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

Analysis of Immunization Financing Indicators of the WHO-UNICEF Joint Reporting Form (JRF), 2006-2012 Department of Immunization Vaccines and Biologicals, World Health Organization June 2014 1

Table of Contents Executive Summary... 6 1. Introduction... 8 2. Data and Methodology... 8 2.1. Data sources... 8 2.2. Identification and estimation of missing and inconsistent data... 9 2.3. Country selection criteria... 11 3. Global trends... 14 3.1. Line item in national budget for purchasing vaccines used in routine immunization... 14 3.2. Line item in national budget for purchasing injection supplies for routine immunization... 15 3.3. Government expenditures on vaccines... 16 3.4. Government expenditures on routine immunization... 17 4. Trends in WHO Regions... 19 4.1. African Region... 19 4.2. Americas Region... 22 4.3. Eastern Mediterranean Region... 24 4.4. European Region... 26 4.5. South East Asian Region... 29 4.6. Western Pacific Region... 31 5. Trends in GAVI eligible countries... 33 6. Econometric Analysis... 35 7. Conclusions and way forward... 45 Annex 1 - JRF Template of financing data and related instructions (2012)... 47 Annex 2 Selection of countries based on availability of time series... 49 2

List of Figures Figure 1: Government Funding Vaccines (2006-2012)... 17 Figure 2: Government Funding Routine Immunization (2006-2012)... 18 Figure 3: AFR, Government Funding Vaccines in 33 selected countries (2006-2012)... 20 Figure 4: AFR, Government Funding Routine Immunization in 10 selected countries (2006-2012)... 20 Figure 5: AMR, Government Funding Vaccines in 24 selected countries (2006-2012)... 23 Figure 6: AMR, Government Funding Routine Immunization in 19 selected countries (2006-2012)... 23 Figure 7: EMR, Government Funding Vaccines in 9 selected countries (2006-2012)... 25 Figure 8: EMR, Government Funding Routine Immunization in 6 selected countries (2006-2012)... 25 Figure 9: EUR, Government Funding Vaccines in 25 selected countries (2006-2012)... 27 Figure 10: EUR, Government Funding Routine Immunization in 4 selected countries (2006-2012)... 27 Figure 11: SEAR, Government Funding Vaccines in 7 selected countries (2006-2012)... 30 Figure 12: SEAR, Government Funding Routine Immunization in 4 selected countries (2006-2012).. 30 Figure 13: WPR, Government Funding Vaccines in 17 selected countries (2006-2012)... 32 Figure 14: WPR, Government Funding Routine Immunization in 4 selected countries (2006-2012)... 32 Figure 15: GAVI Countries, Government Funding Vaccines in 52 selected countries (2006-2012)... 34 Figure 16: GAVI Countries, Government Funding Routine Immunization in 22 selected countries (2006-2012)... 34 Figure 17: Kernel density estimate for LOG of GOVERNMENT EXPENDITURE on VACCINES per SURVIVING INFANT: ALL COUNTRIES... 38 Figure 18 Kernel density estimate for LOG of TOTAL EXPENDITURE on VACCINES per SURVIVING INFANT: ALL COUNTRIES... 38 Figure 19 Scatterplot and quadratic fit for LOG of GOVERNMENT EXPENDITURE on VACCINES per SURVIVING INFANT vs. GNI pc: GAVI and NON GAVI COUNTRIES... 39 Figure 20 Scatterplot and quadratic fit for LOG of TOTAL EXPENDITURE on VACCINES per SURVIVING INFANT vs. GNI pc: GAVI and NON GAVI COUNTRIES... 39 Figure 21 Boxplot of logarithm of TOTAL and GOVERNMENT EXPENDITURE on VACCINES per SURVIVING INFANT across time: GAVI (panel 1) and NON GAVI (panel 0) COUNTRIES... 40 List of Tables Table 1: Trends of completeness across the analysis period (2006 2012)... 12 Table 2: Trend in the number of countries reporting line item in national budget for purchasing vaccines (2006-2012)... 14 Table 3: Trend in the number of countries reporting line item in national budget for purchasing supplies (2006-2012)... 15 Table 4: Trend in the percentage of total expenditure on vaccines financed by government (2006-2012)... 16 Table 5: Trend in the percentage of total expenditure on routine immunization financed by national government (2006-2012)... 18 Table 6: AFR- African Region, 46 countries... 19 Table 7: AMR- Americas Region, 35 countries... 22 Table 8: EMR- East Mediterranean Region, 22 countries... 24 Table 9: EUR- European Region, 53 countries... 26 3

Table 10: SEAR- South East Asian Region, 11 countries... 29 Table 11: WPR- West Pacific Region, 27 countries... 31 Table 12: GAVI countries, 73 countries... 33 Table 13 Linear Panel model estimates for LOG of GOVERNMENT EXPENDITURE on VACCINES per SURVIVING INFANT: ALL COUNTRIES... 43 Table 14 Linear Panel model estimates for LOG of TOTAL EXPENDITURE on VACCINES per SURVIVING INFANT: ALL COUNTRIES... 44 Table 15 Elasticity of EGOV and ETOT to GNI per capita... 45 List of Abbreviations AFR AMR Avg cmyp EIU EMR GAVI EUR JRF Pwa RI SEAR SHA WHO WPR WHO African Region WHO Americas Region Average comprehensive Multi-Year Plans Economist Intelligence Unit WHO Eastern Mediterranean Region Global Alliance for Vaccines and Immunization WHO European Region Joint Reporting Form Population Weighted Average Routine Immunization WHO South Eastern Asian Region System of Health Accounts World Health Organization WHO Western Pacific Region 4

