Analysis of Immunization Financing Indicators of the WHO-UNICEF Joint Reporting Form (JRF),

Transcription

1 Analysis of Immunization Financing Indicators of the WHO-UNICEF Joint Reporting Form (JRF), Department of Immunization Vaccines and Biologicals, World Health Organization February 2016

2 Acknowledgements This report has been prepared by Nikhil Mandalia (WHO consultant) and Claudio Politi (WHO/HQ), with input and contributions from WHO immunization financing regional focal points Amos Petu (AFRO), Alexis Satoulou-Maleyo (AFRO), Jorge Mendoza Aldana (WPRO), Irtaza Chaudhri (EMRO), Niyazi Osman Cakmak (EURO), Pushpa Wijesinghe (SEARO), Claudia Patricia Castillo (PAHO/AMRO) and Cara Bess Janusz (PAHO/AMRO). 1

3 Contents Acknowledgements... 1 List of Figures... 4 List of Tables... 5 List of abbreviations... 6 Executive summary... 7 Introduction... 8 Data and Methodology Data Sources Identification and estimation of missing and inconsistent data Country selection criteria Reporting Statistics Global Analysis African Region Region of the Americas Eastern Mediterranean Region European Region South Eastern Asia Region Western Pacific Region Gavi Countries Conclusion Annexes Annex 1 - African Region Tables AFR - Government expenditure on routine immunization (JRF 6540) AFR - Percentage of government expenditure on routine immunization funded by government (JRF 6560) AFR - Government expenditure on vaccines (JRF 6510) AFR Total expenditure on vaccines (JRF 6520) AFR Percentage of government expenditure on vaccines funded by government (JRF 6530). 81 Annex 2 Region of the Americas Tables AMR Government expenditure on routine immunization (JRF 6540) AMR Percentage of government expenditure on routine immunization funded by government (JRF 6560) AMR Government expenditure on vaccines (JRF 6510) AMR Total expenditure on vaccines (JRF 6530)

4 AMR Percentage of vaccine expenditures funded by government (JRF 6530) Annex 3 Eastern Mediterranean Region Tables EMR Government expenditure on routine immunization (JRF 6540) EMR Percentage of total routine immunization expenditures funded by government (JRF 6560) EMR Government expenditure on vaccines (JRF 6510) EMR Total expenditure on vaccines (JRF 6520) EMR Percentage of total expenditure on vaccines funded by government Annex 4 European Region Tables EUR Government expenditure on routine immunization (JRF 6540) EUR Percentage of total expenditure on routine immunization funded by government (JRF 6560) EUR Government expenditure on vaccines (JRF 6510) EUR Total expenditure on vaccines (JRF 6520) EUR Percentage of total expenditure on vaccines funded by government Annex 5 South Eastern Asia Region Tables SEAR Government expenditure on routine immunization (JRF 6540) SEAR Percentage of government expenditure on routine immunization funded by government (JRF 6560) SEAR Government expenditure on vaccines (JRF 6510) SEAR Total expenditure on vaccines (JRF 6520) SEAR Percentage of total expenditure on vaccines funded by government (JRF 6530) Annex 6 Western Pacific Region Tables WPR Government expenditure on routine immunization (JRF 6540) WPR Percentage of total expenditure on routine immunization funded by government (JRF 6560) WPR Government expenditure on vaccines (JRF 6510) WPR Total expenditure on vaccines (JRF 6520) WPR Percentage of total expenditure on vaccines funded by government (JRF 6530) Annex 7 International exchange rate comparison government expenditure on routine immunization per live birth

5 List of Figures Figure 1 Global Government expenditure on RI Figure 2 Global Government expenditure on vaccines Figure 3 Global Government expenditure on RI per live birth Figure 4 Global Total expenditure on vaccines per live birth Figure 5 African Region Government expenditure on RI Figure 6 African Region - Government expenditure on vaccines Figure 7 African Region - Government expenditure on RI per live birth Figure 8 - African Region - Total expenditure on vaccines per live birth Figure 9 - Region of the Americas - Government expenditure on RI Figure 10 - Region of the Americas - Government expenditure on vaccines Figure 11 Region of the Americas Government expenditure on RI per live birth Figure 12 Region of the Americas Total expenditure on vaccines per live birth Figure 13 - Eastern Mediterranean Region - Government expenditure on RI Figure 14 - Eastern Mediterranean Region - Government expenditure on vaccines Figure 15 - Eastern Mediterranean Region - Government expenditure on RI per live birth Figure 16 - Eastern Mediterranean Region - Total expenditure on vaccines per live birth Figure 17 - European Region - Government expenditure on RI Figure 18 - European Region - Government expenditure on vaccines Figure 19 - European region - Government expenditure on RI per live birth Figure 20 - European Region -Total expenditure on vaccines per live birth Figure 21 - South Eastern Asia Region - Government expenditure on RI Figure 22 - South Eastern Asia Region - Government expenditure on vaccines Figure 23 - South Eastern Asia Region - Government expenditure on RI per live birth Figure 24 - South Eastern Asia Region - Total expenditure on vaccines per live birth Figure 25 - Western Pacific Region - Government expenditure on RI Figure 26 - Western Pacific Region - Government expenditure on vaccines Figure 27 - Western Pacific Region - Government expenditure on RI per live birth Figure 28 - Western Pacific Region - Total expenditure on vaccines per live birth Figure 29 - Gavi countries - Government expenditure on RI Figure 30 - Gavi countries - Government expenditure on vaccines Figure 31 - Gavi countries (Low income group) Total expenditure on vaccines per live birth Figure 32 - Gavi countries (Phase 1 group) - Total expenditure on vaccines per live birth Figure 33 - Gavi countries (Phase 2 & 3 groups) - Total expenditure on vaccines per live birth

