Immuniza(on financing in non-gavi countries

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1 Immuniza(on financing in non-gavi countries Building the investment case for rotavirus vaccines through evidence mee4ng, Singapore HELEN SAXENIAN APRIL 27, 2017 Page 1

2 Outline of today s presenta(on I. Importance of Immuniza4on and Immuniza4on Financing II. Gavi and non-gavi Countries: Implica4ons for Immuniza4on Financing III. Overview of the Resource Guide and Main Messages IV. Financing Introduc4on and Ongoing Immuniza4on Costs in non-gavi Countries V. Conclusions 2

3 I. Importance of immuniza(on and immuniza(on financing Immuniza4on is one of the best buys in health v Vaccines currently save 2-3 million lives every year v Every dollar invested in immuniza4on returns $16-44 in economic returns* The menu of new, lifesaving vaccines has con4nued to expand To take advantage of expanding opportuni4es, immuniza4on programs need predictable financing adequate to the needs v Unreliable financing can lead to stock-outs and unimmunized children v Predictable, long-term financing is crucial for planning and for obtaining the lowest possible vaccine prices. v Some important newer vaccines are more expensive than tradi4onal EPI vaccines 3 *h_p://content.healthaffairs.org/content/35/2/199.abstract

4 II. Gavi and non-gavi countries: Implica(ons for immuniza(on financing What is Gavi? A founda4on in Geneva established in 2000 to accelerate the adop4on of new and underused vaccines in the world s poorest countries & to improve immuniza4on coverage. The world s largest channel of external financing for immuniza4on. 73 Gavi countries, although many now in process of transi4oning from Gavi support. A few have fully transi4oned. Gavi finances introduc4on costs and a share of costs of rou4ne new & underused vaccines. In non-gavi countries governments typically carry that burden themselves, from the start Gavi countries also benefit from Gavi prices. Non-Gavi countries may face higher and uncertain prices, and in some cases, uncertain supply 4

5 Gavi financing model: country contribu(ons For example, Nepal For example, Myanmar For example, Lao, Vietnam For example, Bhutan, Sri Lanka, Mongolia 5

6 Non-Gavi and Gavi Low and Middle Income Countries in Asia Non-Gavi Middle Income Countries Gavi Status, 2017 S4ll fully eligible for support Have crossed the eligibility threshold and in process of transi4oning from support China 1 Bangladesh India Bhutan Malaysia Cambodia Lao Indonesia Philippines Korea, DPR Timor-Leste Mongolia Thailand Myanmar Vietnam Sri Lanka Fully or nearly fully transi4oned from Gavi support Ø Many countries in Asia have benefited from Gavi support. Ø As incomes have risen, many have transi4oned or are in the process of transi4oning from Gavi support 1 China received some Gavi support in the first few years aler Gavi was established. 2 Fully or nearly fully transi4oned from Gavi support 6

7 III. What is the Immuniza(on Financing Resource Guide? 26 accessible briefs on topics in immuniza4on financing Audience: anyone with an interest in immuniza4on financing in low and middle-income countries Wri_en to be accessible and prac4cal while remaining rigorous Available in hard copy and online Briefs can be read (and downloaded) individually or as part of the whole. Produced by the Results for Development Ins4tute (R4D), based on research funded in part by the Bill and Melinda Gates Founda4on. 7

8 Overview of Resource Guide (1 of 2) 8

9 Overview of Resource Guide (2 of 2) 9

10 Main messages/cross-cupng themes 1. Immuniza4on is a public responsibility 2. Immuniza4on financing should be considered in the context of plans for Universal Health Coverage 3. Regular health sector budgets will remain the mainstay of immuniza4on financing 4. Different components of immuniza4on programs have different financing needs 5. Amount of funding is important, but also how it is spent 10

11 IV. Financing New Vaccine Introduc(ons and Ongoing costs of Immuniza(on in Non-Gavi countries How to create fiscal space, or budgetary room for any increased spending on immuniza(on Economic growth increased tax revenues increased public funds for health Over 4me, many governments broad tax base, improve tax administra4on, increasing revenue Realloca4on within government spending (towards health) Realloca4on within health from lower priority ac4vi4es to higher priority ac4vi4es (e.g. immuniza4on) Grants/borrowing Improvements in efficiency Ø Bo_om line: Increased spending on immuniza4on can come from growth in government health spending, or from realloca4ons/ efficiency gains/grants/borrowing within the health sector 11

12 Public spending on health per capita, 2014 Non-Gavi Middle Income Countries Gavi Status, 2017 S4ll eligible Have crossed the eligibility threshold, transi4oning out of support Fully or nearly fully transi4oned from support China 1 $234 Bangladesh $9 India $23 Bhutan $65 Malaysia $252 Cambodia $14 Lao $16 Indonesia $38 Philippines $46 Korea, DPR N.A. Timor-Leste $52 Mongolia $108 Thailand $177 Myanmar $9 Vietnam $77 Sri Lanka $71 Ø Large varia4ons in public spending on health. Countries at a lower level may have more challenges in crea4ng fiscal space. 1 China received some Gavi support in the first few years aler Gavi was established. 2 Fully or nearly fully transi4oned from Gavi support 12