Acknowledgment The report has been prepared by Claudio Politi (WHO headquarters), Ambinintsoa Ralaidovy (consultant), Berete Foungbè (intern) and Daniele Fabbri (University of Bologna). The authors would like to express their gratitude to the WHO immunization financing regional focal points, the members of the Immunization Financing Task Team, and Miloud Kaddar (consultant) for their contributions and valuable comments. 5

Executive Summary This report presents the analysis of financing indicators included in the WHO-UNICEF Joint Reporting Form (JRF) for the period 2006-2012. The immunization financing indicators are the following: Availability of a specific line item in the national budget for the purchase of vaccines used in routine immunization. Availability of specific line item in the national budget for the purchase of injection supplies (such as syringes, needles and safety boxes) used in routine immunization. Expenditure for vaccines financed by government (both as percentage of total expenditure for vaccines and absolute value). Expenditure for routine immunization financed by government (both as percentage of total expenditure for routine immunization and absolute value). In 2012 the majority of member states, 172 out of 194 (89%), reported a specific line item in their national budgets for purchasing vaccines and 148 countries (76%) reported specific budget line item for purchasing supplies 1. The percentage of government funding vaccine expenditure shows, on average, a declining trend from 80% in 2006 to 71% in 2012. However data from 115 selected countries (with completed time-series of the indicator reported or estimated by WHO) shows that government funding vaccine expenditure, in absolute value, is increasing over the period, from 680 $ million in 2006 to 1,358 $ million in 2012. The percentage of government funding routine immunization has slightly declined from 78% in the period 2006-10 to 76% in 2010-12. Similarly as above, data from 47 selected country (with completed time-series of this indicator reported or estimated by WHO) show that government funding routine immunization program in absolute value is increasing over the period 2006-12, from 852 $ million to 1,364 $ million. These findings show a mixed picture in terms of the predictability (annual variance) and total level of financing for immunization, which indicates the need for even greater efforts to advocate for sufficient funding for immunization. The report includes an exploratory econometric analysis to provide evidence on key correlations among variables. The analysis relies on standard linear panel data model to exploit information contained in the JRF financing indicator database. The analysis focus on the following dependent variables: 1 The JRF indicators ask if separated budget lines exist for vaccines and injection supplies, respectively 6

1. Government expenditure on vaccines per surviving infant 2. Total expenditure on vaccines per surviving infant Evidence were found of government expenditure on vaccine per surviving infant per year being more reactive to economic cycle (e.g. increasing in period of economic growth and declining in recession) than total expenditure on vaccine in GAVI countries, while being a- cyclical in the remaining countries. This might be due to GAVI policies reducing the influence of economic cycles and allowing for more stable financing of vaccines. As expected, a positive correlation was found with DTP3 coverage and both government and total expenditure for vaccines. The existence of a specific line item in the government budget and political stability barely correlated with both dependent variables. There are concerns about quality of financing data reported by countries in JRF. Several missing information and inconsistencies have been identified when analyzing time trends and cross-checking other sources of data (e.g. cmyp). Interpolation methods have been used to estimate missing data and replace the inconsistent data. Thus the interpretation of findings should be cautious. Several initiatives have been implemented to improve data reporting on financing indicators, among them: a survey about JRF reporting process administered over a sample of GAVI eligible countries; application of System of Health Account (SHA) methodology to quantify immunization specific expenditures; and a more active feedback process to countries regarding national and sub-national issues hindering accurate tracking of flows and expenditures. 7

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. The financing indicators included in the JRF (see annex 1 for the template on financing data and related instructions) aim to capture the expenditure on routine immunization, the expenditure on vaccines, the percentages financed by government and the existence of national budget lines for the purchase of vaccines and injection supplies. These are key elements of the financial sustainability of immunization programs. The report presents an analysis of financing indicators for the period 2006-2012. The trend analysis highlights evolution of government commitments to sustain the immunization programs. It is conducted at three levels: global, WHO regional offices, and for GAVI eligible countries. An econometric analysis was conducted to assess possible factors influencing government immunization financing. 2. Data and Methodology 2.1. Data sources The sources of data are the WHO-UNICEF Joint Reporting Forms (JRF) reported by countries for the period 2006-2012. Data reported annually by countries are uploaded to the JRF database, available on the WHO Immunization surveillance, assessment and monitoring website 2. The following immunization financing indicators have been extracted from the JRF database: Availability of a specific line item in the national budget for the purchase of vaccines used in routine immunization. Availability of a specific line item in the national budget for the purchase of injection supplies (such as syringes, needles and safety boxes) used in routine immunization. Percentage of total expenditure on vaccines financed by government. Percentage of total expenditure on routine immunization financed by government. Expenditure on vaccines financed by government Expenditure on routine immunization financed by government Total expenditure (from all sources) on vaccines Total expenditure (from all sources) on routine immunization 2 http://apps.who.int/immunization_monitoring/globalsummary/indicators 8

