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

Transcription

1 Analysis of Immunization Financing Indicators from the WHO-UNICEF Joint Reporting Form (JRF), Claudio Politi and Oumar Sagna Department of Immunization Vaccines and Biologicals, World Health Organization December 2011

2 TABLE OF CONTENTS Executive Summary Introduction Data and methodology Findings Line item in the national budget for purchasing vaccines used in routine immunization Line item in the national budget for purchasing injection supplies for routine immunization Percentage of government funding routine immunization Percentage of government funding vaccine costs National budget line for purchasing vaccines and shares of government funding vaccine expenditure Analysis by WHO regions African Region Americas Region Eastern Mediterranean Region European Region South East Asian Region Western Pacific Region Analysis by GAVI eligible countries Conclusions ANNEXE 1 - WHO Regions and countries data ANNEXE 2 - GAVI eligible countries data

3 Executive Summary This report presents the analysis of financing indicators included in the WHO-UNICEF Joint Reporting Form (JRF) for the period together with overview of the past decade. The four financing indicators are the following: Availability of a specific line item in the national budget for purchase of vaccines used in routine immunization. Availability of specific line item in the national budget for purchase of injection supplies (such as syringes, needles and safety boxes) used in routine immunization. Percentage of expenditure for routine immunization financed using government funds. Percentage of expenditure for vaccines financed using government funds. Two new questions about total expenditure (in absolute values, from all resources) on vaccines used in routine immunization and total expenditure (in absolute values, from all resources) on routine immunization were added in the JRF template 2010 with the aim of improving the reliability of the financing indicators. JRF 2010 financing data were cross-checked with time series and, for GAVI eligible countries, with cmyp data to fill missing data and/or correct inconsistencies. The majority of countries, 174 out of 193 (90%), reported a specific line item in their national budgets for purchasing vaccines in One hundred and fifty-one countries (or 78%) also reported specific budget line item for purchasing supplies. The percentage 1 of government funding routine immunization decreased in the last three years, from 83% to 79%; low-income countries and GAVI eligible countries report decreasing proportions of government financing: low income countries from 36% to 29% and GAVI eligible countries from 71% to 67% in the years The percentage of government funding vaccine expenditure shows also a declining trend, from 83% in 2008 to 77 % in 2010 despite the general increase of government vaccine expenditure in absolute values. In particular, low-income countries reported decreased proportions of government financing of vaccines from 36% in 2008 to 19% in 2010 and GAVI eligible countries from 72% to 63%. These trends could be the result of new vaccine introduction and campaigns supported by higher proportions of donors' funding. WHO regions show variations in the reported indicators. For instance, African and South East Asian regions reported marked declining proportions of government financing routine immunization; Europe and Americas reported some decreases; whereas Eastern Mediterranean Western Pacific regions reported increasing proportions of government financing of routine immunization. 1 Population weighted averages (pwa). 3

4 1. Introduction 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. Periodically, WHO carries out worldwide analyses of the JRF financing indicators which are accessible through the WHO Immunization Financing website 2. This is the fifth report; the previous analyses were carried out for the periods: This report presents the analysis for the period together with overview of the past decade of four financing indicators included in the JRF, namely: 1. Availability of a specific line item in the national budget for purchase of vaccines used in routine immunization. 2. Availability of specific line item in the national budget for purchase of injection supplies (such as syringes, needles and safety boxes) used in routine immunization. 3. Percentage of expenditure for routine immunization financed using government funds. 4. Percentage of expenditure for vaccines financed using government funds. 2. Data and methodology The JRF template includes a section with the following questions on immunization financing: 1. Are there line items in the national government budget specifically for the purchase of vaccines used in routine immunizations? (Yes/No) 2. Are there line items in the national government budget specifically for the purchase of injection supplies (such as syringes, needles, and safety boxes) for routine immunizations? (Yes/No) 3. What amount of government funds was spent on vaccines used in routine immunization? 4. What is the total expenditure (from all sources) on vaccines used in routine immunization? 2 4

5 5. If total amounts are not available for the previous questions please provide an estimated percentage of total expenditure on vaccines financed by government funds 6. What amount of government funds was spent on routine immunization? 7. What is the total expenditure (from all sources) on routine immunization? 8. If total amounts are not available for the previous question, please provide an estimated percentage of total expenditure on routine immunization financed by government funds. The questions about "total expenditure (from all resources) on vaccines used in routine immunization" and "total expenditure (from all resources) on routine immunization" were added in the JRF template 2010 with the aim of improving the reliability of the financing indicators. Previously the JRF template requested only the estimated percentages of government funding of vaccines and routine immunization. By adding the two new indicators (in absolute values) it is now possible to calculate the percentages and crosscheck absolute values with other sources, such as comprehensive Multi-Year Plans (cmyps). All data reported annually by countries in the Joint Reporting Form are stored in the JRF database, accessible through the WHO Immunization surveillance, assessment and monitoring website 3. The subset of financing indicators has been retrieved and cross-checked against data from previous years for potential missing values and inconsistencies. The response rates to the above questions for the year 2010 were the following: 78-80% of countries reported on the questions related to the existence of line items in the national budget and 69-81% of countries reported on the questions related to routine immunization and vaccine expenditures, respectively. That means missing data for countries about the existence of line items in the national budget and missing data for countries about immunization and vaccine expenditures. Some inconsistencies were also identified, in particular in the questions related to routine immunization and vaccine expenditures. There were wrong currencies stated, some typing errors and, in some GAVI eligible countries, amounts not aligned with data reported in their cmyps. To the extent possible, attempts have been made to recover missing values and/or correct obviously inconsistent data based on the information collected since 2000 in order to increase the pool of countries for the overall analysis. The missing data for the qualitative budget line item indicators in 2010 were assessed based on the trends observed over the period If, for a given year, a country 3 5