6 List of Tables Table 1 - No. of countries selected in each analysis group Table 2 Reporting Statistics All Quantitative Indicators Table 3 Reporting Statistics - Government expenditure on vaccines (JRF 6510) Table 4 Reporting Statistics - Total expenditure on vaccines (JRF 6520) Table 5 Reporting Statistics - Percentage of total expenditure on vaccines funded by government (JRF 6530) Table 6 Reporting Statistics - Government expenditure on RI (JRF 6540) Table 7 Reporting Statistics - Total expenditure on RI (JRF 6550) Table 8 Reporting Statistics - Percentage of total expenditure on RI funded by government (JRF 6560) Table 9 Global Line item in national budget for vaccines Table 10 Global Government Expenditure on Routine Immunization Table 11 Government expenditure on vaccines Table 12 African Region Indicators summary Table 13 African Region - Government expenditure on RI per live birth Table 14 African Region Reporting Statistics Table 15 Region of the Americas Indicators summary Table 16 Region of the Americas - Government expenditure on RI per live birth Table 17 Region of the Americas Reporting statistics Table 18 Eastern Mediterranean Region Indicators summary Table 19 Eastern Mediterranean Region - Government expenditure on routine immunization per live birth Table 20 - Eastern Mediterranean Region - Reporting statistics Table 21 European Region Indicators summary Table 22 European Region - Government expenditure on routine immunization per live birth Table 23 European Region Reporting statistics Table 24 South Eastern Asia Region Indicators summary Table 25 - South Eastern Asia Region - Government expenditure on RI per live birth Table 26 - South Eastern Asia Region Reporting statistics Table 27 Western Pacific Region Indicators summary Table 28 - Western Pacific Region - Government expenditure on RI per live birth Table 29 - Western Pacific Region Reporting statistics Table 30 Gavi countries Indicators summary Table 31 - Government expenditure on RI per live birth by Gavi (2016) co-financing groupings Table 32 Gavi countries Distribution of defaulting countries Table 33 - Gavi Phase 2 & 3 countries - Government expenditure on vaccines per live birth (17 Countries with full time series) Table 34 - Gavi Phase 2 & 3 countries - Total expenditure on vaccines per live birth (17 Countries with full time series)

7 List of abbreviations AFR WHO African Region AMR WHO Region of the Americas cmyp comprehensive Multi-Year Plan EIU The Economist Intelligence Unit EMR WHO Eastern Mediterranean Region EUR WHO European Region High Country HPV Human Papillomavirus JRF Joint Reporting Form LIC Low Country LMIC Lower Middle Country PCV Pneumococcal Conjugate Vaccine PWA Population Weighted Average RI Routine Immunization SEAR WHO South Eastern Asia Region SHA System of Health Accounts UMIC Upper Middle Country WPR WHO Western Pacific Region 6

8 Executive summary This report presents an analysis of the financing indicators included in the WHO-UNICEF Joint Reporting Form (JRF) for the period By 2014 the majority of WHO member states had reported a specific line item in the national budget for the purchasing of vaccines. The number of countries reporting the inclusion of the line item in 2014 was 173 (89% of all member states), additionally 90% (66 countries) of all Gavi eligible countries reported the line item, an increase from As governments increased their expenditure on vaccines over the five year period, the aggregated expenditure of 70 countries with a full time-series increased from 1,535 million US$ in 2010 to 1,893 million US$ in Donor funds for vaccines also increased over the same period, resulting in a decrease to the percentage of total vaccine costs funded by government, from 73% to 70%. The aggregated government expenditure on routine immunization was calculated over the same 70 countries, with results showing an increase from 1,759 million US$ in 2010, to 2,164 million in As routine immunization costs also capture the costs of vaccines, the growth in donor support for vaccine costs has had an effect on the percentage of total routine immunization costs funded by government, illustrated by a decrease from 75% in 2010 to 73% in The results of the global analysis indicate that financial commitment to immunization is increasing, as represented by the increasing domestic funds that governments are allocating for the use of immunization. Despite this, Gavi and other donor support is growing at such a rate that is drowning out the proportion of government funding for immunization, reducing the overall financial ownership of countries. Analysis of individual regions displayed a large disparity that exists between relatively richer and poorer regions; the countries in both the European region and the region of the Americas show greater self-sufficiency in supporting their own immunization costs, with over 90% of total routine immunization costs being funded by government on average over the five years period. However, the African region is the most reliant on donor support having only funded 50% of total routine immunization costs with domestic funds in 2010; but this has fallen to 40% in

