By the Numbers: Transparency Fuels Immunization Advocacy
As countries around the world expand their immunization programs to reach more children and to incorporate new and under-utilized vaccines, high implementation costs often exceed public immunization budgets.
Development partners have been covering the difference, but as countries become wealthier, they will no longer qualify for assistance. To continue delivering life-saving vaccines, governments need to establish long-term, domestic funding solutions for their immunization programs before they graduate from international funding. Sabin’s Sustainable Immunization Financing (SIF) Program enables 22 countries in this transition to develop their own financing solutions by organizing workshops, peer-to-peer exchanges and informational sessions among them.
One measure of country immunization ownership is the government’s spending on routine immunization per surviving infant. National counterparts can use this data to demonstrate program efficiency or emphasize the need for increased immunization financing.
The UNICEF/World Health Organization (WHO) Joint Reporting Form (JRF) is the only source for annual data on national routine immunization spending. However, many countries either misreport or neglect to report this crucial data consistently. In 2014, in an attempt to prevent misreporting, SIF proposed validation rules, which the WHO has now integrated into the JRF process. Using these rules, the reporting software now presents error messages if a country enters an illogical value or omits one. The WHO has also made a concerted effort to guide African countries through the reporting process to encourage more accurate and complete reporting.
Using JRF data, parliamentarians and public immunization officials in the Democratic Republic of Congo (DRC), Senegal and Cameroon have advocated for higher government contributions. Those in DRC have also compared their JRF data against internally reported spending data to ensure accurate budget tracking. This has led to more careful oversight of country immunization spending, and has motivated efforts by DRC parliamentarians to increase the immunization budget.
As we wrote last year, immunization expenditure reporting from sub-Saharan African countries decreased markedly from 2011 to 2012, but the frequency of reporting rebounded in 2013, as did total expenditures. Although frequency and accuracy of JRF data did not improve significantly in 2014, 21 of the 22 SIF countries (including 11 out of 12 countries in sub-Saharan Africa) reported their routine immunization expenditures using the JRF. As a comparison, only 21 of 35 non-SIF program countries in the region reported these data for 2014.
Although we are not yet seeing widespread improvements in reporting practices, average reported national spending on immunization is on the rise. 2014 JRF data from countries in Africa reveals a 25 percent increase in average government spending on immunization per surviving infant in 2014. The global average also rose significantly, with an increase of 22 percent (see Figure 1 below).
Figure 1: Government Routine Immunization Expenditures per Surviving Infant (JRF 6730)
Figure 2 shows SIF countries ranked from highest to lowest routine immunization expenditures per infant. To account for economic differences, the rankings are graphed against 2014 gross national income (GNI). Countries are divided into quadrants based on average GNI and routine immunization expenditures. As shown, Cambodia, Ethiopia and Uganda are performing better than expected based on their GNI, while Nigeria and Vietnam are underperforming. The remainder of the SIF countries are performing close to expectations.
Figure 2: GNI versus Ranking of Countries’ Routine Immunization Expenditures, 2014
However, the rankings only tell part of the story. When absolute monetary amounts for routine immunization expenditures are compared instead of ranks, many SIF countries are clustered together within a small range — as shown in Figure 3. Of the 21 reporting countries, 16 spent between $1 and $16 per surviving infant in 2014. Of the remaining five countries (Armenia, Georgia, Moldova, Mongolia and Cambodia), only Cambodia performs better than expected based on its GNI, and Mongolia performs notably worse than we would predict based on its GNI.
Figure 3: GNI versus Countries’ Routine Immunization Expenditures, 2014
As expected, ranked and absolute routine immunization expenditures correlate with GNI. However, in the case of countries such as Nigeria, Vietnam and Mongolia, immunization spending has not kept up with economic growth. As demonstrated in the Democratic Republic of Congo, country-specific institutional solutions, such as budget tracking or advocacy, could improve immunization expenditures in the long run.
Many challenges still exist in the JRF reporting process. Countries still generally underreport their spending on routine immunization, and outside funds are not always routed through the national level. Organizations often provide funding or supplies directly to a community, so the national government does not have a way of tracking that spending. Also, even though subnational government spending should be included in JRF data, many countries do not have a mechanism to track how much local governments spend on immunization programs.
With continued economic growth and improvements in reporting — combined with financing solutions such as budget tracking and advocacy — domestic spending on routine immunization could continue to rise, each dollar bringing countries one step closer to full ownership of their immunization programs.