6 had not reported the data, but had done so for other years, uniformly reporting either Yes or No, the observed trend was taken as sufficient ground for imputing missing values so as to continue the trend 4 Missing data for the indicators measuring the percentage of government funding in vaccines and immunization expenditures was more difficult to impute than categorical qualitative data. Traditionally, the level of reporting the indicator is lower than for qualitative categorical indicators. The methods used for computing the indicators of percentages of government financing vaccines and routine immunization are as follows: 1) The reported data "estimated percentage of total expenditure on vaccines financed by government funds" and "estimated percentage of total expenditure on routine immunization financed by government funds" have been considered first. 2) If the above reported data were not available for a given country, the indicator was calculated by dividing the amount of government financing for vaccines (or for routine immunization) by the total expenditure from all sources for vaccines (or for routine immunization). Inconsistencies between currencies reported in the numerator and in the denominator (reported on USD or local currency) were also checked and converted in USD by using the annual average exchange rate in 2010 available on World Bank database 5. 3) If total amounts (both numerator and denominator) were not available for a given country, the observed time series was used to fill the missing values. i) for upper middle and high income countries, it was judged acceptable to assume continuation of achieved trend (usually high percentage of government participation); ii) for countries in other income groups such an approach was deemed inappropriate, since many lower income countries that reported these indicators showed a decrease in the percentage of governmental participation from 2007 to ) For GAVI-eligible countries, data from countries Comprehensive Multiyear Plans (cmyp) costing and financing tool were also used as additional source to cross-check and to fill missing data. Findings are presented in the following sections as aggregates and compared across WHO regions. Detailed country data are reported in the Annexes together with summaries for each WHO region and for GAVI eligible countries. 4 For instance, if a country reported "Yes" in 2008 and in 2010, but there was no reporting in 2009, the missing value was entered as "Yes". An important supposition made is that once a country makes the transition from not having a line item in the national budget for the purchasing of vaccines (reporting "no") to having one (reporting "yes"), it was assumed that the country would continue to have this budget line in subsequent years. Thus if the last reported answer for a country was "yes", the missing values for subsequent years would be imputed as "yes". 5 Official exchange rate (LCU per US$, period average). 6

7 3. Findings 3.1 Line item in the national budget for purchasing vaccines used in routine immunization In 2010 the majority of countries, 174 out of 193 (90%) reported a specific line item in their national budgets for purchasing vaccines. There has been a further increase, in particular in the number of GAVI eligible countries that reported a budget line item for vaccines from 61 (85%) in 2008 to 65 (90%) in 2009 and From 2008 to 2010 Eastern Mediterranean region, Europe, South East Asia and Western Pacific regions reported each two additional countries with a line item of national budget. Africa region kept constant, 41 countries, whereas the Americas reported a decrease of one country from 2009 to Figure 1: Number of countries in each region with line item in the national budget for purchasing vaccines used in routine immunization( ) Number of countries WPR SEAR EUR EMR AMR AFR

8 Table 1 -Trend in the number of countries reporting line item in national budget for purchasing vaccines Total Yes per Region (No. Countries) AFRO AMRO EMRO EURO SEARO WPRO Overall Low Income countries GAVI Eligible countries Total Yes per Region (% of Countries) AFRO 89% 89% 89% AMRO 91% 91% 89% EMRO 81% 90% 90% EURO 87% 91% 91% SEARO 73% 82% 91% WPRO 85% 89% 93% Overall 87% 90% 90% Low Income countries 80% 83% 83% GAVI Eligible countries 85% 89% 90% 3.2 Line item in the national budget for purchasing injection supplies for routine immunization The number of countries that reported a line item in the national budget for purchasing injection supplies for routine immunization shows some fluctuations over the 11-year period from 2000 to 2010 (Figure 2), though the overall trend shows an increase from 121 countries in 2000 to 151 countries in

9 Africa, South East Asia and Western Pacific regions reported increase in the number of countries with budget line for injection supplies from 2008 to The other regions remain constant or with a slight decline. The number of GAVI eligible countries with a line budget for supplies increased from 54 (75%) in 2008 to 60 (83%) in Figure 2: Number of countries in each region with line item in the national budget for purchasing injection supplies used in routine immunization( ) Number of countries WPR SEAR EUR EMR AMR AFR

10 Table 2 -Trend in the number of countries reporting line item in national budget for purchasing Supplies Total Yes per Region (No. Countries) AFR AMR EMR EUR SEAR WPR Overall Low Income countries GAVI Eligible countries Total Yes per Region (% of Countries) AFR 80% 83% 85% AMR 91% 91% 89% EMR 86% 86% 86% EUR 64% 68% 62% SEAR 64% 82% 91% WPR 67% 74% 74% Overall 76% 79% 78% Low Income countries 63% 77% 71% GAVI Eligible countries 75% 85% 83% 3.3 Percentage of government funding routine immunization The percentage 6 of government funding on routine immunization declined in the last three years, from 80% to 76% as population weighted averages (pwa) and from 77% to 78% as a simple average of the countries' percentages (avg). 6 Percentages are provided in table 3 and 4 both as population weighted averages (pwa) and countries' simple averages (avg). Figures 3-12 use only simple averages. 10