9 Introduction In December 2010, global health leaders committed to making the following 10 years the Decade of Vaccines ( ), and in doing so initiated the Global Vaccine Action Plan (GVAP). During the last 15 years significant progress has been made in expanding the reach of immunization programmes globally. In spite of large increases to populations, immunization coverage remains on an upward trend playing a crucial part in reducing child mortality. Important too, are the increasing number of vaccines being introduced into the immunization schedules of many countries, with vaccines against Hepatitis B and Haemophilus type B integrated into routine operations in 176 and 192 countries respectively. Over a ten year period ( ) it is estimated that the number of deaths caused by traditional vaccine-preventable diseases (diphtheria, measles neonatal tetanus, pertussis and poliomyelitis) fell by 0.9 million 1. In addition to the uptake of an increased amount of traditional vaccines, the past 15 years has also witnessed the rise in availability of new and more sophisticated vaccines, such as pneumococcal conjugate, Rotavirus and Human papillomavirus virus vaccine. Accelerated initiatives have been implemented in order to shorten the historic time lag that has existed in the introduction of these new vaccines between high and low income countries. However, with these new and underused vaccines comes the burden of additional cost. These new vaccines come at a significantly higher cost than traditional vaccines, and it is important to note that the burden is relatively greater for countries that are classified as being Low and Lower-middle income, given the harsher fiscal constraints they face in comparison to Upper-middle and High come countries. As one of the most cost-effective public health interventions, countries are continually encouraged to give priority to national immunization programs. The Global Vaccine Action Plan (GVAP) reiterates this, advocating country commitment and ownership of immunization as key tenets of effective immunization systems. The GVAP provides the global framework for planning immunization strategies over the period 2011 to 2020, and insists that the demonstration of commitment must come through a combination of actions. This includes the setting of ambitious but attainable targets, allocating sufficient domestic resources so that these targets can be reached, ensuring immunization plans are well integrated into national health plans and additionally making sure that the implementation of these plans are fully carried out. Instrumental in providing support to low income countries is the Gavi Alliance, whose key goal is to accelerate the uptake and use of underused and new vaccines. Gavi facilitate the introduction of vaccines through co-financing arrangements with each country, reducing the financial encumbrance on the country by taking the majority of the financial cost of the vaccines initially and then gradually increasing the proportion paid by countries overtime. 1 Sources for estimates: measles and neonatal tetanus, in World Health Statistics 2012, Geneva, World Health Organization, 2012; diphtheria and poliomyelitis, for 2000: (accessed 10/02/2016) 8

10 Given the rise in immunization costs and the increased external support that countries are now able to receive, many questions are now being raised over the sustainability of these immunization programmes. Accordingly, the importance of government ownership over immunization planning, budgeting and financing has been pushed to the foreground. Unfortunately, the abundance of donor support, whilst no doubt beneficial, may inadvertently serve to undermine the long-term sustainability of immunization services. The goal of self-sufficiency is apparent for countries; however a misalignment of incentives could occur between the donor and country in the short-term leading to governments treating the external aid as a substitution for, rather than an addition to, government immunization spending. Additionally, if there is a smaller share of domestic resources being mobilized relative to a large share of external resources, incentives for the governments to address the inefficiencies or bottlenecks in the delivery of immunization services is somewhat diminished. This shirking of responsibility may stunt the development of national capacity and will likely hinder progress towards the building of proper governance, undermining the long-term sustainability of the immunization programme. Another key concern of low ownership is its potential distortive effect on the budgeting and planning processes. As external funding often comes in the form of direct support for a vaccine/project, it becomes difficult for governments to discern the exact flow of resources coming into the country and with this comes uncertainty over what the outlay for expenditure on immunization should be. This budgetary uncertainty can have a detrimental effect in the way of producing discontinuous and unproductive delivery of immunization services. For example, if district managers are unaware of their own budget allocations they then face an impossible task in their processes of planning and implementation. Given the concerns over long-term sustainability, ownership and commitment, Gavi and other partners have implemented policies targeted at addressing these issues. Particularly important is the Gavi co-financing policy for the introduction of new and underused vaccines, which looks to address the issue of financial sustainability by gradually transferring financial ownership of vaccine costs over a period of time according to the growth in income of the country. Since 1998, the WHO-UNICEF Joint Reporting Form (JRF) mechanism has been collecting data on immunization financing as part of a set of immunization indicators designed to measure immunization coverage and system performance in WHO member states. The financing indicators included in the JRF aim to capture the expenditure on routine immunization, the expenditure on vaccines, the percentage financed by government and the existence of a national budget line for the purchase of vaccines. With the current focus on the sustainability of immunization programmes, the JRF financing indicators analysis provides a good opportunity explore the global, regional and country trends in financial ownership of, and commitment to immunization. This report presents an analysis of the financing indicators for the period

