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 October 2017

2 Acknowledgements This report has been prepared by S. Mona Aghdaee (WHO consultant), Antonello Lenti (WHO intern) and Claudio Politi (WHO/HQ), with inputs and contributions from Patrick Lydon (WHO/HQ), Xiao Xian Huang (WHO consultant), Cara Bess Janusz (WHO/AMRO), Amos Petu (WHO/AFRO ES), Alexis Satoulou (WHO/AFRO CW), Irtaza Chaudhri (WHO/EMRO) and Niyazi Cakmak (WHO/EURO). 1

3 Contents Acknowledgements... 1 List of abbreviation... 3 Executive summary Introduction Data and Methodology WHO-UNICEF Joint Reporting Forms (JRF) Additional data sources Identification and estimation of missing and inconsistent data Reporting Statistics Country Selection Criteria Global Analysis Regional Analysis African Region Region of the Americas Eastern Mediterranean Region European Region South East Asia Region Western Pacific Region Analysis for Gavi eligible countries Analysis by Income Classification Discussion and Conclusions

4 List of abbreviation AFR AMR cmyp EMR EUR GVAP HIC JRF LIC LMIC PWA RI SEAR UMIC WPR WHO African Region WHO Region of the Americas comprehensive Multi-Year Plan WHO Eastern Mediterranean Region WHO European Region Global Vaccine Action Plan High Income Country Joint Reporting Form Low Income Country Lower Middle Income Country Population Weighted Average Routine Immunization WHO South Eastern Asia Region Upper Middle Income Country WHO Western Pacific Region 3

5 Executive summary The report presents the analysis of the financing indicators from the WHO-UNICEF Joint Reporting Form (JRF) for the period The immunization financing indicators included in this analysis are the following: - Existence of specific line item in the national budget for the purchase of vaccines used in routine immunization. - Total expenditure (from all sources) on routine immunization, including vaccines. - Government expenditure on routine immunization, including vaccines. - Total expenditure (from all sources) on vaccines used for routine immunization. - Government expenditure on vaccines used for routine immunization. JRF financing data were cross-checked by analyzing time series, data from Gavi co-financing payments and from comprehensive Multi-Year Plans for immunization (cmyps); missing data and inconsistencies were corrected and replaced by WHO estimates when it was considered appropriate. To allow consistent time trend analyses, countries with completed time series of observations on the four JRF financial indicators for the entire period have been selected, 77 countries fit this criteria. By selecting the countries with full six years observations on the four indicators, the analysis provides unbiased trends of immunization expenditure. The majority of selected countries for this analysis, 63 out of 77 (82%), reported to have specific line item in their national budgets for purchasing vaccines in Globally, government expenditures on routine immunization and on vaccines have increased over the six-year period. The average (population weighted) of expenditure on routine immunization per live birth in the 77 selected countries increased from US$ 29 in 2010 to US$ 36 in 2015 (+23%). The average (population weighted) expenditure on vaccines per live birth increased from US$ 25 in 2010 to US$ 30 in 2015 (+20%). However, percentage of government funding vaccine expenditure shows a declining trend, this is because external funds for introduction of new vaccines increased at a faster pace leading the percentage of total vaccine costs funded by government decreasing from 84% in 2010 to 60% in Similar trend is visible in government expenditures on routine immunization, which fell from 84% in 2010 to 63% in Overall during the period , governments have allocated more funds towards purchasing vaccines than other cost of immunization programs such as service delivery: the government share allocated to purchase vaccines has increased from 65% to 74%. This could be affected by the introduction of new vaccines supported by Gavi 4

6 and related co-financing policy. Gavi might provide incentives to countries with limited financial resources to prioritize vaccine expenditures. Analysis of JRF indicators in Gavi countries confirms the positive impact of Gavi co-financing policy in mobilizing domestic funds for immunization: Aggregate government funding on routine immunization in Gavi eligible countries has increased in absolute values from US$ 336 million in 2010 to US$ 381 million although the government expenditure as percentage of the total expenditure on routine immunization declined. Analysis of JRF indicators by countries income shows large disparity among low and high income countries, with high income countries spending on average US$ 500 per live birth on their routine immunization, while expenditure on routine immunization is only US$ 6.3 on average in low income countries. High and upper-middle income counties are fully funding their immunization program and low income countries on average, rely on external fund for financing over 70% of their immunization costs. 1. Introduction Although over last decades remarkable progress has been made in immunization coverage, the vaccinepreventable diseases remain a major cause of infant morbidity and mortality worldwide and coverage gaps persist between high, middle and low income countries. In December 2010, global health leaders committed to address challenges in immunization field by launching the decades of vaccines initiative ( ). Fulfilling this commitment WHO, UNICEF, Gavi and Bill & Melinda Gates Foundation, with collaboration of other partners, developed the Global Vaccine Action Plan (GVAP) for the period as a new roadmap to address vaccination gaps and prevent millions of vaccine-preventable diseases and deaths. The plan was endorsed by the 194 Member States of the World Health Assembly in May With the presence of numerous international organizations, public and private donors in health and immunization, substantial financial resources have been mobilized for vaccination and immunization. Among GVAP six strategic objectives, two objectives focus on financing issue: all countries commit to immunization as a priority (strategic objective 1) and immunization programs have sustainable access to predictable funding, quality supply and innovative technologies (strategic objective 5). Key indicator to monitor progress towards the strategic objective 1 is the domestic expenditure for immunization per person targeted. The final goal of global community is to lead countries to be self-sufficient and to ensure sustainable flow of funds to immunization. Sustainable financing and country ownership are key GVAP principles. Countries agreed to report their progress towards the GVAP goals annually through its monitoring and evaluation framework. 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 5