11 The African region is still dependent on external sources for funding about half of its routine immunization costs, and Americas and European regions appear the most selfsufficient, reporting percentages of costs financed by the government between 91-95% (pwa) and 95-96% (avg) in the period Low income countries reported the lowest percentage of government funding of routine immunization, from 36% in 2008 to 29% in 2010 (avg) showing a steady decreased over the three past years. GAVI eligible countries report decreasing proportions of government financing from 51% in 2008 to 48% in 2009 and 2010 (avg); from 71% in 2008 to 67% in 2010 (pwa) Figure 3: Percentage of expenditure on routine immunization financed by government ( ) 120% 100% 80% 60% 40% 20% 0% AFR AMR EMR EUR SEAR WPR

12 Table 3 : Trend in the percentage of total expenditure on routine immunization financed by national government Simple Average (%) AFR 53% 49% 52% AMR 95% 95% 91% EMR 76% 81% 81% EUR 96% 96% 95% SEAR 66% 63% 60% WPR 68% 71% 66% Overall 78% 77% 77% Low Income countries 36% 28% 29% GAVI Eligible countries 51% 48% 48% Population Weighted Average (%) AFR 50% 40% 47% AMR 97% 96% 96% EMR 72% 76% 74% EUR 97% 96% 96% SEAR 94% 88% 88% WPR 95% 96% 96% Overall 83% 80% 79% Low Income countries 41% 25% 31% GAVI Eligible countries 71% 65% 67% 3.4 Percentage of government funding vaccine costs In the period , the overall percentage of government funding of vaccine costs has been in the range of 74-83% (pwa) and 73-77% (avg). In the last three years, , the trend of percentage of government funding vaccine costs shows a decline, from 77% to 73% (avg) and from 80% to 74% (pwa). This could be the result of new vaccine introduction and campaigns supported by higher proportions of donors' funding. 12

13 The regional analyses show some differences. The African region reports decreasing percentages of government funding from 52% to 40% (avg) over the period of 2008 to Western Pacific region 7 reports a decline from 73% in 2008 to 66% (avg) in Low income countries reported the lowest percentages of government funding for vaccine costs, from 27% in 2008 to 18% in 2010 (avg) confirming their dependence on external funding. GAVI eligible countries reported decreased proportions of government financing over the last three years, from 47% in to 38% (avg) in However, 41 GAVI eligible countries reported that government financing vaccine costs increased in absolute values, whereas 18 countries reported a decline also in absolute values 8. Figure 4: Percentage of expenditure on vaccines financed by government ( ) 120% 100% 80% 60% 40% 20% 0% AFR AMR EMR EUR SEAR WPR Percentages calculated as simple countries averages in the South East Asian and in West Pacific regions differ substantially from percentages calculated as population weighted averages because the presence of the two highly populated countries, China and India. 8 The remaining 13 GAVI eligible countries did not report or they provided inconsistent data. 13

14 Table 4: Trend in the percentage of total expenditure on vaccines financed by national government Simple Average (%) AFR 52% 54% 40% AMR 96% 95% 92% EMR 73% 77% 78% EUR 94% 92% 91% SEAR 58% 62% 59% WPR 73% 70% 66% Overall 77% 77% 73% Low Income countries 27% 27% 18% GAVI Eligible countries 47% 47% 38% Population Weighted Average (%) AFR 51% 47% 38% AMR 97% 96% 96% EMR 78% 73% 76% EUR 95% 93% 93% SEAR 94% 89% 90% WPR 97% 95% 92% Overall 83% 79% 77% Low Income countries 36% 27% 19% GAVI Eligible countries 72% 66% 63% 4. National budget line for purchasing vaccines and shares of government funding vaccine expenditure JRF indicators showed an increasing number of countries that have a line item in their national budgets for the purchase of vaccines and a slight increase in the percentage of government funding the expenditures of vaccine used for routine immunization over the past 11 years. 14

15 Figure 5shows the 11 year trends of the two indicators for 1) countries with national budget line item for the purchase of vaccines since ) countries without national budget line and 3) countries which introduced the budget line during the period The graph shows that the 152 countries that had a line item in their national budgets for the purchase of vaccines since 2000 have had an average percentage of vaccine expenditures financed by national governments between 79% and 83% (avg); while those 13 countries reporting no budget line item for the purchase of vaccines averaged between 43% and 51% (avg), with a declining trend in Furthermore, 20 countries that introduced the budget line during this period reported increasing the percentage of government funding from 32% to 44% and a decline to 40% (avg) in These findings show that the budget line item for vaccines could contribute to increase government funding, but it is not sufficient to reach sustained levels. Figure 5: National budget lines for purchasing vaccines and percentages of vaccine expenditure financed by government ( ) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Without National Budget line for vaccines (13 countries ) National Budget line for vaccines introduced during the period (20 countries) With National Budget line since 2000 (152 countries)

16 5. Analysis by WHO regions In the following sections summary analyses of each WHO region are presented. In particular, regional JRF financing indicators are presented for the years Detailed country information is reported in Annex African Region In the African region 41 and out of 46 countries have been reporting line items in national budgets for vaccine over the last three years, while the number of countries with line item of supplies increased from 37 to 39. The proportion of government funding routine immunization decreased from 53% in 2008 to 49% in 2009 and increased in 2010 to 52%. The proportion of government funding vaccines increased from 52% in 2008 to 54% in 2009 and decreased in 2010 to 40%. This latter decline could be the result of more a precise reporting mechanism (the two new questions on total expenditure added in the JRF template 2010) and the result of higher donors' funding introduction of new vaccines and immunization campaigns. AFR - African Region, 46 countries No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization - avg 53% 49% 52% population weighted average 50% 40% 47% % of government funding vaccines - avg 52% 54% 40% population weighted average 51% 47% 38% 16

