Case study on Immunization Expenditures in Madagascar

A component of the Public Expenditure Review in Health

Prepared by Thomas S. OConnell, Senior Health Specialist, Economics and Finance, UNICEF
15 May 2015

Contents
Introduction .................................................................................................................................................. 3
Background ................................................................................................................................................... 3
Methodology................................................................................................................................................. 3
GAVI Alliance Financing Review .................................................................................................................... 4
Approach ................................................................................................................................................... 4
Findings ..................................................................................................................................................... 5
Assessing the financial sustainability of the immunization program ....................................................... 6
Increasing the effectiveness and efficiency of how resources are used. ................................................. 9
UNICEF study on Sub-national financial bottlenecks .................................................................................. 10
Aim .......................................................................................................................................................... 11
Four areas of assessment........................................................................................................................ 11
Methods .................................................................................................................................................. 12
Findings ................................................................................................................................................... 12
Taking action ............................................................................................................................................... 14
Annex 1 Mission to Madagascar to assess fiscal space requirements for successful graduation from GAVI
Alliance support. ......................................................................................................................................... 14
Terms of Reference (ToR) ....................................................................................................................... 14
Specifically:.............................................................................................................................................. 15
Annex 2 ToR for UNICEF sub-national Bottleneck Analysis of immunization financing ............................. 16
Overall approach:.................................................................................................................................... 16

Introduction
To identify potential options to reduce the financial constraints faced by the Government, the World
Bank and UNICEF are carrying out a Public Expenditure Review (PER) in the Education, Health and
Nutrition sector. This represents one of the three sector case studies to be carried, out, with the other
two assessing nutrition and education systems. The aim is to provide the Government of Madagascar
with substantive recommendations on how to achieve better education, health and nutrition outcomes
through an improved budget allocation and public expenditure management system.

Background
Madagascar is one of the poorest countries in the world. In 2010 nearly 80 percent of the population
was living on less than $1.25 per day - 92 per cent lived on less than $2 PPP per day. In comparison with
poverty levels elsewhere in the world, Madagascars position has deteriorated since the beginning of the
decade. Madagascars surface area of 596,790 km2 makes it the fourth largest island in the world. In
2012, the population was estimated at around 17.16 million inhabitants and the rate of demographic
growth at 2.9%. With that population size and population growth rate, it is expected that Madagascar
will need to invest in immunization to meet the vaccination requirement of the children.
According to the World Bank Atlas approach, per capita income is approximately USD 400. Poverty levels
rose by 9 percent between 2005 and 2010, with 77 percent of households living below the poverty line
(World Bank and INSTAT figures), ranking 151 in the world on the UNDP Human Development Index.
Importantly, Household poverty is strongly correlated with low resilience to cope with external shocks,
economic or otherwise.
Table 1: Development of main macroeconomic indicators between 2006 and 2012
Unit

2006

2007

2008

2009

2010

2011

2012

GDP at
current Thousands
prices
of US$

5 515236.34

7342905.88

9394330.37

8589560.14

8837041.79

9 911781.30

9975124.87

379.07

471.44

419.09

419.22

457.21

447.44

GDP per
head

US $

292.96

Source: World Bank, World Development Indicators, 6 May 2014

Between 2002 and 2008, national development strategies by the government of Madagascar yielded
steady improvements in health, nutrition and education indicators. World Bank data indicates that the
share of health in total public expenditure was above 7 percent between 2008 and 2012, with a peak
close to 12 percent in 2009.

Methodology
The Case study is based upon two separate inquiries on immunization financing and expenditures in
Madagascar, in light of the aforementioned contraction of the overall fiscal space. The first draws upon
the findings of the GAVI Alliance Immunization Financing Review conducted by UNICEF, WHO and Sabin

in June 2014. The second draws upon work by UNICEF to assess sub-national bottlenecks to the flow,
use and tracking of funds for routine immunization services.

GAVI Alliance Financing Review

An Immunization Financing Review conducted in Mozambique from 12 to 17 May 2014 was designed to
identify current and potential challenges to the financing of immunization. Furthermore, the
participation of international partner agencies in the mission led to an initiation of a robust dialogue
process for concerted effort to ameliorate the challenges. The below table shows the projected cofinancing obligations due to GAVI for vaccine procurement faced by the government. HPV vaccine costs
are not included in the calculations, as the data form the pilot study is not yet available.
Table 1: Co-financing required
Vaccine
1 DTP-Hep B-Hib;
pentvalent
2 PCV10,
Pneumococcal conjugate
vaccine
3 Rotavirus vaccine
4 HPV (pilot stage only)
Human Papilloma Virus vaccine

