded Immunization Programs

• but the opportunities for financing expanded
  immunization programs and the introduction of new
  vaccines has never been stronger

Steve Landry Co-Chair GAVI Financing Task Force
2
GAVI is an Alliance
Governments- industrialized countries United
States Canada United Kingdom
Governments-developing countries India
Mozambique Mongolia
Vaccine industry- industrialized
country Wyeth-Ayerst, USA
WHO

• Vaccine industry-
• developing
• country
• Serum Institute, India

UNICEF
The World Bank
Technical health institute CDC, USA
The Bill Melinda Gates Foundation
Research institute Institut Pasteur, France
Foundation UN Foundation
NGO Sierra Leone Red Cross,
3
Strategic Objectives

• Improve access to sustainable immunization
  services
• Expand use of all existing, safe and
  cost-effective vaccines where they address a
  public health problem
• Accelerate development and introduction of new
  vaccines and technologies
• Accelerate RD efforts for vaccines needed
  primarily in developing countries
• Make immunization coverage a centerpiece in
  international development efforts

4
GAVI and Vaccine Fund Structure
GAVI Board
Vaccine Fund
WG
SEC
FTF
CTF
TFRD
ITF
RWG
Governments and ICC partners
5
GAVI/Vaccine Fund

• Options for Support
• Service delivery
• 20/child immunised)
• Vaccine introduction
• Hep B, Hib, YF
• Injection safety
• AD Syringes 3 years

• Basic Conditions for Support
• GNP/capita lt US 1000
• ICC or equivalent
• Immunization assessment in last 3 yrs
• Multi-year plan for immunization
• Strategy for injection safety

Funds to support vaccine research and
development Accelerated Development and
Introduction Programs
6
75 countries eligible for Vaccine Fund support

7
Status of approvals

8
Common Problems in Immunization Financing (1)

• Continuous increases in program costs resulting
  from program improvements and expansions
• Inadequate, unpredictable national resources -MOH
  budgets limited and unprotected from economic
  shocks

9
Common Problems in Immunization Financing (2)

• Unpredictable external resources
• Vulnerable to changing partner trends
• Support tied to partner priorities
• Traditional dependence on partners
• Less than optimal attention paid to program
  inefficiencies
• Challenging systems for financial management
• Budgetary allocations based on low vaccine costs

Sticker Shock
10
Fluctuations in Financial Flows
11
What Will GAVI/Vaccine Fund Do?

• Provide additional resources to increase
  coverage, improve program safety efficiency,
  introduce newer vaccines
• Improve partner coordination and contributions
• Support essential information systems and
  capacity building
• Foster movement toward sustainable financing
• Evolution toward adequacy and reliability in both
  domestic and external resources to meet expanding
  program objectives
• Improvement in program efficiency and financial
  management

12
Results Long-term commitments
Multi-year commitments to 64 countries, as of
November 2002
Immunization services 368 million
(40) (including safety) New under-used
vaccines 537 million (60) TOTAL 905 million
13
Vaccine Fund Investments

• Additive Catalytic
• Support national plans
• Medium-term - 3 to 8 year commitments
• Assumes a transition of financial responsibility
  from Vaccine Fund to governments and partners
• Vaccine Fund - recapitalized to support new set
  of national priorities
• Challenge transition of financial responsibility

14
Vaccine Fund Catalyzing funding for vaccine
introduction

Government/Partners
5
10
20
Years
15
Vaccine Fund Catalyzing funding for vaccine
introduction
Vaccine Fund (Hep B, Hib, YF)

Government/Partners
5
10
20
Years
16
Vaccine Fund Catalyzing funding for vaccine
introduction
Vaccine Fund (Hep B, Hib, YF)

Government/Partners
5
10
20
Years
17
Vaccine Fund Catalyzing funding for vaccine
introduction
Vaccine Fund (next priorities)
Vaccine Fund (Hip B, Hib, YF)