17 100% Figure 6: Budget line for purchasing vaccines and percentage of government funding for vaccines, AFR Average ( ) 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% % of countries with a line item in national budget for the purchase of vaccines used in routine immunization % Expenditure on vaccines used in routine immunization financed by national government Americas Region Most of the countries in the Americas have line items in the national budgets for purchasing vaccines and routine immunization supplies, 31 countries out of 35 in Proportions of government funding for routine immunization and vaccines are high, 91% and 92% in 2010, respectively (96% as population weighted). Despite a slight decrease in the last two years, these data confirm that majority of countries in America region are still largely self-sufficient in term of vaccines and routine immunization financing. AMR - American Region, 35 countries No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization - avg 95% 95% 91% population weighted average 97% 96% 96% % of government funding vaccines - avg 96% 95% 92% population weighted average 97% 96% 96% 17

18 100% Figure 7: Budget line for purchasing vaccines and percentage of government funding for vaccines, AMR Average ( ) 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% % of countries with a line item in national budget for the purchase of vaccines used in routine immunization % Expenditure on vaccines used in routine immunization financed by national government Eastern Mediterranean Region In the Eastern Mediterranean region 19 countries reported line item in national budgets for vaccine and 18 countries line item for injection supplies in The percentages of government funding for routine immunization and vaccines are increasing in the last three years and they are relatively high, 81% and 78%, respectively in EMRO- East Mediterranean Region, 21 countries No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization - avg 76% 81% 81% population weighted average 72% 76% 74% % of government funding vaccines - avg 73% 77% 78% population weighted average 78% 73% 76% 18

19 100% Figure 8: Budget line for purchasing vaccines and percentage of expenditure of government funding for vaccines, EMR Average ( ) 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% % of countries with a line item in national budget for the purchase of vaccines used in routine immunization % Expenditure on vaccines used in routine immunization financed by national government European Region The European region reports increasing numbers of member states with a line item in the national budget for purchasing vaccines (up to 48 or 91%, in 2010), and slight decreasing number of member states with line item for purchasing immunization supplies (33 countries or 62%, in 2010). The proportions of government funding for routine immunization and vaccines have been high even though showing slight decline, to 95% and 91% respectively in EUR - European Region, 21 countries No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies

20 % of government funding routine immunization - avg population weighted average 96% 97% 96% 96% 95% 96% % of government funding vaccines - avg 94% 92% 91% population weighted average 95% 93% 93% 100% Figure 9: Buget line for purchasing vaccines and percentage of government funding for vaccines, EUR Average ( ) 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% % of countries with a line item in national budget for the purchase of vaccines used in routine immunization % Expenditure on vaccines used in routine immunization financed by national government South East Asian Region In the South East Asian Region, 10 member states out of 11 (or 91%) reported a line item in national budget for vaccines and routine immunization supplies in The average proportions of government funding are moderately declining over the period, from 66% in 2008 to 60% in 2010 for routine immunization expenditure, and from 62% in 2009 to 59% in 2010 for vaccine costs. However, the proportions of government funding are relatively high when calculated as population weighted averages, 88% - 90% in SEAR - South East Asian Region, 21 countries 20

21 No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization - avg 66% 63% 60% population weighted average 94% 88% 88% % of government funding vaccines - avg 58% 62% 59% population weighted average 94% 89% 90% Figure 10: Budget line for purchasing vaccines and percentage of government funding for vaccines, SEAR Average ( ) 100% 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% % of countries with a line item in national budget for the purchase of vaccines used in routine immunization % Expenditure on vaccines used in routine immunization financed by national government Western Pacific Region In Western Pacific region, 25 countries out of 27 (or 93%) had a line item in the national budget for vaccines, and 20 (or 74%) countries had a line item for routine immunization supplies in

22 National governments are responsible for funding around 66% of both vaccines and routine immunization programs. The two indicators showed some fluctuations and overall decrease in Population weighted averages remain high, 92-96% in WPR - West Pacific Region, 27 countries No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization - avg 68% 71% 66% population weighted average 95% 96% 96% % of government funding vaccines - avg 73% 70% 66% population weighted average 97% 95% 92% 120% Figure 11: Budget line for purchasing vaccines and percentage of government funding for vaccines, WPR Average ( ) 100% 80% Percentage 60% 40% 20% 0% % of countries with a line item in national budget for the purchase of vaccines used in routine immunization % Expenditure on vaccines used in routine immunization financed by national government

23 6. Analysis by GAVI eligible countries The majority of GAVI eligible countries had introduced line items in their national budgets by 2010: 65 out of 72 countries (or 90%) have introduced budget line item for purchasing vaccines and 60 countries (or 83%) have introduced budget line item for purchasing immunization supplies. Both government funding for routine immunization and vaccines decreased as percentages over the period , from 51% to 48% (from 71% to 67% as population weighted averages) and from 47% to 37% (from 72% to 63% as population weighted averages), respectively. As mentioned above, the decline could be the result of more precise data reported and/or the result of higher donors' funding introduction of new vaccines and campaigns. Forty one countries reported increasing absolute values of government financing vaccine costs in the last three years whereas 18 countries reported a decline also in absolute values. GAVI eligible countries, 72 countries No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization - avg 51% 48% 48% population weighted average 71% 65% 67% % of government funding vaccines - avg 47% 47% 37% population weighted average 72% 66% 63% 23