11 Data and Methodology Data Sources The main source of data is the WHO-UNICEF Joint Reporting Forms (JRF) reported by countries for the period JRF data is reported annually by countries, with this data then uploaded to the JRF database which is available on the WHO Immunization surveillance, assessment and monitoring website. 2 The JRF includes one qualitative indicator and six immunization expenditure indicators: The qualitative indicator is expressed in the form of a Yes/No answer: o Availability of a specific line item in the national budget for the purchase of vaccines used in routine immunization (JRF 6500). Four indicators are expressed in absolute values (US$ or local currency): o Government expenditure on vaccines used for routine immunization (JRF 6510). o Total expenditure (from all sources) on vaccines used for routine immunization (JRF 6520). o Government expenditure on routine immunization, including vaccines (JRF 6540). o Total expenditure (from all sources) on routine immunization, including vaccines (JRF 6550). Two indicators are expressed in percentages (%): o Percentage of vaccine expenditure used for routine immunization financed by government (JRF 6530). o Percentage of routine immunization expenditure financed by government (JRF 6560). Data reported in local currency amounts has been converted to US dollars, using the annual average exchange rate available on the Economic Intelligence Unit (EIU) 3 database. Three additional sources of data have been used in the preparation of this analysis: countries comprehensive Multi-Year Plans (cmyps) 4, multi-country immunization costing and financing studies (EPIC) 5 co-ordinated by the Bill and Melinda Gates Foundation, and the UN Population Division s database 6. Both the cmyps and EPIC studies were used to cross-check and in some cases supplement countries reported JRF data (see section: Identification and estimation of missing and inconsistent data). From the UN population data, information regarding the number of live births for each country was extracted to allow for the financing indicators to be expressed in terms of per live birth per year and additionally to provide data for population weighted average estimates. In addition, Gross National (GNI) per capita data extracted from the World Bank World Development

12 Indicators 7 has been used for the aggregation of countries by group and Gavi co-financing group. Identification and estimation of missing and inconsistent data Interest in the JRF financing indicators has increased over time alongside the increased focus on financial sustainability of immunization. The utilization of the indicators has also improved with countries paying closer attention to the emerging trends, as are the global community and the World Health Assembly. In spite of this, the completeness and accuracy of immunization and vaccine expenditure data for the full range of countries is currently lacking; errors, inconsistencies and missing data frequently identified when compiling and analysing the JRF data. When the JRF data is reported, various techniques are used to assess its consistency and accuracy. The following five rules of internal validity were used to assess the consistency of the country reported data: 1. Total expenditure (from all sources) on routine immunization must be higher than total expenditure (from all sources) on vaccines. 2. Total expenditure (from all sources) on routine immunization must higher than or equal to government expenditure on routine immunization. 3. Total expenditure (from all sources) on vaccines must be higher than or equal to government expenditure on vaccines. 4. Government expenditure on routine immunization must be higher than the government expenditures on vaccines. 5. The reported percentage of government funding and the calculated percentage of government funding (obtained by dividing the reported amount of government funding by the total expenditure for both routine immunization and vaccine expenditures) must be equal. Reported expenditure figures were compared against Gavi disbursement and co-financing amounts where data was available. The time-series of each of the indicators were thoroughly examined to help recognise extremely divergent values reported from one year to the other, alongside mistakes such as typing and currency reporting errors. These potential inconsistencies were recorded and shared with member states through WHO regional offices as a mechanism of providing active feedback, allowing for the member states to revise their JRF submissions. Due to this, data used in previous JRF financing indicator analyses has been subject to change. Inconsistent data points were either dropped or replaced with WHO estimates. In addition to replacing data, estimates were used in place of missing data to help create a full time-series of observations for countries. Of course, the use of estimates were used sparingly so as not to augment the dataset too heavily. A number of methods different were used to develop the estimations:

13 Estimations for the qualitative budget line item indicator were assessed based on the trends observed over the time-series. If for a given year, a country had not reported data but had done so for the other years, uniformly reporting Yes or No, and then the observed trend was taken as sufficient reason for imputing missing values so as to continue the trend. Estimations for the quantitative expenditure indicators were calculated as follows: o If a country was missing one of the three expenditure figures (for either vaccines or routine immunization) but reported the other two (i.e. missing government expenditure, but reported total expenditure and percentage of total expenditure funded by government) then the missing indicator would be calculated accordingly. o By taking the average of available data i.e. if a country failed to report an indicator for a certain year but managed to report for the previous and subsequent year, then the average of those two data points may have been used to fill the missing observation. o By assuming the continuation of a previous long running time series trend, using simple linear stepwise extrapolation i.e. if the subsequent 3 years of data was available, then it would be used to calculate the 4 th and missing year of data. o By using data extracted from a country s comprehensive Multi-Year Plan (cmyp) Costing and Financing tool, if the missing data was that of the country s baseline expenditure year. o By using data extracted from the BMGF EPIC studies. The country response rates, number of inconsistencies and the number of estimations calculated have been summarised and are elaborated on in the reporting statistics section. 12