7 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. JRF financial indicators are key elements for sustainability and self-sufficiency of any immunization program. Their analysis provides evidence on countries moving towards ownership and commitment of GVAP goals as well as success of Gavi policies. This report presents an analysis of financing indicators for the period The trend analysis highlights improvements in government commitments to sustain the immunization programs. The analysis is conducted at four different levels: global, WHO regional offices, for Gavi eligible countries and by income levels. The structure of the report is the following: the next section describes the sources of data and the process of data cleaning and estimation. Section 3 and 4 present global and regional analysis; section 5 presents the analysis of Gavi eligible countries and section 6 presents the analysis by countries income. Section 7 includes discussion and conclusions. 2. Data and Methodology The source of data for the present analysis is WHO-UNICEF Joint Reporting Form (JRF). The WHO- UNICEF JRF collects data on immunization financing as part of a set of indicators designed to measure immunization coverage and system performance in WHO Member States, 194 countries. The JRF financing indicators are used extensively by the WHO, UNICEF and other organizations and academics for the purpose of measuring the extent to which countries are investing on their national immunization as well as the role of external funds. Additional sources of data have been used for the analysis: countries comprehensive Multi- Year Plan (cmyp) 1, the UN Population Data 2 and World Bank Development Indicators WHO-UNICEF Joint Reporting Forms (JRF) In an effort to minimize the burden of data gathering and monitoring, WHO and UNICEF jointly developed a standard questionnaire for reporting data on immunization indicators starting in The content

8 of the Joint Reporting Form was developed through a consensus process among staff from UNICEF, WHO and selected ministries of health (MOHs). Information collected through JRF include estimates of national immunization coverage, reported cases of vaccine-preventable diseases, immunization schedule, indicators of immunization system performances as well as financing indicators. Concerning the financial aspect of immunization programs, JRF includes six immunization expenditure indicators. Four indicators are expressed in absolute values of US$: Total expenditure (from all sources) on routine immunization, including vaccines. Government expenditure on routine immunization, including vaccines. Total expenditure (from all sources) on vaccines used for routine immunization. Government expenditure on vaccines used for routine immunization. Two indicators are expressed as percentages (%): Percentage of routine immunization expenditure financed by government Percentage of vaccine expenditure used for routine immunization financed by government. Furthermore, to reflect the level of commitment for each country in national immunization programs investments, the following indicator is collected: Availability of a specific line item in the national budget for the purchase of vaccines used in routine immunization. The rationale for creating an indicator reflecting the national budget line for vaccine purchasing is based on the assumption that the line item can contribute to improved financing. The expectation is that the presence of a line item for vaccines will encourage national governments to increase their budgetary efforts for immunization programs. It is assumed that governments that choose to introduce an immunization-related line item into the national budget will have a commitment to these programs. The presence of line item also permits tracking of allocations and increases transparency in the allocation of funds, and can allow stakeholders (EPI managers, Members of Parliaments, Civil Societies and International Organizations) to better monitor the government's budgetary effort. 2.2 Additional data sources Comprehensive Multi-Year Plans are useful source of information to cross-check JRF reported data. cmyp are multi-year plan for immunization which consolidates plans for several activities including program management, immunization delivery, monitoring, evaluation as well as cost and expected sources of financing. Countries cmyps are thus used for the present analysis to cross-check JRF reported data, by comparing equivalent expenditure and financing figures of the plans. UN Population Data has been used to extract the live birth indicator to calculate the financing indicators per live birth as well as population weighted average 7

9 estimates. Furthermore, Gross National Income (GNI) per capita has been extracted from World Bank World Development Indicators to be used for the analysis by income groups and Gavi countries. 2.3 Identification and estimation of missing and inconsistent data The analysis covers the period from 2010 to Countries started reporting JRF financing indicators since 2000, however only in recent years the quality and accuracy of the reported data have progressively improved. The GVAP set 2010 as the baseline year to monitor progress of the implementation of the global plan. Despite the global emphasis on the importance of JRF financial indicators, many countries fail to fully report them. WHO has made attempts to recover missing values and correct inconsistent data based on the information collected since 2000 in order to increase the number of valid observations for more comprehensive analysis. Identification of inconsistent data and imputation is done according to guidelines and principles. The following 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. In case one of the above criteria is not met for a reported value, the value is replaced by estimates based on the following methods: Average of available data; Assumed continuation of time series trend; Data from comprehensive Multiyear Plans (cmyp) costing and financing tool when available (mainly for GAVI eligible countries). The following sections provide details on selection criteria and the trends of response rates from countries, number of inconsistencies identified and estimates made by WHO. 8