24 100% Figure 12: Budget line for purchasing vaccines and percentage of government funding for vaccines, GAVI Averages ( ) 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% % of countries with a line item in national budget for the purchase of vaccines used in routine immunization % Expenditure on vaccines used in routine immunization financed by national government Conclusions The analysis shows the importance of the WHO-UNICEF joint reporting mechanism to monitor worldwide trends among regions and countries on key immunization financing indicators for decision making. Despite some problems of missing and inconsistent data, the analysis captures important developments: more and more countries (up to 90% of countries in 2010) are introducing line items in their national budgets for purchasing vaccines. This is evidence of priority given to immunization around the world and result of advocacy initiatives carried out at global and country levels. Governments are financing on average 77% (79% population weighted) of routine immunization expenditures and 73% (77% population weighted) of vaccine expenditure. However there are variations among regions and, in particular, low income countries report low government financing levels. Declining trends of percentages of government financing in the recent years in low income and GAVI eligible countries could be the result of higher donor's funding the introduction of new vaccines and campaigns. These trends will require close monitoring and further analysis. Efforts continue to be made to improve the quality of data by providing detailed instructions and definitions in the reporting template, by including indicators expressed in absolute values (instead of simple percentages) and by providing regular feedback to WHO regional and country offices on the findings. It is also expected that countries using 24

25 the cmyp tools will gradually harmonize the estimates used in the planning process and those reported through the JRF system. 25

26 ANNEXE 1 - WHO Regions and countries data 26

27 AFR- African Region Summary Number of countries of which: 46 Low income 25 Low middle income 11 Upper middle income 7 High income 1 Indicators: No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization (avg) 53% 49% 52% % of government funding vaccines (avg) 52% 54% 40% 27

28 AFR - African Region TABLE 1 A: LINE ITEM IN NATIONAL BUDGET Country GAVI Eligibles countries WB income group Algeria Upper Middle Income Yes Yes Yes Yes Yes Yes Angola GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Benin GAVI Low Income Yes Yes Yes Yes Yes Yes Botswana Upper Middle Income Yes Yes Yes Yes Yes Yes Burkina Faso GAVI Low Income Yes Yes Yes Yes Yes Yes Burundi GAVI Low Income Yes Yes Yes Yes No No Cameroon GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Cape Verde Lower Middle Income Yes Yes Yes Yes Yes Yes Central African Republic GAVI Low Income Yes Yes Yes Yes Yes Yes Chad GAVI Low Income Yes Yes Yes Yes Yes Yes Comoros GAVI Low Income No No No No No No Congo GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Côte d'ivoire GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Democratic Republic of the Congo GAVI Low Income Yes Yes Yes Yes Yes Yes Equatorial Guinea High Income No No No No No No Eritrea GAVI Low Income No No No No No No Ethiopia GAVI Low Income No Yes Yes Yes Yes No Gabon Upper Middle Income Yes Yes Yes Yes Yes Yes Gambia GAVI Low Income Yes Yes Yes Yes Yes Yes Ghana GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Guinea GAVI Low Income Yes Yes Yes Yes Yes Yes Guinea-Bissau GAVI Low Income Yes Yes Yes Yes Yes Yes Kenya GAVI Low Income Yes Yes Yes Yes Yes Yes Lesotho GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Liberia GAVI Low Income Yes Yes No Yes Yes No Madagascar GAVI Low Income Yes Yes Yes No Yes Yes Malawi GAVI Low Income Yes Yes Yes Yes Yes Yes Mali GAVI Low Income Yes Yes Yes Yes Yes Yes Mauritania GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Mauritius Upper Middle Income Yes Yes Yes No No Yes Mozambique GAVI Low Income Yes Yes Yes Yes Yes Yes Namibia Upper Middle Income Yes Yes Yes Yes Yes Yes Niger GAVI Low Income Yes Yes Yes Yes Yes Yes Nigeria GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Rwanda GAVI Low Income Yes Yes Yes Yes Yes Yes Sao Tome and Principe GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Senegal GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Seychelles Upper Middle Income Yes Yes Yes No No Yes Sierra Leone GAVI Low Income Yes Yes Yes Yes Yes Yes South Africa Upper Middle Income No No No No No No Swaziland Lower Middle Income Yes Yes Yes Yes Yes Yes Tanzania GAVI Low Income Yes Yes Yes Yes Yes Yes Togo GAVI Low Income Yes Yes Yes No Yes Yes Uganda GAVI Low Income Yes Yes Yes Yes Yes Yes Zambia GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Zimbabwe GAVI Low Income Yes No Yes No No Yes Total Yes No No Data Low Income Low Middle Income Upper Middle Income High Income countries In italics WHO estimates Line item in national budget for vaccines Line item in national budget for supplies