13 New vaccine introduc(on requires one-(me introduc(on costs that must be adequately budgeted for Types of one Cme costs associated with new vaccine introduccon Expansion and/or rehabilita4on of some of the of cold chain, addi4onal vehicles Training of health workers Prin4ng of training materials and immuniza4on cards IEC/Social mobiliza4on Modifica4on to surveillance system Note that Gavi provides US$0.80 per birth for infant vaccines to contribute to introduc4on costs, or $100,000, whichever is higher 13

14 Ongoing (recurrent) costs from a new vaccine introduc(on Main categories Vaccines and injec4on supplies Incremental costs in opera4on of cold chain and logis4cs Incremental costs in immuniza4on services at point of service (fixed site or outreach) How typically financed Most governments retain this func4on at the na4onal level. Procurement done na4onally because of specialized exper4se required and economies of scale. Typically there is a line item in the MOH budget for vaccines and injec4on supplies. Can be financed at different levels of the system. Typically part of shared costs at health facility level. How services are financed depends on health financing system in country (budget lines, capitated payments, e.g.) 14

15 Costs of vaccines and injec(on supplies Main categories Vaccines and injec4on supplies Prices paid will depend on product choice, procurement method, volumes purchased, contract length, payment terms, and other factors Incremental costs in opera4on of cold chain and logis4cs Incremental costs in immuniza4on services at point of service (fixed site or outreach) 15

16 Price varia(on across non-gavi countries (source WHO Price Report, Vaccine Product Price and Procurement, Working Document 2016 edi(on) Prices may be lower with larger volumes purchased Prices tend to be correlated to country income level Pooled procurement 1 (e.g. UNICEF Supply Division, PAHO Revolving Fund) likely to achieve lower prices than self-procurement v Why? Pooling purchasing volumes, mul4-year contracts, on-4me payments, payment in hard currencies (US$, euros) v Example: 2015 prices obtained for pentavalent vaccine (DTwP-HepB-HiB) Non-Gavi middle income countries reporcng prices Single dose, average price [minimum, maximum] 10-dose UNICEF-procuring countries $2.73 [$2.35-$3.10] $1.55 [ $1.55-$1.55] Self-procuring $4.68 [$2.17-$5.10] $2.22 [$2.22-$2.22] 1 Not all countries may be able to use pooled procurement mechanisms because of legal/ regulatory mechanisms (although many countries have overcome these constraints) 16

17 Prices of rotavirus vaccine Comparators: PAHO Revolving Fund (serves a mix of low income, lower middle and upper middle income countries) 2 dose rotavirus, 2017: US$6.50 per dose UNICEF Supply Division price for Gavi countries: Rota1 (currently limited supply): 1.88 per dose Rota5: $3.20 per dose WHO s Product, Price, and Procurement V3P Plauorm 17

18 WHO s Product, Price and Procurement Pla^orm (V3P) Created in 2014 to increase price transparency Many middle income countries had li_le knowledge of prices that other countries of similar size, income and geography pay In addi4on to price paid, provides contextual details that are essen4al to understanding price (volumes, contract length, procurement mechanism (self-procurement or procurement through UNICEF SD, and other factors)) In 2016, 51 countries shared price data on the plauorm 18

19 Excerpt from V3P database for Rota 19

20 III. Conclusions (1/2) v Immuniza4on one of the best buys in health; immuniza4on financing is a public responsibility v Gavi countries have received support for new vaccine introduc4on, campaigns, rou4ne vaccines, and other support v Non-Gavi countries, in most cases, need to cover the one 4me costs associated with introduc4on ac4vi4es and the recurrent costs of immuniza4on from their own budgets. (Specifics will vary depending on the country s health financing system.) v Many countries in Asia that benefited from Gavi support have transi4oned or in the process of transi4oning from Gavi support 20

21 III. Conclusions (2/2) v Once introduc4on decision made, need to find budgetary room for one- 4me new introduc4on costs and incremental ongoing costs v Include in budget submission and follow through to budget approval v Procurement choices influence how much the country will pay for vaccines and injec4on supplies; efficiency gains may be possible v WHO s V3P project provides informa4on on prices that other countries are paying by procurement method, income level, volumes, contract length, manufacturer v Just scratched the surface today on immuniza4on financing topics. For more in-depth informa4on on a range of topics, please consult the resource guide! 21

22 Immuniza(on Financing Resource Guide Team Helen Saxenian (project lead) Daniel Arias Danielle Bloom Cheryl Cashin Meghan O Connell Paul Wilson helensaxenian@gmail.com darias@r4d.org dbloom@r4d.org ccashin@r4d.org moconnell@r4d.org pw2101@cumc.columbia.edu 22

23 Extra slides 23

24 Overview of Resource Guide (1 of 2) 2. Universal Health Coverage and ImmunizaCon Financing Defines Universal Health Coverage (UHC) Explains main kinds of health financing arrangements and examines transi4ons many countries are going through as they move toward UHC Outlines some of the opportuni4es and risks for immuniza4on service delivery and financing that these transi4ons pose 24

25 Overview of Resource Guide (1 of 2) 7. DomesCc Trust Funds Defines trust fund Explains the main kinds of trust funds, possible sources of revenues, governance op4ons Outlines some possible advantages and disadvantages of trust funds as a way of financing immuniza4on Illustrates with the example of Bhutan (discussed in more depth in case study brief) 25

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