10 2.4 Reporting Statistics This section presents the statistics of reporting for each JRF financing indicator. The quality of country reporting for the JRF financing indicators has been a critical issue since the beginning of the reporting. Countries are facing many challenges in the quantification of immunization expenditure data. In response to this, several initiatives have been undertaken by WHO and International Partners as a comprehensive effort to strengthen local and regional capacity. In particular, active feedback between countries and WHO has been intensified. In addition, immunization financing data has been disseminated and used for advocacy; preparation and dissemination of a specific JRF guidance note by the Gavi Immunization and Financing Sustainability (IF&S) Task Team 4. The guidance note provides countries with comprehensive definitions for each indicator as well as instructions on how to collect, estimate, validate and report the correct data. The graph and tables below describe the reporting statistics for the JRF financing indicators over the period 2010 to Figure 1. Reporting Statistics. Percentages of missing and inconsistencies 100% JRF financing indicators of data quality 80% 60% 40% 37% 39% 39% 38% 35% 30% 20% 0% 8% 7% 5% 6% 5% 1% Missings inconsistencies Table 1 Reporting Statistics All JRF financing indicators All six JRF financing indicators Missing Inconsistencies Estimations

11 Figure 1 and Table 1 summarize reporting statistics for 194 countries, across all indicators between the years 2010 and The number of missing indicators has decreased significantly during this period. The sharpest decline is associated with year 2015, the number of missing values dropped from 411 in 2014 to 355 in Inconsistencies follow a similar pattern, a steady decline in 2010 to 2014 and a substantial fall in 2015.In 2015, only 12 inconsistencies are identified in JRF financial indicators across countries. As a result of the reduction in missing and inconsistent values, the number of imputed estimations has also decreased. In 2010, 231 estimations have been calculated while this number was only 78 in This reporting statistics clearly indicates that the initiatives and support from WHO and International Partners have impact on the increasing response rate and data quality. Government expenditure on vaccines Table 2. Reporting Statistics. Details on each JRF financing indicator Missing Inconsistencies _ Estimations Total expenditure on vaccines Missing Inconsistencies Estimations Percentage of total expenditure on vaccines funded by government Missing Inconsistencies Estimations Government expenditure on routine immunization Missing Inconsistencies Estimations Total expenditure on routine immunization Missing Inconsistencies Estimations Percentage of total expenditure on routine immunization funded by government Missing Inconsistencies Estimations

12 As Tables 2 displays, despite the general increase in response rate in all indicators, there is a noticeable difference between indicators reporting on vaccines and those reporting on routine immunization. For instance, the number of missing data for the government vaccine expenditure is 52 in 2015, while this number reaches to 73 for the government expenditure on routine immunization. This wide gap between two set of indicators highlights challenges countries face in quantifying expenditure on routine immunization. Lack of a well-established information management system in some countries makes it difficult to record and track all the costs associated with routine immunization while vaccine expenditure information can be identified easily. Moreover, quantifying the costs that are included in routine immunization is challenging as health systems have many integrated services and shared costs are not easy to be distinguished and tracked down (administrative cost, outreach ). Survey on the difficulties faced by countries in reporting JRF financing indicators is available on the WHO website Country Selection Criteria To allow consistent time trend analyses, countries with completed time series of the following indicators for the entire period have been selected. 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. Total expenditure (from all sources) on routine immunization, including vaccines. By selecting the countries with full six years observations on the main four indicators, the analysis reflects the unbiased picture of existing expenditure trends in countries. Moreover, full time-series observations are essential to calculate consistent and unbiased population weighted averages. Table 3 provides the number of countries included in global and regional analyses. 5 Collection and reporting of immunization financing data for the WHO/UNICEF Joint Reporting Form - Results from country survey (2014): 11

13 of which are Gavi 6 eligible: Income classification Table 3. No. of countries selected in each analysis group Regional classification AFR AMR EMR EUR SEAR WPR Global LIC LMIC UMIC HIC Initial Self-fin Phase Phase Phase

14 3. Global Analysis The WHO-UNICEF joint reporting mechanism allows to monitor trends of key immunization financing indicators. Countries which reported complete 6 years observations on four main indicators during the entire period of have been selected to ensure consistent and unbiased analyses: 77 countries fit the criteria and their expenditure indicators have been expressed as population weighted averages and analyzed. Table 4. Global Analysis. Countries by income classification and Gavi eligibility Income Classification Group Total No. of countries Gavi eligible High Income 10 0 Upper Middle Income 27 4 Lower Middle income Low Income TOTAL During the period , the number of countries reporting a specific line item in their national budget for purchasing vaccines decreased from 73 to 63. The level of consistency in reporting varies across regions, with large variations in the American and African regions. Table 5. Global Analysis.77 selected countries. Line item in national budget for vaccines Countries with line item in national budget for vaccines Global (77) % 95% 95% 96% 94% 82% AFR (20) % % 19 95% % 19 95% 18 90% AMR (25) 24 96% EMR (7) 6 86% EUR (8) 7 88% SEAR (8) 8 100% WPR (9) 8 89% Gavi (40) 38 95% 23 92% 6 86% 7 88% 8 100% 9 100% 39 98% 24 96% 6 86% 7 88% 8 100% 9 100% 38 95% 23 92% 7 100% 7 88% 8 100% 9 100% % 24 96% 6 86% 7 88% 8 100% 8 89% 37 93% 19 76% 6 86% 7 88% 6 75% 7 78% 35 86% 13