29 AFR - African Region TABLE 2 A: Government Funding Country Gavi Eligibles countries WB Income Group Algeria Upper Middle Income 100% 100% 100% 100% 100% 100% Angola GAVI Lower Middle Income 18% 100% 29% 14% 14% 34% Benin GAVI Low Income 42% 78% 18% 52% 84% 31% Botswana Upper Middle Income 100% 100% 100% 100% 100% 100% Burkina Faso GAVI Low Income 21% 30% 33% 69% 69% 69% Burundi GAVI Low Income 0% 8% 9% 5% 22% 39% Cameroon GAVI Lower Middle Income 51% 34% 96% 44% 13% 18% Cape Verde Lower Middle Income 84% 84% 84% 84% 84% 84% Central African Republic GAVI Low Income 0% 74% 4% 20% 66% 36% Chad GAVI Low Income 80% 45% 65% 80% 53% 53% Comoros GAVI Low Income 0% 4% 6% 21% 30% 30% Congo GAVI Lower Middle Income 100% 100% 13% 37% 37% 37% Côte d'ivoire GAVI Lower Middle Income 31% 5% 55% 35% 32% 32% Democratic Republic of the Co GAVI Low Income 0% 2% 0% 3% 2% 2% Equatorial Guinea High Income 100% 100% 100% 37% 74% 100% Eritrea GAVI Low Income 0% 0% 14% 20% 20% 15% Ethiopia GAVI Low Income 0% 7% 5% 0% 12% 51% Gabon Upper Middle Income 100% 100% 100% 88% 95% 98% Gambia GAVI Low Income 10% 35% 35% 100% 20% 30% Ghana GAVI Lower Middle Income 20% 20% 20% 70% 70% 70% Guinea GAVI Low Income 65% 30% 24% 60% 40% 22% Guinea-Bissau GAVI Low Income 0% 0% 18% 0% 0% 6% Kenya GAVI Low Income 100% 100% 48% 90% 10% 85% Lesotho GAVI Lower Middle Income 100% 100% 48% 100% 100% 100% Liberia GAVI Low Income 4% 4% 6% 2% 2% 28% Madagascar GAVI Low Income 10% 9% 5% 12% 10% 10% Malawi GAVI Low Income 33% 100% 36% 30% 50% 50% Mali GAVI Low Income 20% 100% 20% 50% 45% 45% Mauritania GAVI Lower Middle Income 100% 100% 11% 100% 100% 70% Mauritius Upper Middle Income 100% 100% 100% 100% 100% 100% Mozambique GAVI Low Income 100% 100% 27% 100% 100% 29% Namibia Upper Middle Income 100% 100% 100% 100% 100% 100% Niger GAVI Low Income 72% 29% 14% 20% 20% 16% Nigeria GAVI Lower Middle Income 90% 74% 71% 70% 70% 70% Rwanda GAVI Low Income 25% 25% 25% 25% 25% 25% Sao Tome and Principe GAVI Lower Middle Income 46% 25% 6% 33% 33% 59% Senegal GAVI Lower Middle Income 100% 17% 27% 80% 28% 41% Seychelles Upper Middle Income 100% 100% 100% 100% 100% 100% Sierra Leone GAVI Low Income 2% 2% 2% 0% 0% 0% South Africa Upper Middle Income 100% 100% 100% 100% 100% 100% Swaziland Lower Middle Income 100% 100% 100% 90% 90% 90% Tanzania GAVI Low Income 75% 21% 19% 70% 21% 23% Togo GAVI Low Income 15% 10% 8% 17% 1% 45% Uganda GAVI Low Income 15% 13% 36% 60% 21% 21% Zambia GAVI Lower Middle Income 73% 95% 19% 65% 65% 77% Zimbabwe GAVI Low Income 0% 0% 0% 3% 3% 41% Average Median Low Income Lower Middle Income Upper Middle Income High Income No Data In italics WHO estimates % Government funding vaccines % Government funding Routine immunization 52% 54% 40% 53% 49% 52% 49% 40% 26% 56% 39% 43% 28% 33% 19% 36% 29% 32% 70% 66% 45% 63% 57% 60% 100% 100% 100% 98% 99% 100% 100% 100% 100% 37% 74% 100%

30 AMR - American Region Summary Number of countries of which 35 Low income 1 Low middle income 8 Upper middle income 21 High income 5 Indicators: No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization (avg) 95% 95% 91% % of government funding vaccines (avg) 96% 95% 92% 30

31 AMR - American Region TABLE 1 B: LINE ITEM IN NATIONAL BUDGET Country GAVI Eligibles countries WB income group Antigua and Barbuda Upper Middle Income Yes Yes Yes Yes Yes Yes Argentina Upper Middle Income Yes Yes Yes Yes Yes Yes Bahamas High Income Yes Yes Yes Yes Yes Yes Barbados High Income Yes Yes Yes Yes Yes Yes Belize Lower Middle Income Yes Yes Yes Yes Yes Yes Bolivia GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Brazil Upper Middle Income Yes Yes Yes Yes Yes Yes Canada High Income No No Chile Upper Middle Income Yes Yes Yes Yes Yes Yes Colombia Upper Middle Income Yes Yes Yes Yes Yes Yes Costa Rica Upper Middle Income Yes Yes Yes Yes Yes Yes Cuba GAVI Upper Middle Income Yes Yes Yes Yes Yes Yes Dominica Upper Middle Income Yes Yes No Yes Yes Yes Dominican Republic Upper Middle Income Yes Yes Yes Yes Yes Yes Ecuador Upper Middle Income Yes Yes Yes Yes Yes Yes El Salvador Lower Middle Income Yes Yes Yes Yes Yes Yes Grenada Upper Middle Income Yes Yes Yes Yes Yes No Guatemala Lower Middle Income Yes Yes Yes Yes Yes Yes Guyana GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Haiti GAVI Low Income No No No No No No Honduras GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Jamaica Upper Middle Income Yes Yes Yes Yes Yes Yes Mexico Upper Middle Income Yes Yes Yes Yes Yes Yes Nicaragua GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Panama Upper Middle Income Yes Yes Yes Yes Yes Yes Paraguay Lower Middle Income Yes Yes Yes Yes Yes Yes Peru Upper Middle Income Yes Yes Yes Yes Yes Yes Saint Kitts and Nevis Upper Middle Income Yes Yes Yes Yes Yes Yes Saint Lucia Upper Middle Income Yes Yes Yes Yes Yes Yes Saint Vincent and The Grenadines Upper Middle Income Yes Yes Yes Yes Yes Yes Suriname Upper Middle Income Yes Yes Yes Yes Yes Yes Trinidad and Tobago High Income Yes Yes Yes Yes Yes Yes United States of America High Income Uruguay Upper Middle Income Yes Yes Yes Yes Yes Yes Venezuela Upper Middle Income Yes Yes Yes Yes Yes Yes Total Yes No No Data Low Income Low Middle Income Upper Middle Income High Income In italics WHO estimates Line item in national budget for vaccines Line item in national budget for supplies