Government/Partners
5
10
20
Years
18
Vaccine Fund Catalyzing funding for vaccine
introduction
Vaccine Fund (next priorities)
Vaccine Fund (HepB B, Hib, YF)

Government/Partners
5
10
20
Years
19
Vaccine Fund Catalyzing funding for vaccine
introduction
Vaccine Fund (AIDs, Malaria, TB?)
Vaccine Fund (next priorities)
Vaccine Fund (HepB B, Hib, YF)

Government/Partners
5
10
20
Years
20
Vaccine Fund Catalyzing funding for vaccine
introduction
Vaccine Fund (AIDs, Malaria, TB?)
Vaccine Fund (next priorities)
Vaccine Fund (HepB B, Hib, YF)

Government/Partners
5
10
20
Years
21
(No Transcript)
22
Meeting the Challenge

• Multiyear plans applications did not include
  rigorous financial analyses nor plans for
  addressing resource gaps
• GAVI requirement 2 years after initial Vaccine
  Fund award
• Established consultative process for determining
  how to support countries improve the financial
  sustainability of immunization efforts

23
Defining Financial Sustainability
Obtain and use

• Although self-sufficiency is the ultimate goal,
  in the nearer term, sustainable financing is the
  ability of a country to mobilize and efficiently
  use domestic and supplementary external resources
  on a reliable basis to achieve target levels of
  immunization performance.
• - GAVI Board, London, June 2001

24
Things do look brighter!
25
EXTRA SLIDES
26
Why Financial Sustainability Plans?

• Mechanism and process for analysis, exploration
  of options, planning, consultation, and
  negotiation
• Structures the conversation between MOH and
  MOF, country and partnersthe ICC
• GAVI requirement 2 years after initial Vaccine
  Fund award

27
What Is a Financial Sustainability Plan?

• FSP is a governments statement about how it is
  going to match financing with program objectives
  over the medium- to long-term
• An assessment of the financing challenges
• A strategy for dealing with those challenges
• In consultation and negotiation within
  government, and with funding partners

28
Resource Requirements Likelihood of Future
Funding
29
The Big Picture

• Government expenditure on immunization/total
  government health budget
• Morocco 2.2
• Bangladesh 4.4
• Cote dIvoire 4.6
• Colombia 2.8

Kaddar, Miloud et al., PHR Project, Abt
Associates, May 2000
30
Cost Profile of Immunization Programs
31
Variability in Financing
32
Year to Year Variability in Financial Flows
33
What is financial sustainability?

• Narrow focus (traditional)
• Funding for vaccine purchase and/or
• Self-sufficiency

• Broad focus (new direction)
• Full immunization system
• Sufficient and reliable funding over the
  long-term, from all sources (public, private
  national, external)
• New attention to fiscal and program management

34
Good Immunization Financing

• Promotes equity
• Achieves efficiency
• Provides resources in an adequate, timely and
  reliable manner
• Engenders accountability
• Encourages highest level of self-sufficiency

Always choices and always trade-offs. . .
35
Immunization Financing Options

• Bilateral/ multilateral project grants
• HIPC/debt relief proceeds
• National budget support
• Vaccine Fund

• Domestic Public
• Domestic Private

• External Public
• External Private

• General revenues
• (central and sub-national)
• Social health insurance

• User fees
• Cross-subsidies
• Health Insurance

• Philanthropic grants
• Contributions

• Mixed External and Domestic
• Financing Mechanisms

• Development loans

• Revolving funds (PAHO, VII)
• National trust funds

36
Highly Indebted Poor Countries HIPC The Big
Picture
How to influence the big picture?
Poverty Reduction Strategy
Health
Immunizations
37
Success in Tanzania

• Poverty Reduction Strategy Paper completed
• Debt relief funds released
• Substantial increase in immunization budget
• 2001 1.89 million
• 2002 3.47 million
• 2003 9.52 million
• 2004 8.13 million