15 Each of the four main JRF financial indicators- expressed as population weighted average per live birthfollowed an upward trend: in fact, their minimum level is at the baseline, while the respective peak is reached in the last year, except the government expenditure on vaccines which shows a slightly lower figure in 2015 compared to the previous year (Table 6, Figure 2). Table 6. Global Analysis. Indicator summary (population weighted average, US$ per live birth in 77 selected countries) Indicators Expenditures on Routine Immunization (RI) Total RI expenditure per live birth $33.1 $36.1 $35.4 $36.9 $41.7 $43.2 Government RI expenditure per live birth $29.2 $31.2 $31.4 $30.6 $34.9 $36.9 % of total RI funded by government 88% 86% 89% 83% 84% 85% Expenditures on Vaccines Total vaccine expenditure per live birth $27.6 $30.5 $29.2 $31.5 $35.5 $35.9 Government vaccine expenditure per live birth $25.1 $27.0 $26.3 $26.2 $30.5 $30.0 % of total vaccine funded by government 91% 89% 90% 83% 86% 84% The total expenditure grew more than the government expenditure: - The total expenditure on routine immunization and the total expenditure on vaccines showed a similar percentage increase throughout the period (approximately a 30% growth rate), peaking to US$ 43.2 and US$ 35.9 in 2015 respectively; - The government expenditure on routine immunization grew from US$ 25.1 in 2010 to US$ 36.9 in 2015 (+26.4%), while the government expenditure on vaccines was US$ 25.1 at baseline and reached US$ 35.9 in 2015 (+19.5%). 14

16 The comparison between growth rates of the four different indicators leads to these remarks: - The percentage of expenditures funded by governments is decreasing, due to other external sources of funding, such as those provided by GAVI support (Table 6; figure 3); - Since the government expenditure on routine immunization grew in percentage terms more than the government expenditure on vaccines, a new allocation of resources occurred; indeed, throughout the six-year period, the share of service delivery passed from 14% to 19% of the government expenditure on routine immunization (Figure 4). Figure 2. Global Analysis. JRF financial indicators (population weighted average, US$ per live birth in 77 selected countries) 45 GLOBAL ANALYSIS Total and Government Expenditures on Routine Immunization and Vaccines

17 Figure 3. Global Analysis. Total Expenditure on Vaccines, by source of financing (population weighted average, US$ per live birth in 77 selected countries) 40 GLOBAL ANALYSIS Total Expenditure on Vaccines % 11% 10% 17% 14% 16% % 89% 90% 83% 86% 84% 5 0 $27,6 $30,5 $29,2 $31,5 $35,5 $35,9 Figure 4. Global Analysis. Composition of the Government Expenditure on Routine Immunization (population weighted average, US$ per live birth in 77 selected countries) 40 GLOBAL ANALYSIS Government Expenditure on Routine Immunization % 13% 16% 14% 13% 19% % 87% 84% 86% 87% 81% 5 0 $29,2 $31,2 $31,4 $30,6 $34,9 $36,9 Vaccines Service delivery 16

18 4. Regional Analysis WHO member states are grouped into six WHO regions: African region, region of the Americas, South- East Asia region, European region, Eastern Mediterranean region, and Western Pacific region. The following section describes and analyses JRF financial indicators according to WHO regions African Region 47 countries are in African Region (AFR). Twenty countries have complete 6 years observations on the four financing indicators during the period of , 17 of them are Gavi eligible 7. Table 7 provides information of the selected countries, their income status and Gavi eligibility. Table 7. AFR. Selected countries by income classification and Gavi eligibility Income Classification Group Total No. of countries Gavi eligible High Income 1 0 Upper Middle Income 1 0 Lower Middle income 6 5 Low Income TOTAL All 20 selected countries in the African region reported to have line item in 2010, 2011 and In 2012, Congo reported to drop the line item, and in the next year, reported to add the line item back. In 2015, Congo dropped the line item again. At the end of the period, another country (Comoros) dropped the line item as well, which resulted in 18 countries having line items in 2015 (Table 8). 7 Of which: 12 countries are Initial Self-financing, 4 countries are in Phase 1 Preparatory transition, 1 country is in Phase 2 - Accelerated transition. 17

