Advocacy and political will for sustainability

e McQuestionSabin Vaccine Institute

Mike McQuestionMeeting of the Regional Working Group on

Immunization for Gavi-supported countries in the Western Pacific

WHO/WPRO Manila, Philippines19 January 2016

Introduction

Sabin SIF Program:

•Funded by Bill & Melinda Gates Foundation (2008-present) and GAVI Alliance (2012-present)•Fifteen pilot countries chosen in 2008 in consultation with GAVI partners, seven more (GAVI-graduating) countries in 2012 •Seven Senior Program Officers based in Africa (4), Asia (2), Europe (1) backed by three Washington, DC-based Sabin staff

The Sustainable Immunization Financing Program

The SIF Program facilitates and catalyzes efforts to secure sustainable funding for immunization programs in twenty-two lower and middle income countriesSIF Senior Program Officers coordinate directly with counterparts in government ministries and parliaments, subnational decision makers and the private sector to develop innovative financing solutions

Outline

• Advocacy and institutional change• Case studies

Change scenario• How can we move from the current

dependent situation, where countries rely on outside funding for immunization, to the goal of sustainable country ownership?

• Focus on the key public institutions: MoH, MoF, parliament, subnational governments

• Induce institutional changes through targeted advocacy efforts

Change scenario• Institutional change (innovation) means

developing new ways of working, ie new best practices

• Each institution must innovateMinistry of health begins to monitor and report

program efficiency (ie, expenditures per fully immunized child), allowing a stronger immunization investment case to be made

Change scenarioMinistry of finance considers these efficiency

estimates when it recommends and follows the execution of the immunization budget

Subnational governments, elected bodies form realistic immunization budgets, actively follow EPI performance

Parliament scrutinizes the annual health and EPI budgets, follows program execution (technical and budgetary), helps mobilize constituents, approves vaccine legislation

Government, parliament write or update laws

Institutional innovation• Expected results of these innovations

• Larger, more efficient immunization budgets• Up-to-date legislation guaranteeing those

budgets (earmarking) and providing for other aspects of vaccination

• More domestic stakeholders actively supporting immunization

• Public comes to expect a high-performing national immunization program provided by their government (public good)

Institutional logics

• The state institutions- government and parliament- must work together

• But these institutional actors follow different logics

• For those who follow a welfare logic, one might argue that immunization is a basic human right

Institutional logics

• According to the logic of medicine and public health, no one should be left unvaccinated

• Economic logic holds that immunizations are a justifiable investment provided the data show they are cost effective or cost savings

Institutional logics• According to the logic of public finance,

the EPI program deserves a bigger budget provided there is unmet need, adequate revenues and the program meets three criteria: absorptive capacity, allocative efficiency and value for money

Institutional logics

• Political logic maintains that inmunizations are part of the social contract, something the state should provide as a public good

• In addition, to assure a well functioning EPI program is to deserve more votes!

Institutional innovation • Innovation comes through advocates

(champions) who do the necessary institutional work

• They explain their case in rational terms• They use different techniques

Mimicry: associate the change with other, existing practices

Theorize: elaborate causal argumentsEducate: impart the new skills needed (Lawrence

and Suddaby 2006)

Institutional innovation

• These are observable processes Champions and those they engage produce

texts- written, spoken, symbolic- for or against the innovation

Connecting these texts, actors construct the innovation, arriving at a common understanding of the meaning of the new idea or practice (Phillips and Malhotra 2008)

Case studies

• The art of advocacy is knowing how to formulate messages that fit into each particular institution’s logic and how to deliver them effectively

• Some examples: – EPI manager makes investment case to MPs– Finance officer convinces health director to

cross analyze data, report expenditure per fully immunized child

Case studies

• Advocacy examples, continued– Rotary and Lions clubs convince Government

of Nepal to create an immunization trust fund– MPs from National Assembly convince

provincial MPs to join national MP immunization network

– EPI team analyzes provincial immunization expenditures, demonstrates program efficiency, avoids mandated budget cut

Institutional innovation

• “…organizational change is unplanned and goes on largely behind the backs of groups that wish to influence it” (DiMaggio and Powell 1983:157).

Thank you!

SIF Domains

• Legislation• Advocacy Coalitions• Financing Mechanisms• Budget, resource Tracking

SIF Graduation CriteriaFinancing Arrangements:•Self-sufficiency. Domestic financing covers all routine immunization functions except new vaccine introduction •Composition. Federal, provincial, and municipal governments jointly finance routine immunization•Sustainability. Financing is structured in a way that protects finance flows from economic, political, or institutional disruptions•Legislation. Public financing for immunization is guaranteed by law

SIF Graduation CriteriaBudget and oversight:•Method. Routine immunization budget is based on actual expenditures •Disbursement. Treasury disburses full approved immunization program budget to Ministry of Health•Allocation. Ministry of Health allocates full disbursed budget to immunization program•Resource tracking. In-year program expenditures are tracked at national and subnational levels•Absorptive capacity. Immunization program spends 90% or more of its allocated budget•Reporting. Allocated immunization budget and expenditures are reported to the finance office in the Ministry of Health•Oversight. Legislators oversee execution of approved immunization budget

SIF Graduation CriteriaPolicy and advocacy:•Policy. Routine immunization program explicitly supported in national health policy/plans/expenditure frameworks•Transparency. Federal and subnational officials, parliamentarians, the public are regularly informed about immunization outputs and expenditures (value for money) •Representation. Parliamentarians participate in immunization-related field activities

Public Goods• Public (collective) good: “The achievement of a common

goal, or satisfaction of a common interest” (Olson 1965)• Under certain conditions, actors in a collectivity will provide a

public good through collective action– Unattainable individually: can only be provided collectively– Jointness of supply: available to everyone if available to anyone– Non-excludability: cannot be feasibly withheld from any group member

• Examples: – A lighthouse, an army, a public education system, an immunized

society, a world without polio (Smith et al. 2007)– The SIF Program’s public good is a sustainably financed national

immunization program

• Necessary conditions for collective action Monitoring and feedback on the contributions

each actor makes toward the public goodMonitoring and feedback on progress being

made toward the goal (efficacy)Strategies change as neededActors learn from one anotherIndividual actors are publicly recognized for

their contributions

Collective action

Collective action• In practice, collective action is a process, a

series of individual decisions about whether to participate or not

• An actor decides, taking into account the decisions of nearby others (threshold effect) (Oliver et al 1985)

• If there is an organizing group, or a critical mass of committed actors, it is more probable the collective action will succeed

Examples of collective activities for sustainable immunization financing MoH, MoF and counterparts regularly analyze

expenditures and program outputs together to make the investment case for immunization

MoH, MoF and parliamentary counterparts meet regularly to discuss this updated information and follow immunization budget performance throughout the year

Parliament participates actively in formulating sector budget

Parliamentarians regularly visit, assess immunization performance in their constituent areas

SIF Program: Collective action

• Collective action ends when the country finds its particular sustainable financing solution Adequate, reliable funding External dependencies minimized or eliminated Supporting legislation enacted

SIF Program: Collective action

Thank you!