38
Loans for Immunization

• Considerable apprehension
• Various concerns. . .
• Why do we have to get into debt for
  immunization?
• Wont loans lead to more donor dependence?
• Isnt the point to get out of debt, not into
  more of it?
• GAVI FTF QA/case studies

39
Overview of Presentation

• GAVI/Financing Task Force/Vaccine Fund
• Immunization financing- what we know
• Approaches to financing improved programs
• What this community can do to contribute to
  sustained immunization financing

40
What thwarts the financing of new vaccine
introduction ?
Sticker Shock of newer vaccines ?

• Immunization lt 5 of total health budget
  -Decimal dust
• Exploration of financing options strongly
  underway

Look at investment in health overall Within
health, efficient and improved investment in
health recognising that immunization programs
will be increasingly more expensive with the
addition of new antigens and the expansion of
coverage
41
What do the financing buffs look to this
community for ?
Health is an investment overall Within health,
prevention services such as immunization are
critical Within preventive healh services,
immunization.. Justify use of new products what
is the disease burden and what is the value of
the intervention Hib Vaccine.

Why should we add a new vaccine?
What is the burden of disease?
42
Financing Task Force work is available on the web
www.vaccinealliance.org
FTF Working Website www.gaviftf.org
43
Things do look brighter!
44
Questions and Concerns/

• What are the macroeconomic consequences of
  borrowing?
• Can loans be used to pay for vaccines? If so,
  what is the implication for our procurement
  procedures?
• Are there circumstances in which loans should
  not be used?
• How sustainable is loan financing? Doesnt it
  just generate more donor dependence?

45
Benefits of loans

• Long-term, secure source of financing
• Large sums of money are available
• In-built flexibility
• Untied money
• Domestic ownership, responsiveness to country
  needs
• Amplification of domestic resources
• Strengthening political commitment
• Policy conditions to support sustainability
• Transparency, accountability, procurement
  efficiencies
• Technical assistance and knowledge-sharing

46
Variability in Cost Structures
47
Variability in Financing Structures
48
Vaccine Fund Disbursement Criteria
DTP3 coverage lt50

• immunization services
• injection safety

• Basic Conditions for Support
• GNP/capita lt US 1000
• ICC or equivalent
• Immunization assessment in last 3 yrs
• Multi-year plan for immunization
• Strategy for injection safety

• immunization services AND
• new / under-used vaccines
• injection safety

DTP3 coverage 50-80
DTP3 coverage gt80

• new / under-used vaccines
• injection safety

49
GAVI/Vaccine Fund Support

• Funds are
• flexible, system neutral
• not to replace current funding
• catalytic and short-term, to complement more
  sustainable sources
• provided over 5 8 years

• Service delivery
• 20/child immunised)
• Vaccine introduction
• Hep B, Hib, YF
• Injection safety
• AD Syringes 3 years
• General funds to support vaccine research and
  development

50
What is the role of GAVI Partners?

• Generate and sustain consensus about
  international community responsibilities
• Advocate for increased investment in human
  capital
• Explore and endorse appropriate financing
  opportunities
• Support preparation and review of financial
  sustainability plans
• Support capacity-building for financial
  sustainability
• Document international experience

51
Coverage of basic vaccines over the last ten years

• Basic immunization coverage worldwide
• Percent

• Aging infrastructure and limited investments
• Mobility and HIV remove workers
• Lack of attention because of invisible effect of
  immunization
• Focus on campaigns (Polio)

• Increasing attention to immunization due to
  availability of effective vaccine
• Infrastructure build-up
• Initiation of national EPI programs

DTP, polio, measles, BCG Source GAVI,
interviews
52
The Challenge Avoid the time lag seen for hepB
and Hib
Million doses
HepB -- all developing countries
The Vaccine Fund established
Hep B available in the US
HepB -- all developing countries, excl. India,
China, Indonesia
Hib available In the US
Hib -- all developing countries
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
GAVI forecasts