The last two indicators on total expenditure (in absolute value and from all sources) were added to the JRF template in 2010 with the aim of improving the reliability and accuracy of the financing indicators. As the analysis covers the period of 2006-2012, data on these two indicators for the years 2006-2009 have been estimated by WHO using the government expenditures and the corresponding percentage of the government financing. Data reported in local currency has been converted in US dollars, using the annual average exchange rate available on the Economic Intelligence Unit (EIU) 3 database. Two additional sources of data have been exploited in the present analysis: countries comprehensive Multi-Year Plans (cmyp) 4 and the UN Population Data 5. cmyps have been used to cross-check countries JRF reported data (see section below), and UN Population Data has been used to express financing indicators per surviving infant per year, e.g. annual expenditure on vaccines per surviving infant. Eventually, the econometric analysis used countries Gross National Income (GNI) per capita extracted from the World Bank World Development Indicators 6 and political stability indicators extracted from the World Bank Worldwide Governance Indicators database 7. 2.2. Identification and estimation of missing and inconsistent data The Global Vaccine Action Plan (2011-2020) provides the global framework for planning immunization strategies in the next decade. Countries are encouraged to give priority and take ownership of the immunization programs. Among the indicators, domestic expenditure per person targeted has been included for monitoring the strategic objective of country commitment to immunization as priority. Countries are asked to report annually on the immunization expenditure through the JRF (and later on through the System of Health Accounts) helping to monitor the progress towards increasing domestic resources for immunization. Despite this context, many countries fail to fully report the financing JRF indicators. To the extent possible, WHO has made attempts to recover missing values and/or correct inconsistent 3 https://eiu.bvdep.com/version-2012413/cgi/template.dll?product=101&user=ipaddress 4 http://www.who.int/immunization/programmes_systems/financing/countries/en/index.html 5 UN Population Division s World Population Prospects the 2010 revision. 6 http://data.worldbank.org/data-catalog/world-development-indicators 7 http://data.worldbank.org/data-catalog/worldwide-governance-indicators 9

data based on the information collected since 2006 in order to increase the pool of countries observations for the overall analysis. Missing data for the qualitative budget line item indicators were assessed based on the trends observed over the period 2006-2012. If for a given year, a country had not reported data, but had done so for other years, uniformly reporting either Yes or No, the observed trend was taken as sufficient reason for imputing missing values so as to continue the trend 8. Missing data for the indicators measuring government funding in vaccines and immunization expenditures were more difficult to impute than categorical qualitative data. Traditionally, the level of reporting these indicators is lower than for qualitative categorical indicators. The methods used to interpolate the missing values are as follows: o If for a given country total annual amounts of government funds (on vaccines and routine immunization) or the total expenditures from all sources (on vaccines and routine immunization) was not available, the estimated percentage of total expenditure financed by government (on vaccines and routine immunization) reported by the country has been used to estimate corresponding missing information. o By taking the average of available data, e.g. previous and following years reported data. o By assuming continuation of a time series trend, e.g. last reported year available. o For GAVI-eligible countries, data from countries comprehensive Multiyear Plans (cmyp) costing and financing tools were used as additional sources to cross-check and to fill missing data. Inconsistencies were identified using the following criteria: 8 For instance, if a country reported "Yes" in 2006 and in 2008, but there was no reporting in 2007, 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 10

o Total expenditure (from all sources of financing) on routine immunization has to be higher than total expenditure (from all sources of financing) on vaccines o Total expenditure (from all sources of financing) on routine immunization has to be higher or equal to expenditure on routine immunization financed by government. o Total expenditure (from all sources of financing) on vaccines has to be higher or equal to government expenditure on vaccines. o Government expenditure on routine immunization has to be higher than the government expenditure on vaccines o 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 from all sources of financing, both for routine immunization and for vaccines expenditures) must be equal. If one of the above criteria was not met for a reported value, that value was replaced using one of the following: the average of available data; or the assumed continuation of time series trend; or data from comprehensive Multiyear Plans (cmyp) costing and financing tool when available (mainly for GAVI eligible countries). The table below summarises the trends of response rates from countries, number of inconsistencies identified and estimates made by WHO. The response rates are worrying as they are declining for all indicators, except for the indicator of total expenditure (from all sources) on vaccines used in routine immunization. It should be noted that countries may opt to report only estimated percentages of government expenditure (on vaccines and routine expenditure) if data in absolute values is not available. 2.3. Country selection criteria To allow consistent time trend analyses, countries with completed time series of the indicators for the entire period 2006-2012 have been selected. There are 115 countries for the indicator amount of government funding on vaccines and 47 countries for the indicator government 11

funding of routine immunization (see Annex 2). The difference in availability of completed time series for each of the two indicators highlights challenges countries face in quantifying expenditure on routine immunization: i) lack of information in countries with poor financial management information systems; ii) lack of accounting and financial skills within Expanded Immunization Program (EPI) staff to record, track and report expenditure data; iii) difficulty in clearly identifying what is included and what is excluded in routine immunization; iv) degree of EPI integration within the various service delivery platforms (e.g. outreach, facilitybased), making it difficult to quantify shared inputs and related costs; v) lack of incentive to estimate routine immunization expenditures. Initiatives to address some of these issues are on-going and will be presented in the section on conclusion and ways forward Table 1: Trends of completeness across the analysis period (2006 2012) Indicators JRF Data 2006 2007 2008 2009 2010 2011 2012 What amount of government funds was spent on vaccines used in routine immunization? What is the total expenditure (from all sources) on vaccines used in routine immunization? What percentage of all spending on vaccines was financed using government funds? What amount of government funds was spent on routine immunization? What is the total expenditure (from all sources) on routine immunization? What percentage of all spending on routine immunization was financed using government funds? Reported 126 134 123 140 145 138 134 Missing 67 59 70 53 48 56 60 Inconsistencies 15 14 14 10 7 10 10 Estimates 23 20 32 24 17 31 38 Reported 119 114 122 Missing 74 80 72 Inconsistencies 11 7 8 Estimates 45 51 47 Reported 151 148 141 153 133 134 112 Missing 42 45 52 40 60 60 82 Inconsistencies 11 17 8 9 11 13 9 Estimates 25 38 39 34 34 37 73 Reported 109 116 113 116 108 97 92 Missing 84 77 80 77 85 97 102 Inconsistencies 48 49 41 52 41 34 22 Estimates 16 15 13 24 18 27 15 Reported 100 92 89 Missing 93 102 105 Inconsistencies 33 31 19 Estimates 19 31 17 Reported 151 140 138 138 125 120 98 Missing 42 53 55 55 68 74 96 Inconsistencies 10 11 10 8 17 14 15 Estimates 26 38 44 43 61 68 92 Findings are presented in the following sections on global trends, trends in WHO regions, trends in GAVI eligible countries, followed by the econometric analysis. The trend analysis 12