19 Table 8. AFR. Indicator summary (population weighted average, US$ per live birth in 20 selected countries) Indicators Countries with line item in national budget for vaccines Expenditures on Routine Immunization : Total RI expenditure Per Live Birth Government RI expenditure Per Live Birth % of total RI funded by government Expenditures on Vaccines: Total vaccine expenditure Per Live Birth Government vaccine expenditure Per Live Birth % of total vaccine funded by government $22.0 $26.7 $22.5 $28.0 $36.2 $28.8 $6.4 $5.9 $5.9 $6.1 $6.7 $8.4 29% 22% 26% 22% 19% 29% $12.7 $15.0 $14.7 $21.8 $24.9 $23.4 $3.5 $2.9 $3.0 $3.7 $3.8 $4.0 27% 19% 20% 17% 15% 17% Over the last six years, the African Region experienced an increase in all the JRF financing indicators expressed as population weighted average per live birth. Even though each expenditure has evolved following a different fluctuating trend, the peak is reached in 2015, with the exception of the total expenditure on vaccines which shows a slight fall at the end of the period. The expenditure on routine immunization has grown at rates different from those shown by the expenditure on vaccines: - The total and government expenditure on routine immunization have both experienced growth rates consistent with the trend recorded globally (an increase of about 30% for the entire period; see Chapter 3); - The total expenditure on vaccines has almost doubled compared to baseline, while the expenditure funded by government underwent a modest increase (+8.6%). The significant increase in the externally funded expenditure on vaccines is clearly due to the GAVI support over the years. 18

20 Figure 5. African Region. JRF financial indicators (population weighted average, US$ per live birth in 20 selected countries) AFR Total and Government Expenditures on Routine Immunization and Vaccines Figure 6. African Region. Total Expenditure on Vaccines, by source of financing (population weighted average, US$ per live birth in 20 selected countries) AFR Total Expenditure on Vaccines % 85% 83% 73% 81% 80% 27% 19% 20% 17% 15% 17% $12,7 $15,0 $14,7 $21,8 $24,9 $23,4 19

21 Figure 7. African Region. Composition of the Government Expenditure on Routine Immunization (population weighted average, US$ per live birth in 20 selected countries) % AFR Government Expenditure on Routine Immunization 50% 50% 54% 50% 50% 40% 44% 53% 60% 56% 47% 6,4 5,9 5,9 6,1 6,7 8,4 Vaccines Service Delivery Table 9 provides information on the government routine immunization expenditure per live birth for the 20 selected countries. The highest increase is in Congo with almost 300% increase from US$ 3.2 in 2010 to US$ 11.4 in Ten countries showed upwards trends, while other 10 countries experienced a decrease in their government expenditure on routine immunization. Gabon is the country with the most decline in the region. Both Gavi and non-gavi countries experienced fluctuating trends throughout the period. Table 9. AFR. Government expenditure on routine immunization per live birth, US$. 20 selected countries Country Income classification Gavi grouping Trend between 2010 and 2015 Percentage change Congo (The) LMIC Phase Increasing 257% Guinea LIC Initial Increasing 204% Tanzania LIC Initial Increasing 167% Rwanda LIC Initial Increasing 137% Seychelles HIC Increasing 82% Swaziland LMIC Increasing 69% Mali LIC Initial Increasing 42% Mozambique LIC Initial Increasing 18% Eritrea LIC Intial Increasing 10% Côte d'ivoire LMIC Phase Increasing 3% Togo LIC Initial Decreasing -3% Mauritania LMIC Phase Decreasing -4% Burkina Faso LIC Initial Decreasing -7% Benin LIC Initial Decreasing -16% Cameroon LMIC Phase Decreasing -17% CAR LIC Initial Decreasing -17% Sao Tome and P. LMIC Phase Decreasing -22% Chad LIC Initial Decreasing -35% Comoros LIC Initial Decreasing -53% Gabon UMIC Decreasing -87% Population Weighted Average $6.4 $5.9 $5.9 $6.1 $6.7 $8.4 Increasing 32% 20

22 4.2. Region of the Americas Thirty-five countries are in the Region of Americas (AMR). Twenty-five of them have six years observations and fit the selection criteria. Table 10 provides information on the countries selected in this region, their income and Gavi eligibility. Table 10. AMR. Selected countries by income classification and Gavi eligibility Income Classification Group Total No. of countries Gavi eligible High Income 4 0 Upper Middle Income 16 2 Lower Middle income 5 3 Low Income 0 0 TOTAL 25 5 Out of the 25 selected countries in the region of Americas, most of the countries have been reporting line item in national budget for vaccine purchase over the period of The number of countries reported to have line item at the beginning of period was 24, and it stayed fairly stable until In 2015, the number dropped substantially to 19 countries having the line item for vaccine procurement. Grenada, Jamaica, Saint Vincent and The Grenadines and Venezuela are the member states that were constantly reported to have a line item in period of 2010 to 2014, while in 2015 they reported to drop line item in national budgets for vaccine purchase. This issue seems to be due to reporting errors. 21

