Addressing immunization financing bottlenecks to achieve immunization

goals: Country case studiesMike McQuestion

Sabin Vaccine InstituteMike McQuestion

SAGE WG on GVAP meetingGeneva, Switzerland

1 September 2015

Introduction

• The quest for sustainable immunization financing necessarily and positively affects overall health systems financing

• Country ownership the result of cumulative institutional change processes within countries

• Two case studies – Uganda: legislation– DRC: resource tracking

Case study: Uganda• November- December 2011: Sabin organizes

a series of peer exchanges among district-level legislators to study immunization financing, legislation

• February 2012: MPs form Ugandan Parliamentary Forum on Immunization (UPFI)

• May 2012: Sabin, USAID, MOH organize a briefing on immunization financing for Uganda Local Government Association

Case study: Uganda• November 2012: UPFI member introduces

Uganda National Immunization Bill to Parliament

• December 2012: During budget hearings, UPFI members convince health minister to increase budget, recruit more health workers– health budget is resubmitted, leading to first

district-level staffing increase since 2008

Case study: Uganda• January 2014: Uganda (temporarily) enters

default status on Gavi co-financing• March 2014: UPFI member introduces

National Immunization Bill to Parliament • May 2014: Speaker of the House requests,

Sabin later arranges a parliamentary study tour to another country with a national immunization fund (Mongolia)

Case study: Uganda

• March 2015: Health Committee revises National Immunization Bill to include explicit public financing provision for newer vaccines (national immunization fund)

• July 2015: Chair of Ugandan NITAG writes Speaker of the House enquiring on status of revised National Immunization Bill– now in second reading status– to be scheduled for vote before end of 2015

Case study: DRC• April 2012: MPs form Parliamentary Forum on

immunization (current membership: 50)• August 2012: Sabin officer, EPI team perform

first R.I. budget flow analysis– reveals serious cash hoarding (Treasury withholding

approved budget) • November 2013- present: MoH EPI team

continuously monitors R.I. budget flow, reports expenditures regularly to ICC, parliament, others

Case study: DRC

Budget Processes

Description Accounting concepts Amount in US$Local Currency

exchange rate to US$ =

1The initial projected immunization program budget (from current cMYP, amount of routine recurrent government projected costs, Spreadsheet 4. Financing)

Projected government R.I. budget

2The adjusted proposed immunization budget after review by the Ministry of Health, Council of Ministers or other budget review institution(s). The amount that was submitted for parliamentary approval.

Immunization budget proposed by MOH

3 The final immunization budget that was approved by parliament. Immunization budget approved by parliamentFramework Indicators

PEFA Indicator KeyFormula Guide

Cash Hoarding

Misclassification

Budget Credibility

Absorptive Capacity

Reporting Accuracy

(Box 7 / Box 6 ) x 100

Phase-V:Reporting 8

Amount of government routine EPI expenditures reported for Indicator 6730 of the WHO/UNICEF Joint Reporting Form (JRF) for the reporting year.

If Box 7 > Box 8, then (Box 8/ Box 7) x 100If Box 7 < Box 8, then (Box 7/ Box 8) x 100

Phase-IV:Expenditure 7 Amount of actual public routine immunization program expenditures.

Includes expenditures against in-year supplementary budgets. Total immunization expenditures as of end fiscal year

[ (Box 5 - Box 6) / Box 5 ] x 100

6 Amount of funds in Box 5 actually allocated by the Ministry of Health to the immunization program.

Amount of disbursed budget actually allocated to immunization program

(Box 7 /(Box 3+ Box 4 ) x 100

Phase-III:Disbursement

5 The amount of funds disbursed by Treasury to the Ministry of Health for immunization.

Amount disbursed against approved immunization budget by Treasury to MOH

Phase-I:Proposed Budget Public Expenditure and Financing

Accountability (PEFA)

Phase-II:Approved

Budget4 Additional in-year funds approved for immunization. Any additional

(supplemental) increases to the budget during the fiscal year.

Total in-year immunization budget increase(s) approved by parliament [ ((Box 3 + Box 4) - Box 5) /(Box 3+ Box 4) ] x 100

End: XXXCountry: Fiscal Year: Start: XXX

Case study: DRC

02468

10121416

2010 2011 2012 2013 2014

Routine immunization program budget performance: DRC (nominal US$m)

(sources: Sabin SIF budget flow analyses, provisional MoH data, WHO/UNICEF JRF)

approved disbursed spent reported

Case study: DRC

Indicator 2010 2011 2012 2013 2014cash hoarding1 57% 63% 10% 41% 31%misclassification2 - - 8% 4% 1%absorptive capacity3 100% 100% 78% 77% 85%budget credibility4 54% 19% 77% 44% 59%reporting accuracy5 9% 35% 100% 100% 100%

4 Program expenditures as a percent of approved budget5 Percent of program expenditures reported (JRF Indicator 6730)

Derived Sabin SIF budget flow indicators: DRC (Provisional MoH data)

Notes:1 Percent of approved budget not disbursed by treasury to MOH2 Percent of immunization allotment not allocated by MOH to immunization program3 Percent of allocated funds spent by immunization program

Case study: DRC

0

20

40

60

80

100

2010 2011 2012 2013 2014

Derived Sabin SIF budget flow indicators: DRC(Sources: Sabin SIF budget flow analyses, provisional MoH data,

WHO/UNICEF JRF)

cash hoarding misclassification absorptive capacity

budget credibility reporting accuracy

Case study: DRC

• 2013, 2014: REPACAV members confront prime minister during annual budget hearings, demand and win R.I. budget increases

• 2014: Minister of Budget promises to preserve 2014 R.I. budget for 2015, does so

Case study: DRC

• October 2013- present: REPACAV undertakes subnational advocacy– REPACAV delegations visit 8/11 provinces,

advocate with governors, parliaments, win provincial immunization, health budget increases

• funding: Sabin, PATH, SANRU (Gavi CSO)– September 2014: MoH adds new R.I. budget

line item to partially finance REPACAV fieldwork

Case study: DRC• December 2014: Minister of Health meets

with REPAVAV delegation, urges them to continue their oversight and provincial advocacy work

• January 2015- present: REPACAV members attend monthly ICC meetings

• August 2015: Prime minister requests monthly briefings by REPACAV on immunization financing status

Thank you!