will present summary tables of key indicators for the period 2006-2012 and graphs of the two indicators, government funding on vaccines and government funding on routine immunization. The original immunization financing data reported by countries in JRF can be accessed via the WHO Immunization surveillance, assessment and monitoring website 9 ; the adjusted time series of financing indicators, including WHO estimates, are available on the WHO Immunization financing website 10. 9 http://apps.who.int/immunization_monitoring/globalsummary/indicators 10 http://www.who.int/immunization/programmes_systems/financing/data_indicators/en/index.html 13

3. Global trends 3.1. Line item in national budget for purchasing vaccines used in routine immunization In 2012 the majority of countries, 172 out of 194 ( 89%), reported a specific line item in national budget for purchasing vaccines (Table 2). From 2006 to 2012, 13 additional countries introduced a line item for vaccines in their national budget; 11 of them are GAVI eligible countries and are eight low income countries, which can be cautiously interpreted as an indication of government commitment to financing vaccines, though the underlying weaknesses of the data must be kept in mind. Table 2: Trend in the number of countries reporting line item in national budget for purchasing vaccines (2006-2012) 2006 2007 2008 2009 2010 2011 2012 2012-2006 AFR (46) 40 39 41 41 44 43 43 3 AMR (35) 30 31 32 31 31 30 31 1 EMR (22) 17 17 17 19 19 19 18 1 EUR (53) 40 43 42 42 42 42 44 4 SEAR (11) 9 9 8 9 10 10 11 2 WPR (27) 23 23 23 24 24 25 25 2 Overall (194) 159 162 163 166 170 169 172 13 Low income countries (35) 25 27 28 29 31 32 33 8 GAVI countries (73) 56 59 60 64 66 67 67 11 Source: JRF 2006-2012 and WHO estimates Source: JRF 2006-2012 and WHO estimates The overall trend worldwide is clearly towards having the line item for purchasing vaccines in the national budget. In particular, almost the totally of low income and GAVI eligible countries have introduced it. 14

3.2. Line item in national budget for purchasing injection supplies for routine immunization The number of countries reporting budget line item for immunization injection supplies increased by nine countries between 2006 and 2012, from 72% to 76%. However, reporting countries showed some variations over the six year period (Table 3). This might be a bias arising from the question in the JRF template: officials reporting in the JRF template might provide different interpretation of the JRF question. Despite instructions that request to indicate yes only if a specific budget line exists, some countries/officials might have responded positively when they have a general budget line for medical supplies and not specifically for immunization supplies. GAVI eligible countries show a similar increasing trend for both line items for purchasing vaccines and immunization injection supplies. 54 GAVI eligible countries (75%) had budget line in 2006, with the number having increased to 65 countries (89%) in 2012. Table 3: Trend in the number of countries reporting line item in national budget for purchasing supplies (2006-2012) 2006 2007 2008 2009 2010 2011 2012 2012-2006 AFR (46) 37 38 37 38 42 42 42 5 AMR (35) 25 29 28 30 29 28 30 5 EMR (22) 18 18 18 18 19 19 18 - EUR (53) 30 30 26 27 24 23 27-3 SEAR (11) 8 9 7 9 10 10 10 2 WPR (27) 21 22 18 20 23 23 21 - Overall (194) 139 146 134 142 147 145 148 9 Low income countries (35) 24 26 23 26 28 30 32 8 GAVI countries (73) 54 59 53 59 62 63 65 11 Source: JRF 2006-2012 and WHO estimates Source: JRF 2006-2012 and WHO estimates The overall trend worldwide is towards having the item line for purchasing injection supplies in the national budget, although at a lower space than having the line item for purchasing vaccines. Eight low income and eleven GAVI eligible countries appear to have introduced both line items at the same time. 15

3.3. Government expenditures on vaccines The average percentage of reported vaccine expenditure financed by government has decreased worldwide between 2006 and 2012, from 80% to 71%, in particular in the last three years, 2010-12. By selecting countries which reported -or which have a WHO estimated- the amount of government funding for vaccine expenditure for the entire time series (115 countries, see Annex 2), it is worth noting that the average annual vaccine expenditure financed by government has steadily increased in absolute values, in particular over the period, 2009-2011 (Figure 1, the green dot line). The different dynamics of the two indicators, one expressed as percentage and the other expresses as absolute values, can be explained by the different rates of increasing vaccine expenditures funded by government and funded by donors: the later increased at a higher rate than government funding. Table 4: Trend in the percentage of total expenditure on vaccines financed by government (2006-2012) 2006 2007 2008 2009 2010 2011 2012 AFR 54% 55% 58% 53% 40% 35% 36% AMR 94% 95% 95% 94% 94% 91% 91% EMR 89% 77% 84% 81% 76% 76% 76% EUR 91% 90% 89% 91% 91% 91% 91% SEAR 69% 62% 75% 65% 65% 58% 58% WPR 81% 76% 78% 77% 71% 70% 72% Overall 80% 78% 80% 78% 73% 71% 71% Low Income countries 30% 32% 36% 29% 19% 15% 18% GAVI countries 50% 46% 53% 48% 38% 32% 33% Source: JRF 2006-2012 and WHO estimates All regions, except the European and partially the Americas, reported decreasing shares of government expenditure on vaccines. The African region reported a decrease from 54-58% in 2006-2008 to 36% in 2012. This is the result of increasing total expenditure on vaccines over the period, of which the share of donor funded grew faster than the share of government funded: introduction of new (relatively expensive) vaccines and GAVI support received by countries. Low income and GAVI eligible countries reported steadily declining shares of government financing vaccine, from 30% to 15% and from 50% to 32%, respectively. 16