23 Table 11. AMR. Indicator summary (population weighted average, US$ per live birth in 25 selected countries) Indicators Countries with line item in national budget for vaccines Expenditures on Routine Immunization Total RI expenditure per live birth $144.4 $153.7 $144.4 $151.8 $194.2 $188.7 Government RI expenditure per live birth $141.7 $149.0 $141.5 $140.3 $186.0 $187.5 % of total RI funded by government 98% 97% 98% 92% 96% 99% Expenditures on Vaccines Total vaccine expenditure per live birth $132.3 $142.0 $130.9 $143.0 $181.2 $168.3 Government vaccine expenditure per live birth $130.5 $137.7 $128.1 $131.9 $173.4 $167.7 % of total vaccine funded by government 99% 97% 98% 92% 96% ~100% The number of AMR selected countries accounts for almost a third of the total number of member states considered in the global analysis. Since the JRF financial indicators of each country have varied over 6 years, the four indicators expressed as population weighted average per newborn have experienced some fluctuations during the period as well. The indicators showed their minimum level in 2012 and reached the peak in 2014, except the government expenditure on routine immunization which exhibits the bounds of the time series delayed by one year. At the baseline, the indicators in the Region of Americas were between 4 and 5 times higher than the global population weighted averages and, over years, they increased at rates even higher than those observed in the global analysis. The government expenditure on routine immunization shows high percentage increase: starting from US$ in 2010, it reached US$ in 2015 (+ 32.3%). In 2015 both routine immunization and vaccines are almost exclusively funded by domestic resources. The significant decrease in external funding is clearly justifiable by observing the characteristics of the sample: out of 25 countries, there are no low income countries, 16 of them are classified as upper middle income and only 5 countries are GAVI eligible (mainly in Phase 2 and 3): in accordance with the dynamics of the GAVI co-financing policy, they all increased the government expenditure over time, moving towards selfsufficiency. Finally, it is noted that the composition of government spending has been stable, recording only an increase in the share of service delivery at the end of the period (Figure 10). 22

24 Figure 8. Region of the Americas. JRF financial indicators (population weighted average, US$ per live birth in 25 selected countries) 200 AMR Total and Government Expenditures on Routine Immunization and Vaccines Figure 9. Region of the Americas. Total Expenditure on Vaccines, by source of financing (population weighted average, US$ per live birth in 25 selected countries) % 3% 99% 97% AMR Total Expenditure on Vaccines 2% 8% 98% 92% 4% 96% ~100% $132,3 $142,0 $130,9 $143,0 $181,2 $168,3 23

25 Figure 10. Region of the Americas. Composition of the Government Expenditure on Routine Immunization (population weighted average, US$ per live birth in 25 selected countries) AMR Government Expenditure on Routine Immunization % 11% 8% 8% 9% 6% 93% 89% 92% 92% 91% 94% $141,7 $149,0 $141,5 $140,3 $186,0 $187,5 Vaccines Service Delivery Table 12 shows data on the government routine immunization expenditure per live birth for 25 the countries with full six years of observations. During this period, 23 countries have a substantial to moderate increase in their expenditure on routine immunization. These growths vary from 1.7% to 360%. Table 12. AMR. Government expenditure on routine immunization per live birth, US$. 25 selected countries Country Income classifification Gavi 24 Trend between 2010 and 2015 Percentage change Argentina HIC Increasing 359% Dominica UMIC Increasing 278% Saint Lucia UMIC Increasing 254% Guatemala LMIC Increasing 197% Dominican Republic UMIC Increasing 165% Paraguay UMIC Increasing 77% Panama UMIC Increasing 68% Venezuela UMIC Increasing 57% Guyana UMIC Phase Increasing 55% Honduras LMIC Phase Increasing 39% Colombia UMIC Increasing 33% Bahamas HIC Increasing 31% Bolivia LMIC Phase Increasing 30% Cuba UMIC Phase Increasing 25% Uruguay HIC Increasing 24% El Salvador LMIC Increasing 23% St.Vincent and G. UMIC Increasing 18% Peru UMIC Increasing 17% Nicaragua LMIC Phase Increasing 13% Grenada UMIC Increasing 8% Ecuador UMIC Increasing 8% Brazil UMIC Increasing 5% Belize UMIC Increasing 2% St. Kitts and Nevis HIC Decreasing -74% Jamaica UMIC Decreasing -80% Population Weighted Average $141.7 $149.0 $141.5 $140.3 $186.0 $187.5 Increasing 32%

26 4.3 Eastern Mediterranean Region 21 countries are in the Eastern Mediterranean Region (EMR). Seven of them have six years observations and are included into the analysis. Table 13 provides information on the selected countries, their income and Gavi eligibility. Table 13. EMR. Selected countries by income classification and Gavi eligibility Income Classification Group Total No. of countries Gavi eligible High Income 0 0 Upper Middle Income 3 0 Lower Middle income 4 3 Low Income 0 0 TOTAL 7 3 Six out of the seven selected countries in the Eastern Mediterranean region have been reporting a line item in national budgets for vaccine purchase over the period of The number of countries reported to have a line item at the beginning of period was 6 and it stayed stable until In 2013, Djibouti which never report a line item, reported it and the number increased to 7. However, the following year, Djibouti dropped the line item so that in 2015, 6 countries reported to have the line item for vaccine procurement. Table 14. EMR. Indicator summary (population weighted average, US$ per live birth in 7 selected countries) Indicators Countries with line item for vaccines in national budget Expenditures on Routine Immunization Total RI expenditure per live birth $23.1 $27.8 $29.9 $37.1 $38.4 $39.6 Government RI expenditure per live birth $11.6 $12.2 $16.7 $17.3 $21.1 $20.9 % of total RI funded by government 50% 44% 56% 47% 55% 53% Expenditures on Vaccines Total vaccine expenditure per live birth $15.9 $23.9 $26.5 $32.2 $30.8 $31.9 Government vaccine expenditure per live birth $9.1 $9.9 $13.3 $14.2 $16.8 $18.0 % of total vaccine funded by government 57% 41% 50% 44% 55% 57% 25