32 AMR - American Region TABLE 2 B: Government Funding Country Gavi Eligibles countries WB Income Group Antigua and Barbuda Upper Middle Income 100% 100% 100% 100% 100% 100% Argentina Upper Middle Income 100% 100% 100% 100% 100% 100% Bahamas High Income 100% 100% 100% 100% 100% 100% Barbados High Income 100% 100% 100% 100% 100% 100% Belize Lower Middle Income 100% 100% 100% 100% 100% 100% Bolivia GAVI Lower Middle Income 100% 100% 100% 85% 85% 85% Brazil Upper Middle Income 100% 100% 100% 100% 100% 100% Canada High Income 100% 100% 100% 100% 100% 100% Chile Upper Middle Income 100% 100% 100% 100% 100% 100% Colombia Upper Middle Income 100% 100% 100% 100% 100% 100% Costa Rica Upper Middle Income 100% 100% 100% 100% 100% 100% Cuba GAVI Upper Middle Income 99% 99% 99% 98% 100% 98% Dominica Upper Middle Income 100% 100% 100% 100% 100% 100% Dominican Republic Upper Middle Income 90% 90% 100% 90% 90% 100% Ecuador Upper Middle Income 100% 100% 100% 100% 100% 100% El Salvador Lower Middle Income 100% 100% 100% 75% 100% 100% Grenada Upper Middle Income 100% 100% 100% 100% 100% 98% Guatemala Lower Middle Income 99% 100% 100% 100% 100% 100% Guyana GAVI Lower Middle Income 97% 100% 100% 89% 88% 67% Haiti GAVI Low Income 10% 0% 0% 10% 10% 9% Honduras GAVI Lower Middle Income 100% 71% 63% 100% 75% 66% Jamaica Upper Middle Income 100% 100% 100% 100% 100% 100% Mexico Upper Middle Income 100% 100% 100% 100% 100% 100% Nicaragua GAVI Lower Middle Income 65% 56% 41% 74% 65% 52% Panama Upper Middle Income 100% 100% 100% 100% 100% 99% Paraguay Lower Middle Income 100% 100% 100% 100% 100% 94% Peru Upper Middle Income 100% 100% 100% 100% 100% 100% Saint Kitts and Nevis Upper Middle Income 100% 100% 100% 100% 100% 100% Saint Lucia Upper Middle Income 100% 100% 100% 100% 100% 100% Saint Vincent and The Grenadi Upper Middle Income 100% 100% 100% 100% 100% 100% Suriname Upper Middle Income 100% 100% 100% 100% 100% 100% Trinidad and Tobago High Income 100% 100% 100% 100% 100% 100% United States of America High Income Uruguay Upper Middle Income 100% 100% 100% 100% 100% 100% Venezuela Upper Middle Income 100% 100% 100% 100% 100% 100% Average Median Low Income Lower Middle Income Upper Middle Income High Income No Data In italics WHO estimates % Government funding vaccines % Government funding Routine immunization 96% 95% 92% 95% 95% 91% 100% 100% 100% 100% 100% 100% 10% 0% 0% 10% 10% 9% 95% 91% 88% 90% 89% 83% 99% 99% 100% 99% 100% 100% 100% 100% 80% 100% 100% 80%

33 EMR - East Mediterranean Region Summary Number of countries of which 21 Low income 2 Low middle income 8 Upper middle income 5 High income 6 Indicators: No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization (avg) 76% 81% 81% % of government funding vaccines (avg) 73% 77% 78% 33

34 EMR - East Mediterranean Region TABLE 1 B: LINE ITEM IN NATIONAL BUDGET Country GAVI Eligibles countries WB income group Afghanistan GAVI Low Income No Yes Yes No No No Bahrain High Income Yes Yes Yes Yes Yes Yes Djibouti GAVI Lower Middle Income No No No No No No Egypt Lower Middle Income Yes Yes Yes Yes Yes Yes Iran (Islamic Republic of) Upper Middle Income Yes Yes Yes Yes Yes Yes Iraq Lower Middle Income Yes Yes Yes Yes Yes Yes Jordan Upper Middle Income Yes Yes Yes Yes Yes Yes Kuwait High Income Yes Yes Yes Yes Yes Yes Lebanon Upper Middle Income Yes Yes Yes Yes Yes Yes Libyan Arab Jamahiriya Upper Middle Income Yes Yes Yes Yes Yes Yes Morocco Lower Middle Income Yes Yes Yes Yes Yes Yes Oman High Income Yes Yes Yes Yes Yes Yes Pakistan GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Qatar High Income Yes Yes Yes Yes Yes Yes Saudi Arabia High Income Yes Yes Yes Yes Yes Yes Somalia GAVI Low Income No No No No No No Sudan GAVI Lower Middle Income No Yes Yes Yes Yes Yes Syrian Arab Republic Lower Middle Income Yes Yes Yes Yes Yes Yes Tunisia Upper Middle Income Yes Yes Yes Yes Yes Yes United Arab Emirates High Income Yes Yes Yes Yes Yes Yes Yemen GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Total Yes No No Data Low Income Low Middle Income Upper Middle Income High income In italics WHO estimates Line item in national budget for vaccines Line item in national budget for supplies