Figure 1: Government Funding Vaccines (2006-2012) Source: JRF 2006-2012 and WHO Estimates 3.4. Government expenditures on routine immunization The average percentage of government funding of routine immunization expenditure appears to be stable in the period 2006 2008, 78% with a slight decline in the years 2011-2012, to 76% (Table 5), The African region is highly dependent on external sources for funding its routine immunization, 50% in 2012. The European and Americas regions appear mostly selfsufficient with averages of over 90% of expenditure funded by governments. Low income countries reported the lowest percentage of government funding routine immunization expenditure, 32% in 2012. GAVI eligible countries reported average percentage of government funding routine immunization at 46% in 2011-12 after a peak of 51% in 2008. The total government expenditure on routine immunization in 47 selected countries (see Annex 2) increased over the period, from 852 million US dollars in 2006 peaking at 1,507 million US dollars in 2009 then decreasing to 1,364 million US dollars in 2012 (Figure 2, green dot line). These findings should be interpreted cautiously as they might reflect misreporting and poor quality of data: as mentioned in the section on data sources and 17

methods, countries have difficulties in quantifying the expenditure on routine immunization, despite the definition and instructions provided by the JRF template. Table 5: Trend in the percentage of total expenditure on routine immunization financed by national government (2006-2012) 2006 2007 2008 2009 2010 2011 2012 AFR 45% 51% 55% 50% 52% 51% 50% AMR 94% 95% 94% 94% 93% 90% 92% EMR 84% 82% 76% 81% 86% 82% 79% EUR 94% 96% 95% 96% 96% 94% 92% SEAR 67% 64% 71% 63% 60% 56% 65% WPR 76% 66% 67% 72% 66% 68% 69% Overall 78% 78% 78% 78% 78% 76% 76% Low Income countries 23% 27% 35% 29% 29% 31% 32% GAVI countries 46% 48% 51% 47% 48% 46% 46% Source: JRF 2006-2012 and WHO Estimates Figure 2: Government Funding Routine Immunization (2006-2012) Source: JRF 2006-2012 and WHO Estimates 18

4. Trends in WHO Regions In the following sections analyses of JRF financing indicators by WHO regions are presented in time series tables and graphs showing government funding on vaccines and government funding on routine immunization. 4.1. African Region Most of the countries in the African Region report having line items in their national budgets for purchasing vaccines and injection supplies. There were 40 in 2006 and 43 countries in 2012, while the number of countries with line item for injection supplies increased from 37 to 42 countries over the same period. Table 6: AFR- African Region, 46 countries Indicators 2006 2007 2008 2009 2010 2011 2012 Line item in national budget: for vaccines (No. of countries) 40 39 41 41 44 43 43 for injection supplies (No. of countries) 37 38 37 38 42 42 42 Government Funding vaccines: % avg in the region 54% 55% 58% 53% 40% 35% 36% % pwa in the region 56% 55% 57% 50% 40% 30% 32% % avg in selected (33) countries 53% 53% 58% 55% 38% 34% 35% Million $ in selected (33) countries 35 40 48 47 49 50 65 $ per surviving infant in selected (33) countries 2.2 2.4 2.8 2.7 2.8 2.8 3.5 Government Funding Routine Immunization: % avg in the region 45% 51% 55% 50% 52% 51% 50% % pwa in the region 48% 52% 53% 46% 44% 45% 38% % avg in selected (10) countries 52% 51% 52% 48% 53% 48% 48% Million $ in selected (10) countries 23 37 39 32 29 28 33 $ per surviving infant in selected (10) countries 4.9 7.8 8.0 6.4 5.7 5.5 6.2 Source: JRF 2006-2012 and WHO Estimates The percentage of reported government funding of vaccines (on average) increased from 54% in 2006 to 58% in 2008 and then progressively decreased to 36% in 2012. However, in absolute values the government funding showed some increases, in particular from 50 million US$ in 2011 to 65 million US$ in 2012 in selected countries (Figure 3). 19

Figure 3: AFR, Government Funding Vaccines in 33 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates Figure 4: AFR, Government Funding Routine Immunization in 10 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates 20

The percentage of government funding for routine immunization increased from 45% in 2006 to 50% in 2012 with fluctuations, though it is unclear if these variances are due to inconsistent reporting or reflect real expenditure variations experienced by national immunization programs over the period. Selected countries also show fluctuations in absolute values of government funding for routine immunization with a peak in 2008, 39 million US$, then a decline to 28 million US$ and an increase in 2012 last year to 33 million US$ (Figure 4). 21