Vaccine
Classification
Underused

465,939

512,024

519,753

New

590,190

648,563

658,353

New

488,499

432,375

456,110

New

Totals

2014

$ 1,544,628

2015

$ 1,592,962

2016

$ 1,634,216

Approach
The approach taken was to conduct in in-depth desk review of existing reports, both published and grey
literature, to assess past trends in immunization and health financing, as well as identify enabling and
constraining factors impacting the fiscal space for health. Documents reviewed included comprehensive
Multi-Year Plans for Immunization (cMYP), WHO/UNICEF Joint Reporting Forms (JRFs), GAVI Annual
Progress Reviews of grants (APRs), GAVI decision letters defining potential grant amounts and cofinancing obligations, as well as secondary data sources such as UNICEF procurement and co-financing
data bases, Poverty Reduction Strategies, Health sector budgets, Public expenditure and financing
reviews, and a variety of economic and growth forecasts by the World Bank, African Development Bank,
IMF and other sources.
The desk review was used to develop preliminary estimates of future trends in domestic and external
financing, as well as the scope and timing of co-financing obligations, to estimate the sufficiency of the
fiscal space for immunization financing during and following graduation from eligibility for GAVI support.
The second step was a field mission, organized by WHO in collaboration with UNICEF, Sabine Vaccine
Institute, the GAVI Secretariat, and JSI, conducted from 12 to 17 May 2014 in Antananarivo
(Madagascar) . During this mission interviews were held with both technical and administrative officials

from the government and major development partners who directly or indirectly provide assistance and
resources for immunization financing, including procurement of traditional vaccines and co-financing of
new and underutilised vaccines.

Findings
The effective financing of the immunization programme relies mainly on predicable and timely funding
from external development partners such as GAVI Alliance grants, UNICEF, WHO, World Bank, with
additional support (technical and resources) provided by other partners such as the development
agencies of the UK, USA, French and EU.
The political crisis of 2009 and subsequent macroeconomic retrenchment has severely constrained the
available fiscal space of the government. Since 2009, authorities have implemented tight budgetary
policies to preserve macroeconomic stability, and necessitating steep cuts in social spending, though
education and health were prioritized, especially government investments in providing immunization
services.
The severe reductions to overall public spending level, with total public spending cut by 3 percent in
nominal terms, corresponds to an almost 40 percent drop in constant terms (2011 base year). For
instance, while the share of public spending allocated to education in the voted budget decreased only
slightly from 2008 to 2012 (19.6 percent in 2008 to 18.0 percent in 2012), in real terms the reduction of
funds severely constrained provision of educational services.
Similarly, the decreased level of Total Health Expenditures had a highly negative impact on access and
utilization of health services, due to critical shortages of essential commodities, technical equipment,
and human resources, combined with an increase in user fees. Outpatient visits alone decreased by
nearly 20 percent by 2013.

Figure 1total public spending from 2000 to 2013, in

constant 2011 dollars

Figure 2 Total public expenditures as a percentage

of GNI, 2000 to 2013

Source : Oprations globales du Trsor, 2000-2012, Note: 2013 data are estimates based on past trends
and expert opinion of the MoF
Formidable challenges constrain the ability of the government to substantively increase the fiscal space
for health. According to the Governments Financial Transactions Table, the government is running a
current account deficit, with revenues at 10% of GDP while total outlays are close to 15% of GDP.

Figure: Trend in fiscal revenue and current expenditure as a % of GDP

Sources: ADB: African Economic Outlook, 2013, Thematic Edition

Assessing the financial sustainability

sustainability of the immunization program
According to data in the annual progress reports, in 2010 the Government was responsible for 17% of
total expenditure on vaccination that is $2,227,201. Using the CMYP baseline figures, the table below
shows that routine vaccination expenditure represents 0.11% of GDP.
Table 5: Costs in 2010
Base year indicators
Total vaccination expenditure
Vaccination Campaign
Routine Vaccination
Total vaccination expenditure per capita
Per child fully vaccinated using DTCP3
% of vaccines and injection equipment

2010
$11 465 130
$2 048 424
$9 415 158
$0.4
$15.2
77.0%

% Government expenditure

9,6%

% Total health expenditure

3.6%

% Total Government health expenditure

39.8%

% GDP

0.11%
$11 465 130

Total
Source: Country cMYP 2011-2015

Between 2011 and 2013, the Government share dropped from 12% to 7%, representing a drop of 5
percentage points in 3 years. There was also a fall in nominal terms. The below table shows that despite
the severe contraction in public sector funding for health overall, the government of Madagascar strove
to preserve, and even increase, funds allocated to immunization services during the 2008-2013 period.
Note that the analysis of health expenditure by the Government in relation to GDP or total expenditure

on vaccination below uses data from the projected budgets for 2011 to 2015, taken from the latest
cMYP.
Comparison between the Ministry of Health budget and the vaccination budget