35 EMR - East Mediterranean Region TABLE 2 C: Government Funding Country Gavi Eligibles countries WB Income Group Afghanistan GAVI Low Income 0% 10% 2% 11% 11% 11% Bahrain High Income 100% 100% 100% 100% 100% 100% Djibouti GAVI Lower Middle Income 0% 0% 26% 32% 26% 50% Egypt Lower Middle Income 100% 100% 100% 100% 100% 100% Iran (Islamic Republic of) Upper Middle Income 100% 100% 100% 100% 100% 100% Iraq Lower Middle Income 100% 100% 100% 100% 98% 98% Jordan Upper Middle Income 100% 100% 100% 100% 100% 100% Kuwait High Income 100% 100% 100% 100% 100% 100% Lebanon Upper Middle Income 100% 100% 100% 100% 100% 100% Libyan Arab Jamahiriya Upper Middle Income 100% 100% 100% 100% 100% 100% Morocco Lower Middle Income 100% 100% 92% 80% 100% 100% Oman High Income 100% 100% 100% 100% 100% 100% Pakistan GAVI Lower Middle Income 100% 80% 100% 70% 80% 80% Qatar High Income 8% 95% 95% 20% 95% 95% Saudi Arabia High Income 100% 100% 100% 100% 100% 100% Somalia GAVI Low Income 0% 0% 0% 7% 6% 6% Sudan GAVI Lower Middle Income 0% 3% 6% 8% 19% 19% Syrian Arab Republic Lower Middle Income 100% 100% 100% 100% 100% 100% Tunisia Upper Middle Income 100% 100% 100% 99% 99% 99% United Arab Emirates High Income 100% 100% 100% 100% 100% 100% Yemen GAVI Lower Middle Income 18% 35% 20% 66% 63% 43% Average Median Low Income Lower Middle Income Upper Middle Income High Income No Data In italics WHO estimates % Government funding vaccines % Government funding Routine immunization 73% 77% 78% 76% 81% 81% 100% 100% 100% 100% 100% 100% 0% 5% 1% 9% 9% 9% 65% 65% 68% 70% 73% 74% 100% 100% 100% 100% 100% 100% 85% 99% 99% 87% 99% 99%

36 EUR - European Region Summary Number of countries of which: 53 Low income 2 Low middle income 6 Upper middle income 14 High income 31 Indicators: No. of countries with line item in national budget for vaccines No. of countries with line item in national budget for injection supplies % of government funding routine immunization (avg) 96% 96% 95% % of government funding vaccines (avg) 94% 92% 91% In italics WHO estimates 36

37 EUR - European Region TABLE 1 C: LINE ITEM IN NATIONAL BUDGET Country GAVI Eligibles countries WB income group Albania Upper Middle Income Yes Yes Yes Yes Yes Yes Andorra High Income Yes Yes Yes Yes Yes Yes Armenia GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Austria High Income Yes Yes Yes Yes Yes Yes Azerbaijan GAVI Upper Middle Income Yes Yes Yes No Yes Yes Belarus Upper Middle Income Yes Yes Yes Yes Yes No Belgium High Income Yes Yes Yes No No No Bosnia and Herzegovina Upper Middle Income Yes Yes Yes Yes No Yes Bulgaria Upper Middle Income Yes Yes Yes Yes Yes Yes Croatia High Income Yes Yes Yes No No No Cyprus High Income Yes Yes Yes Yes Yes Yes Czech Republic High Income Yes Yes Yes No No No Denmark High Income Yes Yes Yes No No No Estonia High Income Yes Yes Yes No No No Finland High Income Yes Yes Yes No No No France High Income No No No No No No Georgia GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Germany High Income No No No No No No Greece High Income Yes Yes Yes Yes Yes Yes Hungary High Income Yes Yes Yes Yes Yes Yes Iceland High Income Yes Yes Yes Yes Yes No Ireland High Income Yes Yes Yes Yes Yes No Israel High Income Yes Yes Yes Yes Yes Yes Italy High Income Yes Yes Yes Yes Yes Yes Kazakhstan Upper Middle Income Yes Yes Yes No Yes Yes Kyrgyzstan GAVI Low Income Yes Yes Yes No No No Latvia Upper Middle Income Yes Yes Yes Yes Yes Yes Lithuania Upper Middle Income Yes Yes Yes Yes Yes Yes Luxembourg High Income No Yes Yes No No No Macedonia Upper Middle Income Yes Yes Yes Yes Yes Yes Malta High Income No No No No No No Monaco High Income Yes Yes Yes No No No Montenegro Upper Middle Income Yes Yes Yes Yes Yes Yes Netherlands High Income Yes Yes Yes Yes Yes Yes Norway High Income Yes Yes Yes No No No Poland High Income Yes Yes Yes Yes Yes Yes Portugal High Income Yes Yes Yes Yes Yes Yes Republic of Moldova GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Romania Upper Middle Income Yes Yes Yes Yes Yes Yes Russian Federation Upper Middle Income Yes Yes Yes Yes Yes Yes San Marino High Income Yes Yes Yes Yes Yes Yes Serbia Upper Middle Income Yes Yes Yes Yes Yes Yes Slovakia High Income Yes Yes Yes Yes Yes No Slovenia High Income Yes Yes Yes Yes Yes Yes Spain High Income Yes Yes Yes Yes Yes Yes Sweden High Income No No No No No No Switzerland High Income No No No No No No Tajikistan GAVI Low Income Yes Yes Yes No Yes Yes Turkey Upper Middle Income Yes Yes Yes Yes Yes Yes Turkmenistan Lower Middle Income No Yes Yes No No No Ukraine GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes United Kingdom High Income Yes Yes Yes Yes Yes Yes Uzbekistan GAVI Lower Middle Income Yes Yes Yes Yes Yes Yes Total Yes No No Data Low Income Low Middle Income Upper Middle Income High Income In italics WHO estimates Line item in national budget for vaccines Line item in national budget for supplies