4.2. Americas Region In the Americas Region 31 countries (89%) reported line items in national budget for purchasing vaccines in 2012 and 30 countries (86%) reported a line item in national budget for purchasing injection supplies. These two indicators have been overall stable in the period (Table 7). Percentages of government funding vaccines and routine immunization expenditure are high, although both indicators slightly decreased from 94% in 2006 to respectively 91% and 92% in 2012 (Table 7), due to increased donor support, in particular GAVI support Table 7: AMR- Americas Region, 35 countries Indicators 2006 2007 2008 2009 2010 2011 2012 Line item in national budget: for vaccines (No. of countries) 30 31 32 31 31 30 31 for injection supplies (No. of countries) 25 29 28 30 29 28 30 Government Funding vaccines: % avg in the region 94% 95% 95% 94% 94% 91% 91% % pwa in the region 97% 98% 98% 97% 97% 96% 96% % avg in selected (24) countries 96% 98% 98% 96% 96% 91% 91% Million $ in selected (24) countries 193 217 211 359 424 397 434 $ per surviving infant in selected (24) countries 42 47 46 78 92 86 93 Government Funding Routine Immunization: % avg in the region 94% 95% 94% 94% 93% 90% 92% % pwa in the region 97% 98% 97% 98% 97% 96% 97% % avg in selected (19) countries 98% 96% 97% 96% 92% 90% 92% Million $ in selected (19) countries 520 696 712 1074 997 926 873 $ per surviving infant in selected (19) countries 78 105 108 164 153 142 134 Source: JRF 2006-2012 and WHO Estimates The total reported expenditure on vaccines in absolute value increased more than double, from 193 million US$ in 2006 to 433 million US$ in 2012 in selected countries with completed time series for this indicator (Figure 5). The absolute values of reported government funding for routine immunization increased from 520 million US$ to 1074 million US $ in 2009 and then declined to 873 million US$ in the last year, 2012 (Figure 6). As mentioned in previous sections, it is unclear if this pattern is the result of misreporting or real changes in expenditures over the period. 22

Figure 5: AMR, Government Funding Vaccines in 24 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates Figure 6: AMR, Government Funding Routine Immunization in 19 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates 23

4.3. Eastern Mediterranean Region In the Eastern Mediterranean Region, the number of countries that reported a line item in their national budget for purchasing vaccines and for purchasing injection supplies has been in the range of 17-19 (out of 22 countries in the region) over the period 2006-2012 (Table 8). The average percentage of government funding for vaccines decreased in the region from 89% in 2006 to 76% in 2012 although there were some fluctuations over the seven year period. The total amount of government funding for vaccines in absolute values in selected countries increased until 2011 before decreasing in 2012 (Figure 7). The average percentage of government funding for routine immunization decreased from 84% in 2006 to 79% in 2012 in the region. In absolute values, the government funding for routine immunization of selected countries showed some fluctuations over the seven year period, increasing from 57 million US dollars in 2006 to 83 million US dollars in 2012 (Figure 8), Table 8: EMR- East Mediterranean Region, 22 countries Indicators 2006 2007 2008 2009 2010 2011 2012 Line item in national budget: for vaccines (No. of countries) 17 17 17 19 19 19 18 for injection supplies (No. of countries) 18 18 18 18 19 19 18 Government Funding vaccines: % avg in the region 89% 77% 84% 81% 76% 76% 76% % pwa in the region 92% 66% 88% 79% 83% 83% 83% % avg in selected (9) countries 89% 73% 80% 80% 80% 80% 80% Million $ in selected (9) countries 95 110 114 141 154 183 159 $ per surviving infant in selected (9) countries 10.4 11.8 12.1 14.8 16.1 18.9 16.3 Government Funding Routine Immunization: % avg in the region 84% 82% 76% 81% 86% 82% 79% % pwa in the region 90% 79% 77% 81% 92% 88% 84% % avg in selected (6) countries 81% 73% 68% 71% 84% 74% 76% Million $ in selected (6) countries 57 102 88 89 75 100 83 $ per surviving infant in selected (6) countries 8.4 14.7 12.6 12.6 10.5 13.9 11.6 Source: JRF 2006-2012 and WHO Estimates 24

Figure 7: EMR, Government Funding Vaccines in 9 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates Figure 8: EMR, Government Funding Routine Immunization in 6 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates 25

4.4. European Region In WHO European Region, the number of countries reporting a line item in the national budget for purchasing vaccines increased from 40 to 44. In contrast to this, the number of countries reporting budget line item for injection supplies decreased from 30 to 27 between 2006 and 2012 (Table 9). Table 9: EUR- European Region, 53 countries Indicators 2006 2007 2008 2009 2010 2011 2012 Line item in national budget: for vaccines (No. of countries) 40 43 42 42 42 42 44 for injection supplies (No. of countries) 30 30 26 27 24 23 27 Government Funding vaccines: % avg in the region 91% 90% 89% 91% 91% 91% 91% % pwa in the region 96% 96% 95% 96% 96% 96% 95% % avg in selected (25) countries 87% 84% 84% 88% 87% 86% 86% Million $ in selected (25) countries 204 269 355 352 369 398 364 $ per surviving infant in selected (25) countries 71 92 139 118 122 154 121 Government Funding Routine Immunization: % avg in the region 94% 96% 95% 96% 96% 94% 92% % pwa in the region 98% 99% 98% 98% 99% 98% 97% % avg in selected (4) countries 88% 89% 93% 96% 88% 97% 81% Million $ in selected (4) countries 150 238 322 201 194 195 183 $ per surviving infant in selected (4) countries 420 669 911 571 554 628 526 Source: JRF 2006-2012 and WHO Estimates The average percentage of government funding for vaccines remained high over the full period, above 90%. In selected countries, the absolute value of government funding for vaccines shows an increasing trend over the period from 204 million US$ to 364 million US$ (Figure 9). 26

Figure 9: EUR, Government Funding Vaccines in 25 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates Figure 10: EUR, Government Funding Routine Immunization in 4 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates 27

