Immunization Financing - UNICEF

12IMMUNIZATION FINANCING IN MENA MIDDLE-INCOME COUNTRIESKey Terms*grantgross domestic productimmunization financingsustainabilityloanA sum of money or a product that is provided by one entity to another withoutexpectation of repayment.A measure of the monetary value of final goods and services – that is, thosethat are bought by the final user – produced in a country in a year. It counts allthe output generated within the borders of a country.The ability of a country to mobilize and efficiently use domestic andsupplementary external resources on a reliable basis to achieve current andfuture immunization targets.Money lent from one entity to another that carries the requirement of futurerepayment. Loans may be on concessional terms (credits) or non-concessionalterms.out-of-pocket spending forhealthDirect expenditure by households for health care.para-public sectorSemi-autonomous public firms, institutions and agencies.poolingpublic financial managementsystemrecurrent costshared costsocial health insurancetransition processtrust funduniversal health coverageuser feeWHO pre-qualified vaccineWHO/UNICEF DTP3coverage estimateThe accumulation and redistribution of prepaid health revenues on behalf of apopulation for eventual transfer to providers in exchange for covered services.The system by which financial resources are planned, directed and controlledto enable and influence delivery of public service goals. It covers all phases ofthe budget cycle, including budget preparation, internal controls and auditing,procurement, monitoring and reporting, and external auditing.A resource that is consumed within one year or has a working life of less thanone year and must be regularly replaced. It is also called operating cost.The cost of a resource that is shared by and can be allocated to multiple healthservices.A health financing model in which coverage is mandatory for the entirepopulation or a subset of the population. Entitlement to covered services islinked to a contribution made by an individual or on the individual’s behalf thatis not related to health risk, and coverage is provided by a government orgovernment-regulated body or bodies.The process during which a country moves, over a number of years, fromeligibility for external assistance to ineligibility, usually based on per capitaincome or other criteria. It is also known as the graduation process.A mechanism that governments can use to ring-fence, or protect, fundingfor specific purposes. Trust funds may receive funds from multiple streamsof revenue and may be legally incorporated with policies and tax regulationsthat vary by country; a governing board oversees the strategy, business plan,management and operations. Trust funds may also have asset managersthat seek to ensure the right rate of return, levels of risk and rate of capitaldepletion.Ensured access to essential health services for an entire population withoutrisk of financial hardship or impoverishment.A charge paid by users of goods or services at the point of use. User fees canbe formal or informal.A vaccine from a manufacturer whose quality has met standards defined bythe World Health Organization for use by United Nations agencies.A country-specific estimate, for a specific year, of the percentage of childrenin a country who have received the third dose of the diphtheria-tetanuspertussis vaccine (DTP3), as reviewed and published by WHO and UNICEF.*Key terms are drawn from the Immunization Financing Resource Guide ( www.immunizationfinancing.org ). In addition, certain terms have been addedfrom WHO’s indicator list for the 2017 data release of its Global Health Expenditure Database. These terms are indicated with a double asterisk.**Definitions from WHO’s Indicator list for 2017 data release re/Index/en .

IMMUNIZATION FINANCING IN MENA MIDDLE-INCOME COUNTRIESAcknowledgementsThis report was written by Miloud Kaddar and Helen Saxenian, MK International Consulting, and initiated, reviewedand edited by Nahad Sadr-Azodi and Kamel Senouci, Health and Nutrition Section, UNICEF Middle East andNorth Africa Regional Office (MENARO), in consultation with Ulla Griffith, Programme Division (PD), UNICEFHeadquarters, New York.The project was funded primarily by Gavi, the Vaccine Alliance. The content is partially based on a consultativereview held in Amman, Jordan in November 2017 with wide participation of colleagues from UNICEF regional,Programme Division and country offices; government counterparts; Gavi; and partner agencies.MENARO and the authors are grateful for the individuals who reviewed this report and provided helpful input.Senior government health officials and other experts and individuals from international organizations took timefrom their busy schedules to be interviewed for this report, and are listed in Annex 1. The many individuals whocontributed to the report may not endorse all its views, and they bear no responsibility for any errors. UNICEF/201713