14 Country selection criteria To allow for consistent analysis over the time period, across countries in each region, and across the regions themselves countries were only selected for analysis if they reported a full 5 year time series (2010 to 2014) for each of the following three indicators: Government expenditure on vaccines used in routine immunization. Total expenditure (from all sources) on vaccines used in routine immunization. Government expenditure on routine immunization, including vaccines. By ensuring consistency amongst the countries in these 3 indicators, the analysis was able to make use of the relationship that exists between the indicators in order to examine the expenditure trends in absolute amounts as well as the manner in which the trends move in proportion to one and other. The full time-series was also necessary so that population weighted averages could be calculated using a consistent population over time. If a country were to fail to report for a given year but still have its population weight taken into account, this would have created biased and deflated averages. The following table presents the number of countries included in each of the regional analyses: Table 1 - No. of countries selected in each analysis group Analysis Group No. of countries Global 70 African Region (AFR) 18 Region of the Americas (AMR) 24 Eastern Mediterranean Region (EMR) 7 European Region (EUR) 7 South Eastern Asia Region (SEAR) 7 Western Pacific Region (WPR) 7 Gavi countries 38 Gavi Low Co-financing Group 14 Gavi Phase 1 Co-financing Group 11 Gavi Phase 2&3 Co-financing Group 13 For certain parts of the analysis the country selection criteria is widened to include all available observations regardless of full time-series; this is most notably the case when calculating the simple average in percentage of total expenditure of both RI and vaccine indicators across entire regions. 13

15 Reporting Statistics The following provides a brief analysis of the trends in reporting for each of the JRF financing indicators. As stated earlier, the quality of country reporting for the JRF financing indicators has long been an issue, with countries facing many challenges when looking to quantify immunization expenditure data. In response to this, initiatives have been undertaken as a comprehensive effort to strengthen local and regional capacities, active feedback, and use of immunization financing data; these initiatives include the preparation and dissemination of a JRF guidance note by the Gavi Immunization and Financing Sustainability (IF&S) Task Team. The guidance note provides countries with comprehensive definitions for each indicator as well as assistance on how to collect, estimate, validate and report the correct data. Additionally, a JRF peer review workshop was organised in early April of 2014 for countries in East and Southern Africa. This allowed for the sharing of best practice amongst country participants, through the critical analysis 2013 JRF data, and additionally gave countries a platform to present feedback to WHO regarding the clarity and general understanding of variables in the JRF template. Particularly important was the fact that the workshop aided the development of capacity at countylevel, contributing to the improvement of reporting for future years. The tables below summarise the reporting statistics for each of the JRF financing indicators over the period 2010 to Table 2 Reporting Statistics All Quantitative Indicators All six indicators Missing Inconsistencies Estimates Table 2 shows the aggregated reporting statistics for all countries, across all indicators between the years 2010 and The number of missing indicators decreased over the five years, from 430 missing in 2010 to 411 in In spite of this decrease, there does not seem to be a discernible trend in the reporting of statistics, with the amount of missing indicators varying greatly between years. Encouraging signs can be seen in the trend for number of inconsistencies identified, which have decreased over time, from 98 inconsistencies in 2010 to 60 in In addition to this, the number of estimates being calculated can be seen to be falling as well from 231 in 2010 to 99 in A fairly significant improvement can be seen across all reporting statistics in the year 2014, which may be attributable to efforts made by countries, as well as supportive activities by WHO and partner organizations. 14

16 Table 3 Reporting Statistics - Government expenditure on vaccines (JRF 6510) Government Expenditure on Vaccines (JRF 6510) Missing Inconsistencies Estimates Table 4 Reporting Statistics - Total expenditure on vaccines (JRF 6520) Total Expenditure on Vaccines (from all sources) (JRF 6520) Missing Inconsistencies Estimates Table 5 Reporting Statistics - Percentage of total expenditure on vaccines funded by government (JRF 6530) Percentage of Total Expenditure on Vaccines Funded by Government (JRF 6530) Missing Inconsistencies Estimates Table 6 Reporting Statistics - Government expenditure on RI (JRF 6540) Government Expenditure on Routine Immunization (JRF 6540) Missing Inconsistencies Estimates Table 7 Reporting Statistics - Total expenditure on RI (JRF 6550) Total Expenditure on Routine Immunization (from all sources) (JRF 6550) Missing Inconsistencies Estimates