27 The four financing indicators- expressed as population weighted average per newborn grew at rates higher than those noticed in the global analysis (see Chapter 3). The total and government expenditure on vaccines has increased more than the expenditure on routine immunization, meaning that resources have been allocated between vaccines and service delivery differently compared to 2010 (Figure 13 shows the composition of the government expenditure on routine immunization over the period). The total expenditure on routine immunization and the government expenditure on vaccines reached their maximum level in 2015, peaking to US$ 39.6 and US$ 18.0 respectively. The total expenditure on vaccines shows the biggest percentage increase among the 4 indicators (+100%), but -as the deployment of domestic resources increased as well- in 2015 the share of externally funded expenditure on vaccines is steady compared to baseline (Figure 12). It is worth noting that, 4 countries out of 7 EMR selected countries, are classified as upper-middle income, while the remaining countries are classified as Phase 1 of GAVI support. Figure 11. Eastern Mediterranean Region. JRF financial indicators (population weighted average, US$ per live birth in 7 selected countries) 45 EMR Total and Government Expenditures on Routine Immunization and Vaccines

28 Figure 12. Eastern Mediterranean Region. Total Expenditure on Vaccines, by source of financing (population weighted average, US$ per live birth in 7 selected countries) 35 EMR Total Expenditure on Vaccines % 59% 57% 41% 43% 56% 45% 50% 55% 57% 50% 44% 0 $15,9 $23,9 $26,5 $32,2 $30,8 $31,9 Figure 13. Eastern Mediterranean Region. Composition of the Government Expenditure on Routine Immunization (population weighted average, US$ per live birth in 7 selected countries) EMR Government Expenditure on Routine Immunization 20 20% 14% 15 20% 18% % 19% 78% 81% 80% 82% 80% 86% 0 $11,7 $12,2 $16,6 $17,3 $21,1 $20,9 Vaccines Service Delivery 27

29 Table 15 provides information on the government expenditure on routine immunization per live birth for 7 selected countries. During the period, Djibouti experienced the highest increase from US$ 36.4 to US$ The second country with the highest increase is Iran with a 108% increase. Overall, 6 countries showed upward trends and directed more resources to immunization since These increases vary from 125% to 23%. In contrast to the regional trend, Yemen underwent a substantial decline during this period since the expenditure on routine immunization decreased from US$ 4.9 in 2010 to US$ 1.3 at the end of the period. This drop is mainly due to conflict and crisis in Yemen, which has contributed to weakening the financial situation of the country. Table15. EMR. Government expenditure on routine immunization per live birth, US$. 7 selected countries Country Income classification Gavi Trend between 2010 and 2015 Percentage change Djibouti LMIC Phase Increasing 126% Iran UMIC Increasing 108% Lebanon UMIC Increasing 96% Tunisia LMIC Increasing 90% Jordan UMIC Increasing 86% Sudan LMIC Phase Increasing 23% Yemen LMIC Phase Decreasing -74% Population Weighted Average $11.7 $12.2 $16.7 $17.3 $21.1 $20.9 Increasing 80% 28

30 4.4. European Region 53 countries are part of the European Region (EUR). Only 8 countries fit the selection criteria of complete 6 years observations of the four financing indicators and are included in the analysis. Four of them are eligible for receiving Gavi fund, in different phases of Gavi co-financing arrangement. Table 16 provides summary information on the number of selected countries, their income status and Gavi eligibility. Table 16. EUR. Selected countries by income classification and Gavi eligibility Income Classification Group Total No. of countries Gavi eligible High Income 3 0 Upper Middle Income 3 2 Lower Middle income 2 2 Low Income 0 0 TOTAL 8 4 From the 8 selected countries in the European region, 7 of them have been reporting line items in national budgets for vaccine purchase over the period of Bulgaria is the country that always reported no line item for vaccine purchase during this period. (Table 17). Table 17. EUR. Indicator summary (population weighted average, US$ per live birth in 7 selected countries) Indicators Countries with line item for vaccines in national budget Expenditures on Routine Immunization Total RI expenditure per live birth $192.4 $209.5 $195.9 $191.4 $184.1 $162.2 Government RI expenditure per live birth $187.2 $202.1 $188.2 $183.4 $175.6 $155.8 % of total RI funded by government 96% 97% 96% 95% 95% 96% Expenditures on Vaccines Total vaccine expenditure per live birth $148.6 $153.2 $135.5 $127.5 $118.5 $100.1 Government vaccine expenditure per live birth $142.7 $148.0 $129.6 $121.3 $110.0 $94.2 % of total vaccine funded by government 96% 97% 96% 95% 93% 94% 29