14IMMUNIZATION FINANCING IN MENA MIDDLE-INCOME COUNTRIESPrefaceEconomic studies have shown that immunization is an excellent investment, yielding one of the highest returns inhealth. One dollar spent on immunization is estimated to generate a 16 return on investment. UNICEF considersgovernments’ budget allocations, whatever their resources, to this life-saving intervention to be states’ foremostcommitment to children and the fulfilment of their obligations under the Convention on the Rights of the Child(CRC). Yet, protecting immunization in governments’ budgets has not been systematically addressed in middleincome countries in the Middle East and North Africa (MENA) region.It is to help governments uphold their commitments to the right of every child to be immunized against preventablediseases that UNICEF has undertaken the present financing study. Based on data, research, interviews, lessonslearned and good practices in the MENA region, the study provides policymakers, senior officials in ministries offinance and health, and parliamentarians or equivalents with a set of key recommendations to secure necessarygovernment financing for this critical childhood intervention. In focusing on middle-income countries, the studyprovides a deeper understanding of the situation and dynamics of two critical subgroups: (1) countries with grossnational incomes per capita too high to make them eligible for outside financial support, yet who face challenges tomeet their immunization goals; and (2) countries eligible for international development assistance, yet who struggleto transition out of aid and co-finance a much greater share of their immunization costs. That means prioritizinghealth within government budgets, prioritizing immunization within health, and working to make programmes asefficient as possible.Key global players are at the vanguard of the immunization drive, including by making newer vaccines accessibleto countries facing resource constraints. Gavi, the Vaccine Alliance, plays a central role in giving eligible countriessupport to adopt new, life-saving vaccines and improve coverage and equity. At UNICEF, the Supply Division makesevery effort to source and supply affordable vaccines, making its procurement services available to countries.Gaining efficiencies and ensuring sustainability are two overarching themes of immunization financing in this report.Where and how countries spend on health is critical: do they allocate funding to ‘do the right thing’ – using budgetsto adequately support the highest priority activities in health, such as immunization? And are they ‘doing thingsright’ – delivering high-quality services and procuring vaccines efficiently? Do budgets include ancillary but crucialallotments for ongoing supervision, training, surveillance, supply and cold chain management, and laboratory controlthat are prerequisites for effective immunization?This report concludes that in most of MENA’s middle-income countries, prioritizing immunization and making itmore efficient is the best way to create room in budgets and to secure more resources. Many of the recommendedfirst steps are information-related: generating and sharing knowledge, equipping policymakers with evidence, anddetermining the role of social insurance. It is our hope that this report and its recommendations will help UNICEF andpartners in the region strengthen their advocacy and support to governments so they live up to their commitmentsto the CRC and build high-performing immunization systems that are accessible to all.Geert CappelaereRegional DirectorUNICEF Middle East And North Africa

IMMUNIZATION FINANCING IN MENA MIDDLE-INCOME COUNTRIES UNICEF/UN027620/Gonzalez Farr15

16IMMUNIZATION FINANCING IN MENA MIDDLE-INCOME COUNTRIESSummaryThis report examines health financing and, within that, immunization financing and vaccine procurement in theMiddle East and North Africa (MENA) region, which consists of 14 middle-income countries (MICs) and six highincome countries. The report focuses on the MICs, given that their lower levels of health expenditure pose morechallenges for financing immunization. Of the 14 MICs, Djibouti, the Sudan and Yemen have been eligible for Gaviassistance since 2000.1 Gavi is a source of support for the introduction of new and underused vaccines, operationalcosts of campaigns, cold chains, and health system strengthening. The three countries eligible for Gavi supporthave introduced pentavalent, pneumococcal conjugate and rotavirus vaccines, and procure vaccines through theUNICEF Supply Division (UNICEF SD) at favourable prices for Gavi countries. The MICs not supported by Gav

MICS Multiple Indicator Cluster Surveys MMR measles-mumps-rubella vaccine MOF Ministry of Finance MOH Ministry of Health NCD non-communicable disease NHA National Health Accounts NIP national immunization programme NITAG National Immunization Technical Advisory Group NRA national regulatory authority OBS Open Budget