17 Table 8 Reporting Statistics - Percentage of total expenditure on RI funded by government (JRF 6560) Percentage of Total Expenditure on Routine Immunization Funded by Government (JRF 6560) Missing Inconsistencies Estimates There is a considerable disparity in reporting between the vaccine expenditure indicators and the indicators pertaining to routine immunization, this is especially evident when looking at the differences between Table 3 which looks at government expenditure on vaccines and Table 6 on government expenditure on RI. The number of missing indicators for vaccine expenditures is almost half that of RI expenditures. In addition, if the number of missing is compared between all indicators it is apparent that total expenditure on RI (JRF 6550) suffers as the indicator with the worst reporting rate over the five year period. The difference in reporting rate between the vaccine and the RI indicators highlights the challenge that many countries have faced in quantifying expenditures for routine immunization. Vaccine expenditure data is known to be relatively easier for countries to gather, given that vaccines are usually procured through central government in a pooled way for all districts in a country. Whereas a lack of sub-national resource tracking can hinder efforts to identify and record routine costs. In addition to this, the fact that immunization is integrated within a number of different service delivery platforms can make it difficult to disaggregate what may be considered shared costs and immunization specific costs. The task is made much more difficult when looking beyond government expenditures on RI and looking to include external funding, which may come in the form of direct support for a project rather than as a supplemental amount to an existing budget. 16

18 Global Analysis 194 countries by income classification and Gavi eligibility: Classification Group Low Lower Middle Upper Middle High N/A Total Total no. of countries Of which are Gavi eligible Line item in national budget for the purchasing of vaccines used in routine immunization Table 9 Global Line item in national budget for vaccines Indicators (Global) Line item in national budget for vaccines (No. of countries) -Global (194) AFR (46) AMR (35) EMR (22) EUR (53) SEAR (11) WPR (27) Gavi (73) By countries had reported a specific line item in the national budget for the purchasing of vaccines representing 89% of all member states. The number of countries reporting the line item increased between the years 2010 to 2014, by 3. However, the increases did not occur in a consistent manner with the number of countries reporting the line item increasing over the years 2010 to 2013, from 170 to 174 but declining in the subsequent year (2014) to 173. It is encouraging that the numbers of countries reporting the inclusion of a line item in the national budget are increasing as this indicates growing government commitment to financing vaccines. However, these results should be interpreted with caution as the inclusion of the budget line item does not always guarantee government funding for vaccines. In addition to this, the level of consistency in reporting varies across each region, with large amounts of variation observable in the European region and the region of the Americas. However, it is unclear as to whether this is a true reflection of the realities for the countries in these regions or whether it is due to erroneous reporting. 17

19 Government Expenditures on Routine Immunization Table 10 Global Government Expenditure on Routine Immunization Indicators % of total RI funded by government in the region (average) -Global (194) 75% 74% 74% 73% 73% -AFR (46) 50% 48% 46% 40% 40% -AMR (35) 95% 93% 94% 95% 95% -EMR (22) 73% 70% 75% 73% 74% -EUR (53) 92% 91% 91% 89% 92% -SEAR (11) 69% 63% 62% 72% 63% -WPR (27) 59% 65% 66% 71% 71% -Gavi (73) 46% 42% 43% 42% 42% % of total RI funded by government in selected countries (average) -Global (70 countries) 68% 64% 66% 68% 67% Aggregated expenditure on RI in selected countries (Millions US$) -Global (70 countries) 1,759 1,843 1,821 1,816 2,164 -AFR (18 countries) AMR (24 countries) 1,076 1,128 1,070 1,076 1,419 -EMR (7 countries) EUR (7 countries) SEAR (7 countries) WPR (7 countries) Gavi (38 countries) Government expenditure on RI Per Live Birth in selected countries (Population Weighted Average US$) -Global (70 countries) AFR (18 countries) AMR (24 countries) EMR (7 countries) EUR (7 countries) SEAR (7 countries) WPR (7 countries) Gavi (38 countries)

20 (Millions US$) Figure 1 Global Government expenditure on RI Government Expenditure on Routine Immunization 100% 90% 80% 70% 60% 50% 40% 75% 68% $1,759 $1,843 $1,821 $1,816 $2,164 74% 74% 73% 73% 68% 66% 64% 67% $2,000 $1,500 $1,000 30% 20% $500 10% 0% Percentage of government funding RI (average in 70 selected countries) Percentage of government funding RI (average for all countries) Aggregated Expenditure in (70) selected countries (Millions US$) $0 The average percentage of total expenditure on routine immunization funded by government, for all countries presented an overall decline over the period 2010 to 2014, from 75% to 73%. The trend is relatively stable, with the magnitude of change across the years relatively low given the trends reported in some regions such as the South-Eastern region, which reported wide variation from year to year. Throughout the five year period, the African region consistently displayed the lowest proportion of government funding for RI, amongst all of the regions. 81% of the countries in the African region (38 countries) are classified as either Low or Lower middle income countries, which is the highest proportion of all regions, and additionally 79% of the countries in the region (37 countries) are Gavi eligible leading to the notion that these countries will be much more reliant on donor support than other regions. The region which had the highest proportion of government funding RI throughout the time series was the region of the Americas, which reported a relatively stable percentage of approximately 95% from year to year. 28 of the 36 countries in this region (78%) are classified as High or Upper middle income which helps to explain the relatively low reliance on external funding for immunization. The region which had the second highest proportion of government funding RI throughout the period was Europe; which is actually the region with the highest proportion of High and Upper middle income countries. 19