The regional percentage of government funding for routine immunization also remains high, above 90%, although with a slight decline in 2010-2012, from 96% to 92%. Overall the data is consistent with other sources that indicate that the majority of countries in the European Region are still largely self-sufficient in term of vaccines and routine immunization financing. Only four countries have completed time series data (reported or estimated by WHO) on the government expenditure on routine immunization in absolute values 11. The trend of these selected countries seem to vary: from 150 million US dollars in 2006 to reach the peak of 322 million US dollars in 2008 and then declining to 183 million $ in 2012 (Figure 10). 11 This is because the majority of countries in the region opted for providing estimates of the percentage of government expenditure. 28

4.5. South East Asian Region All the 11 countries of the South East Asian Region reported a line item for purchasing vaccines in their national budget in 2012 and 10 countries reported a line item for purchasing injection supplies. The average percentage of government funding for vaccines increased in the early years from 69% in 2006 to 75% in 2008 and then decreased to 58% in 2012, due to faster increased donor support (Table 10) Table 10: SEAR- South East Asian Region, 11 countries Indicators 2006 2007 2008 2009 2010 2011 2012 Line item in national budget: for vaccines (No. of countries) 9 9 8 9 10 10 11 for injection supplies (No. of countries) 8 9 7 9 10 10 10 Government Funding vaccines % avg in the region 69% 62% 75% 65% 65% 58% 58% % pwa in the region 93% 93% 98% 91% 91% 91% 91% % avg in selected (7) countries 68% 56% 72% 63% 61% 52% 63% Million $ in selected (7) countries 85 100 107 132 131 134 151 $ per surviving infant in selected (7) countries 2.5 2.9 3.1 3.9 3.9 3.9 4.5 Government Funding Routine Immunization % avg in the region 67% 64% 71% 63% 60% 56% 65% % pwa in the region 73% 90% 94% 87% 87% 89% 91% % avg in selected (4) countries 73% 62% 75% 62% 61% 50% 74% Million $ in selected (4) countries 92 87 91 100 140 126 177 $ per surviving infant in selected (4) countries 3.2 3.0 3.2 3.5 4.9 4.4 6.2 Source: JRF 2006-2012 and WHO Estimates The absolute value of government funding for vaccines in selected countries increased from 85 million US dollars in 2006 to almost double (151 million US dollars) in 2012 (Figure 11). The regional average percentage of government funding for routine immunization shows fluctuations over the period, from 67% in 2006 to 71% in 2008, then 56% in 2011 and 65% in 2012 (Table 10). Selected countries show a similar fluctuating pattern in the absolute values of government funding for routine immunization (Figure 12). 29

Figure 11: SEAR, Government Funding Vaccines in 7 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates Figure 12: SEAR, Government Funding Routine Immunization in 4 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates 30

4.6. Western Pacific Region In the Western Pacific Region, 25 countries reported a line item for purchasing vaccines in their national budget and 21 countries reported a line item for purchasing injection supplies in 2012. Table 11: WPR- West Pacific Region, 27 countries Indicators 2006 2007 2008 2009 2010 2011 2012 Line item in national budget: for vaccines (No. of countries) 23 23 23 24 24 25 25 for injection supplies (No. of countries) 21 22 18 20 23 23 21 Government Funding vaccines % avg in the region 81% 76% 78% 77% 71% 70% 72% % pwa in the region 88% 90% 98% 96% 91% 93% 93% % avg in selected (17) countries 77% 71% 75% 69% 62% 61% 63% Million $ in selected (17) countries 67 83 87 120 144 177 186 $ per surviving infant in selected (17) countries 12.2 14.9 15.8 21.6 25.7 31.3 33.1 Government Funding Routine Immunization % avg in the region 76% 66% 67% 72% 66% 68% 69% % pwa in the region 81% 76% 95% 97% 94% 94% 94% % avg in selected (4) countries 48% 52% 57% 64% 45% 43% 46% Million $ in selected (4) countries 9 9 10 11 13 15 15 $ per surviving infant in selected (4) countries 4.5 4.7 5.1 5.4 6.3 7.3 7.8 Source: JRF 2006-2012 and WHO Estimates The average percentage of government funding for vaccines decreased over the period from 81% in 2006 to 72% in 2012. The absolute value of government funding for vaccines in selected countries steadily increased from 67 million US dollars in 2006 to 186 million US dollars in 2012. (Figure 13). The regional average percentage of government funding for routine immunization decreased from 76% in 2006 to 69 % in 2012, according to the data collected (Table 11). In selected countries where there was completed data for the time series in absolute values, the government funding for routine immunization increased from 9 million US$ to 15 million US$ (Figure 14). 31

Figure 13: WPR, Government Funding Vaccines in 17 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates Figure 14: WPR, Government Funding Routine Immunization in 4 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates 32

