Mike McQuestion, Ph.D., M.P.H., served as Director of Sabin's Sustainable Immunization Financing program from 2007-2016. Prior to his work with Sabin, Dr. McQuestion was the Global Supervisor for the PolioPlus Program of the Rotary Foundation of Rotary International, Technical Officer for PAHO's Diarrheal Diseases Control Program and a volunteer in the U.S. Peace Corps.
 
Why is the financing of immunization something to be concerned about now?
It costs approximately $60 to fully vaccinate a child. That’s way more than the poorest countries can afford. Gavi, the Vaccine Alliance, provides grants to low-income countries to pay for vaccines. Some also receive Gavi health system strengthening grants. Countries need to be under a threshold minimum to be eligible. If a country’s gross national income per capita rises above the threshold (currently $1,580), they graduate from Gavi grant eligibility.
 
As these countries’ economies have grown in the last decade or so, they have been able to finance more and more of their programs. The initial goal of the Global Vaccine Action Plan was that countries would be paying the full cost and own their programs by 2020. But the cost keeps going up as we add new vaccines.
 
Many of these countries will be able to afford to fund immunization programs by 2020, but do they have the willingness to pay? Sabin is addressing this by helping to create the political will for countries to pay for immunization.
 
Countries need to be equitable partners. Countries need to learn how to govern and to provide public goods. Immunization is a classic example. Sabin is working to facilitate transitions from dependency to country ownership, measured by how much of the costs the countries are themselves financing.
 
Why is country ownership so important to the Global Vaccine Advocacy Plan? 
We want immunization to become part of the social contract in each country. We learned this in Latin America in the 1980s when entire societies engaged in the regional effort to eradicate polio. We used every method we could — mass media, elected officials, schools — to immunize every child and find the last case of polio. And in doing so, we created a popular expectation that from then on, all children were going to be immunized by the government. Once immunization becomes a part of the social contract then it is likely the program will be sustainably financed indefinitely by national revenues; a more reliable, long-term solution than philanthropy.
 
How does Sabin engage with countries?
Countries need some support and coaching in order to take ownership of immunization programs. 
 
The first step is to bring together counterparts from the Ministry of Health, Ministry of Finance and Parliament — usually the health committees and the budget committees. This may be the first time these people have sat down together. We start a new dialogue. 
 
When we have our workshops and people interact it is interesting to see how they follow their own institutional logic. For instance, anyone trained as a doctor wants to save every life and reach every last child, they don’t care how much it costs. They don’t really work with financial information. The representative from the Ministry of Finance is concerned about allocating resources and wondering, “Is this really where I should invest?” We also have the logic of politics. Members of parliament and other elected officials realize they are likely to get votes by associating themselves with a great program like immunization; when they can show that they made a program function better by being involved and providing oversight or championed a law or increased the budget. Financing is the one dimension linking them all. Everyone understands the value of money. Monetizing the immunization program — demonstrating how much it costs to immunize each child or prevent one case of measles, say — makes it understandable to everyone. 
 
In our Sabin workshops, national counterparts role play: the manager asks the minister of health to increase the immunization budget or the minister presents the immunization investment case to the parliamentary health committee. They discuss the return on investment, how many children were immunized at what cost per child. They use their own data to buttress these arguments. This is a new role for most of them and they learn from one another. 
 
We bring the institutional counterparts together and challenge them to come up with their own solutions. And they do. 
 
How is legislation a significant step to financing immunization?
A government’s budget is ultimately a statement of its priorities. Once there is a law that mandates a certain percent of the budget for vaccines and immunization, there’s nothing to negotiate – we know we need to fund this just like we need to feed the army and keep the airport open every day. It is a public good. And once you define it as a public good, there’s no going back. The government has to keep the money there to keep the children immunized and the laws make that happen. 
 
Several countries have recently passed laws obliging themselves to finance publicly immunization and even more countries are preparing legislation. When countries pass these kinds of laws they in fact take ownership and are obliged legally to pay the bills for the program. 
 
What is the most compelling reason to increase funding for immunization?
The low-income countries supported by Gavi have really not succeeded in supplying many public goods at all. There may not be schools accessible to all. The roads may or may not be passable. But the ability to bring immunization to everyone is a demonstration that government can do something really important and valuable. The social contract is enriched. Everyone in society comes to expect that government can do more than immunize all the children. 
 
No one wants to invest or live in a country where citizens are at risk of mass epidemics of measles, polio or rubella. If your country is to have a place in the global economy you are going to need to guarantee that these communicable diseases are controlled. 
 
Immunization is a loss leader. You spend a lot on immunization but a well-run program has far-reaching effects. It draws people to the other health services available. It strengthens the overall health system. For example, if a country can put together a disease surveillance system sensitive and specific enough to find cases of polio or measles in the remotest areas, that system can easily be extended to cover other diseases and conditions.  
 
We want rising expectations. We want citizens to expect more and more from their governments and to participate in the democratic process. I can foresee the day when citizens all around the world hold their governments responsible and accountable for keeping all the children immunized. A country that is able to own its immunization program and deliver it with high quality has demonstrated good governance to itself, to the world, to everyone. If you can do that, what else can you do as a government?