From paternalism to country ownership of national immunization

programs

Mike McQuestion, MPH, PhDSabin Vaccine Institute

World Vaccine Congress 2012Gaylord National Convention Center

Washington DC, USA10 April 2012

Outline

• Sabin Sustainable Immunization Financing Program

• Two logics: Immunization as a public good and as a driver of development

• Recent immunization financing trends

• Pathways to country ownership Institutional innovationsCollective action and social learning

Sabin SIF Program

• Six-year program, (2008-2013), funded by Bill & Melinda Gates Foundation

• Fifteen pilot countries chosen in consultation with GAVI and partners (WHO, UNICEF, World Bank), three more being added in 2012 with 2nd grant (GAVI)

• Five Senior Program Officers based in Africa, Asia backed by three Washington, DC-based Sabin staff

Sabin SIF Program• Periodic parliamentary briefings, targeted peer

exchanges of potential innovators• Legislation crafting workshops (Asia,

francophone Africa, anglophone Africa)• Second SIF Colloquium in 2013• Quarterly newsletter Summary Digest• Innovation: Rather than providing funding or

technical assistance, the SIF Program facilitates advocacy work, collective action

Immunization as public good

• Public (collective) good (def): “The achievement of a common goal, or satisfaction of a common interest”

(Mancur Olson 1965)• If the public good is produced, all group

members (citizens) will be better off than if it is not produced (Pareto superiority)

• Examples of public goods: A lighthouse, an army, a public education system

Immunization as public good

• Three characteristics of a public goodUnattainable individually: it can only be

provided collectivelyJointness of supply: available to everyone if

available to anyoneNon-excludability: cannot be feasibly withheld

from any group member

• Immunization (herd immunity) is among the first public goods governments provide

• A national immunization program is a set of well managed expert systems able to control morbidity and mortality by continuously providing state-of-the-art antigens to heterogeneous, often hard to reach populations

• Current investment: ~ US$40/infant

• A considerable accomplishment, particularly in a poor country

Immunization as development driver

Immunization as development driver

• Besides saving lives, immunization programs generate spillover effectsForegone curative costsIncreased labor force productivity (Bloom,

Canning Weston 1995)Political dividendsInstitutional capacity building

• By this logic, immunization is a highly cost-effective driver of development

Dependency

• To reap these dividends a country must own its immunization programSustainable financingTechnical expertise

• Most countries are far from this point• They depend inordinately on external

partners • This dependency short circuits true,

endogenous development processes

Dependency

• In the current, dependent equilibriumWork is done through patron-client

relationships, not institutional engagementTechnical decisions such as new vaccine

introduction are based on external expertiseExternal financing dominates and is generally

off-budgetGovernments underinvest (substitution effect)Public does not credit government

Countries underinvesting given growing economies

Countries could finance immunization in medium term

Rank 2006 US$ 2007 US$ 2008 US$ 2009 US$ 2010 US$

1 Sri Lanka 24 Sri Lanka 26 Cameroon 21 Senegal 56 Ethiopia 172 Nigeria 17 Cameroon 18 Cambodia 7 Sri Lanka 10 Sri Lanka 123 Nepal 12 Senegal 13 Nepal 6 Ethiopia 6 Mali 94 Cameroon 6 Kenya 8 Kenya 5 Madagascar 4 Cameroon 75 Cambodia 5 Republic of Congo 5 Sierra Leone 5 Cameroon 4 Kenya 46 Kenya 4 Cambodia 5 Republic of Congo 4 Cambodia 4 Nigeria 47 Senegal 4 Mali 3 Senegal 4 Republic of Congo 4 Senegal 48 Republic of Congo 4 Nepal 3 Madagascar 2 Nepal 3 Nepal 19 Uganda 3 Uganda 2 Mali 2 Uganda 3 Republic of Congo 1

10 DR Congo 1 Madagascar 2 Liberia 2 DR Congo 1 Cambodia 111 Madagascar 1 Liberia 1 Uganda 1 Mali <1 Madagascar 112 Liberia 1 Sierra Leone 0 DR Congo 0 Liberia - DR Congo 013 Mali <1 Ethiopia - Nigeria - Kenya - Liberia -14 Sierra Leone - Nigeria - Ethiopia - Sierra Leone - Uganda -15 Ethiopia - DR of Congo - Sri Lanka - Nigeria - Sierra Leone -