21 The aggregated government expenditures on RI for 70 selected countries 8, with a full time-series, increased between the years 2010 and The increase did not occur in a consistent manner however, with the expenditure increasing initially from $1,759 million to $1,843 million between 2010 and 2011, after which it saw a slight decline over the next two years to $1,816 million (2013) before a sharp increase in 2014 to $2,164 million. This substantial increase towards the end of the five years was driven mainly by the region of the Americas who reported an increase in aggregate expenditure of over $300 million between 2013 and Cfr. Table 1 20

22 Government Expenditure on Vaccines Table 11 Government expenditure on vaccines Indicators % of total vaccine expenditure funded by government in the region (average) -Global (194) 73% 70% 69% 70% 70% -AFR (46) 42% 38% 34% 37% 37% -AMR (35) 96% 90% 90% 93% 95% -EMR (22) 78% 68% 68% 70% 69% -EUR (53) 91% 91% 88% 89% 89% -SEAR (11) 64% 60% 57% 55% 64% -WPR (27) 69% 70% 73% 75% 73% -Gavi (73) 40% 33% 31% 34% 35% % of total vaccine expenditure funded by government in selected countries (average) -Global (70 countries) 66% 61% 61% 63% 64% Aggregated expenditure on vaccines in selected countries (Millions US$) -Global (70 countries) 1,535 1,623 1,570 1,584 1,893 -AFR (18 countries) AMR (24 countries) 990 1, ,009 1,320 -EMR (7 countries) EUR (7 countries) SEAR (7 countries) WPR (7 countries) Gavi (38 countries) Government expenditure on vaccines Per Live Birth in selected countries (Population Weighted Average US$) -Global (70 countries) AFR (18 countries) AMR (24 countries) EMR (7 countries) EUR (7 countries) SEAR (7 countries) WPR (7 countries) Gavi (38 countries)

23 (Millions US$) Figure 2 Global Government expenditure on vaccines Government Expenditure on Vaccines 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% $1,535 73% 70% 66% $1,623 69% 61% 61% $1,570 $1,584 $1,893 70% 70% 63% Percentage of government funding vaccines (average in 70 selected countries) Percentage of government funding vaccines (average over all countries) Aggregated Expenditure in (70) selected countries (Millions US$) 64% $1,800 $1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 $0 The average percentage of government funding for vaccines declined over the period between 2010 and 2014, from 73% to 70%. The trend is somewhat irregular as the percentage initially drops from 73% in 2010 to 70% in 2011 and further to 69% the following year; but rises to 70% in 2013 and then remains at 70% for Whilst the trend fluctuates, the magnitude of change between years is relatively low and so it can be said that the percentage of government funding vaccines remains stable throughout the five year period. The region of the Americas reported the highest proportion of government funding vaccines throughout the years of the analysis, with the European region not far behind. Once again these results are to be expected given the high and upper middle income status which the majority of the countries in these regions reside in, leading to only a small amount of Gavi support in the region and little reliance on external funding for vaccines. The African region reported the lowest proportion of government funding for vaccines, with a decline reported over the five years from 42% to 37%. Given the high amount of Gavi support in this region, it would be expected that the proportion of government funding would be relatively lower than other regions. The Gavi eligible countries display a decreasing trend in percentage of vaccines funded by government over the five years. Whilst this would seem to be counterintuitive to the Gavi cofinancing mechanism, it is most likely due to the large number of Low and Lower middle income countries who are still introducing new and underused vaccines into their immunization programmes, but are paying relatively low amounts due to co-financing arrangements still being in their infancy. 22

24 US$ Figure 3 Global Government expenditure on RI per live birth Government Expenditure on Routine Immunization in (70) selected countries (PWA Per Live Birth, US$) $41.9 $36.2 $37.5 $36.4 $ % 88% 86% 87% 87% Share of expenditure on vaccines Share of expenditure on service delivery Figure 3 shows the population weighted average government expenditure on routine immunization per live birth for 70 selected countries, as well as the proportion of these RI funds directed towards the procurement of vaccines. The government expenditure on RI per live birth increased over the five year period, albeit with a fluctuating trend, alongside this the government expenditures on vaccines per live birth moved in tandem allowing for the proportion of government expenditure on RI funding vaccines to remain relatively stable at approximately 87%. 23

25 US$ Figure 4 Global Total expenditure on vaccines per live birth Total Expenditure on Vaccines in 70 selected countries (PWA Per Live Birth, US$) $36.3 $39.2 $36.8 $39.4 $ % 84% 85% 79% 82% 0 Government Expenditure on Vaccines Externally Funded Expediture on Vaccines Figure 4 shows the total expenditure on vaccines per live birth for 70 selected countries, which is increasing over time. The trend for total expenditure per live birth is somewhat unusual as it does not display a consistent upward trend which is what would be expected, but instead increased initially from $36.3 in 2010 to $39.2 in 2011 after this however it dropped to $36.8 before steadily increasing over the next two years; eventually reaching $44.4 in During this time the government expenditures on vaccines per live birth followed a similar but muted trend, fluctuating around $32 before increasing in 2014 to $36.6; this meant that the percentage of total vaccine costs funded by government was somewhat erratic showing no consistent pattern, but moving between 87% and 79%. Whilst the trend in proportion of government funding vaccines is unstable, the magnitude is relatively high which is encouraging showing that collectively there are signs of high government commitment and ownership over the vaccine financing aspects of immunization. However, these global trends may mask the realities which regions and countries face and so it is imperative to look closely at trends seen in the different regions in order to have a full overview of current global trends in immunization financing. 24