5. Trends in GAVI eligible countries Looking at the reported data from this desk review, some trends can be described, though great caution must be taken due to the numerous problems with data quality. In 2012, 67 (92%) GAVI eligible countries had a national budget line item for purchasing vaccines; 65 (89%) had introduced a line item for purchasing immunization injection supplies (Table 12). The introduction of these budget lines can be interpreted as an indicator of governments commitment to immunization, though the variances in reported expenditures indicate that continued political advocacy for sufficient financing of immunization by governments and partners is needed Government funding for vaccines increased as a percentage from 50% in 2006 to 53% in 2008 and then decreased to 33% in 2012. In absolute values, for selected countries, it increased over the seven year period, with a decline in the last year, from 280 million US$ in 2011 to 274 million US$ in 2012 (Figure 15). This is due to 1) the number of underutilized and new vaccines introduced with GAVI support; 2) the relative high prices of the supported vaccines; and 3) the relatively modest level of co-financing of new vaccines. Government funding for routine immunization increased from 46% in 2006 to 51% in 2008 and then decreased to 46% in 2012. In absolute values, for selected countries, it shows some fluctuations, though the overall trend is increasing, from 193 million US$ in 2006 to 307 million US$ in 2012 (Figure 16). Table 12: GAVI countries, 73 countries Indicators 2006 2007 2008 2009 2010 2011 2012 Line item in national budget: for vaccines (No. of countries) 56 59 60 64 66 67 67 for injection supplies (No. of countries) 54 59 53 59 62 63 65 Government Funding vaccines: % avg in the region 50% 46% 53% 48% 38% 32% 33% % pwa in the region 79% 75% 82% 74% 71% 66% 66% % avg in selected (52) countries 52% 48% 57% 52% 40% 34% 36% Million $ in selected (52) countries 147 166 215 232 258 280 274 $ per surviving infant in selected (52) countries 2.5 2.8 3.6 3.8 4.2 4.6 4.4 Government Funding Routine Immunization: % avg in the region 46% 48% 51% 47% 48% 46% 46% % pwa in the region 65% 76% 79% 72% 75% 77% 74% % avg in selected (22) countries 58% 51% 55% 52% 51% 44% 49% Million $ in selected (22) countries 193 248 259 246 273 284 307 $ per surviving infant in selected (22) countries 4.7 6.0 6.3 6.0 6.6 6.8 7.4 Source: JRF 2006-2012 and WHO Estimates 33

Figure 15: GAVI Countries, Government Funding Vaccines in 52 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates Figure 16: GAVI Countries, Government Funding Routine Immunization in 22 selected countries (2006-2012) Source: JRF 2006-2012 and WHO Estimates 34

6. Econometric Analysis This section presents an exploratory econometric analysis using the WHO and UNICEF database of immunization indicators collected annually from National Immunization Programs - the WHO and UNICEF Joint Reporting Form on Immunization (JRF) - to provide evidence on correlations among key variables. The analysis relies on linear panel data model to exploit information contained in the JRF database under standard assumptions concerning the structure of the error components. The main focus of the current analysis is on the following dependent variables: 1. Government expenditure on vaccines per surviving infant 2. Total expenditure on vaccines per surviving infant The covariates selected are the following: a. Linear time trend b. GNI per capita c. GAVI eligibility status d. DTP3 coverage e. Presence of a dedicated line item f. Infant mortality rate g. Political stability h. Population growth rate The analysis conducted here complements the study developed by Nader et al. (Health Policy and Planning, 2014;1 8) ) focusing on Gavi-eligible countries. They regress the reported government expenditures on routine immunization (2006-2011) on lagged annual per capita gross national income. The regression results from their study show that the expenditures on routine immunization is positively correlated with GNI per capita 12. We extend that analysis by considering a larger set of countries comprising also high income and other non-gavi countries. Moreover we look also at total expenditures on routine immunization. We suspect that government expenditure might crowd-out external partner funding and vice versa. By comparing results from regression on government vis-à-vis total expenditure we can infer which source of funding reacts more to country macroeconomic conditions. We find larger elasticity of expenditure to GNI per capita in the government expenditure than in the total. This evidence suggests that government expenditure react more to country macroeconomic conditions than external partner funding. 12 A. Nader et al. An analysis of government immunization program expenditures in lower and lower-middle income countries 2006-2012. Health Policy and Planning - 2014;1 8 35

The empirical analysis is conducted using the following steps. Step 1: upload covariates of interest and merge them to the JFR financing data into STATA Step 2: merge covariates to the JFR financing and define estimation sample Step 3: conduct descriptive analysis Step 4: develop econometric analysis by estimating simple panel regression models Step 1: upload covariates of interest The following covariates were collected from different sources: GNI per capita, Infant mortality rate and Population growth rate from the World Development Indicators database; the indicator for Political stability and absence of violence from the Worldwide Governance Indicators project; GAVI eligibility status from the GAVI-Alliance website; Presence of a dedicated budget line item and DTP3 coverage from the JRF Database. The dataset on JRF indicators for years 2006-2012 contains seven observations for each of the 194 countries, i.e. 1358 country-year cells. We set up a covariate dataset comprising the same country-year cells of which there were 36 missing observations relating to the number of surviving infants, total population and DTP3 coverage. 20 of these missing values were imputed by using simple linear prediction from a random effect panel model using lagged and forwarded values of the dependent variable as regressors. The remaining 16 country-year cells were dropped. Step 2: define estimation samples We estimated Models for total (or government) expenditure on vaccines as the key dependent variable of interest were estimated. To allow for comparability across model estimates while preserving the largest country coverage it was opted for a selection of country-year observations such that the same dataset (country-year) is used across different specifications. The original dataset on JRF indicators contains 1358 country-year cells, i.e. seven observation for each of the 194 countries. 20 countries that never reported indicator data and 205 countryyear observations which contain missing values on key indicators were excluded, resulting in 1013 country-year observations. The table below shows the composition of our sample by WHO region and GAVI eligibility status. WHO REGION NON GAVI GAVI Eligible ALL AFRO 10 35 (2) 45 AMRO 27 6 (4) 33 EMRO 13 7 (0) 20 EURO 30 8 (5) 38 SEARO 2 9 (3) 11 WPRO 18 7 (2) 25 ALL 100 72 (16) 172 In parentheses the number of GAVI countries that are graduating. 36