SIF Pilot Countries Ranked on the Amount of Government Funds Spent on Routine Immunization 1

per Surviving Infant2

1 WHO/UNICEF JRF Indicator 6730 (http://www.who.int/immunization_fi nancing/data/en/)

2 UN Population Divis ion Onl ine Database (http://esa.un.org/unpd/wpp/unpp/panel_indicators .htm)

Country ownership

• In the next, more efficient equilibriumNational managers will manage the programsDecisions will be based on national technical

expertise (NITAGs)Any external funding will be on budget and

managed as national funds are managedGovernments will allocate US$40 per infant

for routine immunization, by lawImmunization will be part of social contracts

Equilibrium change

• How can we move from the current dependent equilibrium to a superior one wherein each country owns its immunization program?

• Three intertwined, endogenous pathwaysinstitutional innovationcollective action social learning

Institutional innovation

• Key public institutions (ministry of health, ministry of finance, parliament, subnational governments) develop new ways of working

• Each institution must innovateMinistry of health begins to monitor and report

program efficiency (ie, expenditures per fully immunized child), allowing a stronger immunization investment case to be made

Institutional innovation Ministry of Finance considers these efficiency

estimates when it recommends and follows the execution of the immunization budget

Parliament scrutinizes the budget and follows program execution (technical and budgetary)

Government and parliament write and enact a national vaccination law

Expected results: Larger, more efficient national immunization budgets, legislation guaranteeing immunization budgets (earmarking, dedicated revenue sources)

Institutional innovation• Assuming they are motivated, what can

champions in these public institutions do? Can they induce the innovations needed to move their countries toward the sustainable immunization financing goal?

• Yes, particularly if we: provide peer to peer learning opportunities support them as collective actors

Institutional innovation How do innovations happen? Four distinct

mechanisms have been identified• Top -> down: Champions at national level

conceive and push through the changesExamples: Sri Lanka, Nepal, Mali

• Collaboration among institutions: they innovate together, sometimes producing unexpected results Intergovernmental: national + subnational Intersectoral: government + private sector

Example: Rotary PolioPlus Program

Institutional innovation

Four distinct mechanisms, continued• Bottom -> up: Champions at organizational

level conceive, disseminate the changesexamples: Sierra Leone, Cameroon, Uganda

• Third parties: Champions in the institutions or organizations bring in help from the outside examples: Kenya, Cameroon, Nepal

Institutional innovation Three current SIF Program examples:

Public institutions (Democratic Republic of Congo): The President of the Budget Commission, National Assembly, works with the MoH immunization program team to prepare more defensible annual budgets

Other domestic institutions (Nepal): Rotary and Lions Clubs, banks, industrial houses have formed a private fund to co-finance the immunization program

Institutional innovation• Three current examples, continued:

Third parties (West Africa): WHO, Sabin, UNICEF collaborate to train budget officials on immunization program budgeting using Multi-Year Plan (cMYP) tool

• Institutional innovations are unpredictable “…organizational change is unplanned and goes on

largely behind the backs of groups that wish to influence it” (DiMaggio and Powell 1983:157).

Collective action

• Under proper conditions, heterogeneous actors following different logics will act collectively to secure a public good

• Some rules of collective actionEach actor, each institution must accept the

common goal (the immunization program sustainably financed, technically self reliant)

All collective actors must contribute: free riding is not tolerated

Collective action

• Rules of collective action, continued External agencies- here Sabin’s SIF Program-

help coordinate the collective action, monitor contributions, provide feedback and extol public recognition of individual actors

Flexibility: Strategies change as needed An independent (exogenous) measure, or

certification process, defines when the public good is secured

Social learning

• Once mobilized, collective actors will be exposed to new ideas, new environments, new social phenomena

• One of these phenomena is social learning (social cognition), in which each actor observes the behaviors and standards of other influential actors People acquire large, complex behavioral

repertoires without having to learn them through trial and error

A global public good

• Through collective action and social learning, peers learn from each other and decide jointly whether or not to undertake the institutional innovations needed to secure the public good

• Coordination, monitoring and feedback induce a race to the top among countries

• Result: The global public good of a fully immunized world

Summary

• Most countries are underinvesting, do not own their immunization programs

• Countries can appropriate their immunization programs through several endogenous change mechanisms

• External partners support, don’t control

• Together, we can produce the global public good of a fully immunized world

Thank you for your attention!