31 The European region shows a decrease in all four financial indicators calculated as population weighted average per live birth. Contrary to what has been observed in the global analysis (see Chapter 3), the indicators- after peaking in declined steadily and then reached their minimum level at the end of the period. Even though the government expenditure on vaccines is still 3 times bigger than the global population weighted average, it decreased from US$ in 2010 to US$ 94.2 in 2015 (-34%), while the government expenditure on routine immunization declined from US$ in 2010 to US$ in 2015 (-17%). Since the government expenditure on vaccines decreased more than the government expenditure on routine immunization, the latter reveals that service delivery received an ever larger share of domestic resources during the six-year period. As Figure 14 exhibits, the total and government expenditures evolved parallel over time, therefore the percentage of the total routine immunization funded by government could remain constant, while the percentage of vaccines funded by government fell slightly from 96% in 2010 to 94% in 2015 (see Figure 15). Figure 14. European Region. JRF financial indicators (population weighted average, US$ per live birth in 7 selected countries) 220 EUR Total and Government Expenditures on Routine Immunization and Vaccines

32 Figure 15. European Region. Total Expenditure on Vaccines, by source of financing (population weighted average, US$ per live birth in 7 selected countries) % 3% 96% 97% EUR Total Expenditure on Vaccines 4% 5% 96% 95% $148,6 $153,2 $135,5 $127,5 $118,5 $100,1 7% 93% 6% 94% Figure 16. European Region. Composition of the Government Expenditure on Routine Immunization (population weighted average, US$ per live birth in 7 selected countries) EUR Government Expenditure on Routine Immunization % 24% 31% 34% 37% 40% 76% 73% 69% 66% 63% 60% $187,2 $202,1 $188,2 $183,4 $175,6 $155,8 Vaccines Service Delivery 31

33 Figure 16, shows the share of funding allocated to vaccine purchase and service delivery. In 2010, 76% of the resources were directed to vaccine costs. This share declined throughout the period and reached to 60% in During the period, the share of service delivery varies from 24% to 40 %. Table 18 provides data on the government routine immunization expenditure per live birth for 8 selected countries that fit the analysis criteria. Two countries (Armenia and Georgia) have a substantial increase in their routine immunization expenditure. Both of them are middle income countries and in phase 2 of Gavi support. The data reveals that Gavi policies have helped them to re-direct their domestic fund to immunization. The other 6 countries showed declining trends. This decrease ranges from -6.3 % to %. The country with the major decline is Azerbaijan, although it is in phase 2 Gavi and an upper-middle income country. The 3 high income countries in our list also experienced moderate to a considerable drop. Iceland, The Netherlands and Andorra decreased their government expenditure on routine immunization by -8.9%, -17.8% and -31.4% respectively. Table 18. EUR. Government expenditure on routine immunization per live birth, US$. 8 selected countries Country Income classification Gavi Trend between 2010 and 2015 Percentage change Armenia LMIC Phase Increasing 544% Georgia UMIC Phase Increasing 69% Bulgaria UMIC Decreasing -6% Tajikistan LMIC Phase Decreasing -6% Iceland HIC Decreasing -9% Netherlands HIC Decreasing -18% Andorra HIC Decreasing -31% Azerbaijan UMIC Phase Decreasing -54% Population Weighted Average $187.2 $202.1 $188.2 $183.4 $175.6 $155.8 Decreasing -17% 32

34 4.5. South East Asia Region 11 countries are in South East Asia Region (SEAR), 8 countries have full six years observations and are included into the analysis. 6 of them are eligible for receiving Gavi support, in different phases of Gavi cofinancing arrangement. Table 19 provides information on the number of countries, their income status and Gavi eligibility. Table 19. SEAR. Selected countries by income classification and Gavi eligibility Income Classification Group Total No. of countries Gavi eligible High Income 0 0 Upper Middle Income 2 0 Lower Middle income 5 5 Low Income 1 1 TOTAL 8 6 From the 8 selected countries in South East Asia region, all of them have been reporting line items in national budgets for vaccine purchase over the period of However, the number of countries that reported to have a line item decreased to 6 at the end of period. Two countries, Timor-Lest and Maldives, dropped the line item in 2015 while they had reported it in previous years. The selected countries represent most of the region, therefore the main JRF financial indicators listed below computed as population weighted averages per newborn- are supposed to be representative of the totality of SEAR values. However, it should be noted that India, accounting for 70% of the total number of live births, greatly affects the population weighted averages. Table 20. SEAR. Indicator summary (population weighted average, US$ per live birth in 8 selected countries) Indicators Countries with line item for vaccines in national budget Expenditures on Routine Immunization Total RI expenditure per live birth $7.7 $8.0 $9.7 $8.6 $8.6 $13.6 Government RI expenditure per live birth $6.1 $6.5 $8.4 $6.2 $6.3 $7.1 % of total RI funded by government 78% 81% 87% 72% 74% 52% 33