26 African Region 47 countries by income classification and Gavi eligibility: Classification Group Low Lower Middle Upper Middle High Total Total no. of countries Of which are Gavi eligible Table 12 African Region Indicators summary Indicators Line item in national budget for vaccines (No. of countries) Government Routine Immunization Expenditures: % of total RI funded by government in the region (average) 50% 48% 46% 40% 40% % of total RI funded by government in (18) selected countries (average) 40% 35% 37% 36% 33% Aggregated Expenditure in (18) selected countries (Millions US$) Expenditure Per Live Birth in (18) selected countries (PWA US$) Government Vaccine Expenditures: % of total vaccines funded by government in the region (average) 42% 38% 34% 37% 37% % of total vaccines funded by government in (18) selected countries (average) 32% 24% 25% 27% 29% Aggregated Expenditure in (18) selected countries (Millions US$) Expenditure Per Live Birth in (18) selected countries (PWA US$) DTP3 Coverage: DTP3 Coverage in the region (%) DTP3 Coverage in (18) selected countries (%) Introduction of New and Underused Vaccines (Cumulative no. of countries): Rotavirus PCV HPV The 18 countries selected for analysis are listed in Table 12. Most of the countries in the African region report having line items in their national budgets for purchasing vaccines. The trend in number of countries reporting a line item for the purchase of vaccines appears relatively stable over the period at 44 countries, however this masks the unstable trends that a number of countries are reporting; it appears that whilst some countries are reporting to adding the line item in the national budget, others are dropping it in equal measure. Two countries reported to dropping the line item between 2013 and 2014, they were The Congo and South Africa. 25

27 (Millions US$) Figure 5 African Region Government expenditure on RI Government Expenditure on Routine Immunization 100% 90% 80% $52 $49 $50 $52 $58 $60 $50 70% 60% 50% 40% 30% 20% 10% 50% 48% 40% 35% 46% 40% 40% 37% 36% 33% $40 $30 $20 $10 0% Percentage of government funding RI (average % in 18 selected countries) Percentage of government funding RI (average % in all countries) Aggregated Expenditure in (18) selected countries (Millions US$) $0 The government expenditures on RI showed signs of an overall increase over the period 2010 to 2014, from $52 million to $58 million. Initially, the aggregated expenditure dropped from $52 million in 2010 to $49 million in 2011 after which it increased in a consistent manner over the remaining 3 years. The percentage of government funding for routine immunization in the region fell (on average) over the five year period, showing a consistent decreasing trend from 50% in 2010 to 46% in 2012 after which it fell to 40% in 2013 and remained for Whilst governments are directing more and more funds towards the routine costs of the immunization program, increasing amounts of external support continue to diminish the overall proportion which is funded by government. Given that routine immunization costs encompass the costs of vaccines, it seems that the decreasing trend in percentage of government funding RI correlates with the increased introduction of new and underused vaccines supported by donors. 26

28 (Millions US$) Figure 6 African Region - Government expenditure on vaccines Government Expenditure on Vaccines 100% 90% 80% $28 $28 $32 $32 $35 $30 70% $25 60% 50% 40% 42% $24 38% 34% 37% 37% $20 $15 30% 20% 10% 32% 24% 25% 27% 29% $10 $5 0% Percentage of government funding vaccines (average % in 18 selected countries) Percentage of government funding vaccines (average % in all countries) Aggregated Expenditure in (18) selected countries (Millions US$) $0 The percentage of reported government funding of vaccines (on average) decreased from 42% to 34% over the period 2010 to 2012, after which it climbed to 37% in 2013 and However, during this period the government expenditures on vaccines saw an overall increase overall albeit with a somewhat fluctuating trend. Initially, the government expenditure on vaccines drops from $28 million in 2010 to $24 million in 2011, before increasing substantially over the next 2 years to $32 million in 2013 where it remains going into countries in the region showed an increase in government funding for vaccines when comparing their reported spending in 2014 with their reported figures for Whilst the government expenditure on vaccine exhibits an increasing trend, the overall decrease in percentage of government funding vaccines comes mainly as a result of greater increases to total expenditure on vaccines over the period 2010 to The increasing trend in expenditures in vaccines is a result of the introduction of new and underused vaccines into African countries routine immunization schedules. The number of countries in the region which have introduced PCV, Rotavirus and HPV vaccines can be seen in Table 12 and can be seen to broadly comply with the increasing trend in vaccine expenditures. All but 9 countries in the region are classified as Low or Lower middle income countries, which is cause for Gavi eligibility in 38 countries. This high proportion of Gavi support in the region serves to explain the high uptake of PCV and Rotavirus vaccines and hence the escalating total expenditures. 27