Source: Preliminary report on the review of documents by the mission to analyse the sustainable
financing of vaccination in Madagascar, draft version of 30 July 2014; Ministry of Health, Government of
Madagascar; WHO; UNICEF; SABIN. Unpublished mission report, 2014
Nonetheless, over the period 2010 to 2013 there was a drop from $2,227,201 in 2010 to $1,859,064 for
annual spending on immunization services provision. The figure below shows this declining trend in
domestic funding, as compared to the proportion of funds from GAVI and other external sources.
Figure 1: Proportional breakdown of vaccination funding

Projected expenditures and financing gaps for immunization

The Government currently pays a relatively small share of the costs of the vaccination programme, with
most expenditures for the purchase of vaccines, fuel, and payment of salaries. The projected cost of
vaccination for 2011-15 as estimated using the latest cMYP is around $185,414,104. The partners
forecasted share would total to $129,782,756 (70%). Of this, only 5% is already committed, about
$8,955,734. This leaves roughly 65% of the gap to be secured, around $119,877,669, which would be
largely from non-government sources throughout the period of 2011-2015.
When including domestic funding gaps, the total shortfall totals approximately $176,459,016, including
$120,827,022 for projected operational expenses. This means that about 30% of the total requirements
contained in the cMYP estimates, domestic plus external, remain unmet.

Meeting the co-financing obligation

Since 1997, EPI has had a budget line for the purchase of routine vaccines. With the introduction of new
vaccines, the funds allocated to the budget fall short of the full costs of procuring traditional and new
vaccines. Thus, one of the concerns of both government and partners is developing sustainable sources
of predicable and sufficient financing to meet demands of expanding immunization coverage whilst
simultaneously meeting rapidly growing co-financing obligations.
Currently, over 80% of programme resources are provided by the technical and financial vaccination
partners. In addition, over the period 2010 to 2013, between 30 to 45% of the cost of procuring
traditional vaccines was paid for directly by UNICEF.
Figure: Purchase of traditional vaccines

While the economy is again growing, current projections do not predict generation of sufficient
domestic revenues for the government to finance expansion of immunization coverage to achieve
objectives of universal and equitable access to save lives and minimize illness from vaccine preventable
diseases. One potential option is increased mobilization of domestic resources. In terms of providing a
more secure fiscal space for the specific requirements of vaccine procurement and supply chain
management at all levels, the ministry notes that there is a draft law on the sustainable financing of
vaccination, the passage of which would permit the government to earmark resources for vaccination.
However, with some traditional partners indicating a progressive reduction in financial support to
immunization, the consensus view by government and partners interviewed was that the financing gap
for immunization can only be filled over the next few years if increasing domestic resources are
combined with additional financing from existing and new partners.

Increasing the effectiveness and efficiency of how resources are used.

A final series of recommendations by the mission team focused on systems strengthening to better use
data on operations and resource management to assess performance of immunization services and
systems at all levels. One innovative example is support by UNICEF to the Health Ministry to carry out an
assessment of barriers to the timely flow, optimal use and accurate tracking of funds for implementing
immunization services at the sub-national level (see following section)
Suggested Actions

Proposed leads
1. Build capacity of teams responsible for vaccination at all levels

Action 1.1: Train operational Actors in Governance and

Management

Ministry of Public Health & Technical and

Financial Partners

Action 1.2: Train data administrators at the operational level en

DQS/UDD

Ministry of Public Health / Technical and

Financial Partners

2. Improve monitoring of EPI expenditure at all levels,

Action 2.1: Actively participate in the Public Health
Expenditures Review and in the regional reviews

Ministry of Budget and Finance- Ministry of

Public Health

Action 2.2: Update and finalise the cMYP (Detailed Action plan
being created, to be integrated in cMYP including pessimistic
scenarios)

EPI manager & Technical and Financial

Partners

Action 2.3: Share information on national and sub-national

expenditures monitoring during ICC and CCSS meetings

Ministry of Public Health / Technical and

Financial Partners

Action 2.4: Quarterly meetings on harmonisation of financial

and technical data analysis at national and subnational level

Ministry of Budget and Finance- Ministry of

Public Health with Technical and Financial
Partners

3. Strengthen reporting, management and feedback on expenditures at all levels

Action 3.1: Draft a template to collect sub-national information
on expenditure

Planning Directorate; Ministry of Public

Health with Technical and Financial Partners

Action 3.2: Draft and spread the report on the expenditure

Planning Directorate

4. Finalize the draft law on the sustainable funding of vaccination

Action 4.1: Hold a workshop on the appropriation of the

Immunization Financing Law (Health, Finance, Parliament)

Ministry of Public Health (EPI service)

Action 4.2: Send the project of Law to the Government for

validation

Ministry of Public Health (EPI Service)

Action 4.3: Send the project of law for vote within the National
Assembly

Ministry of Health (Cabinet)

5. Strengthen Ministry leadership in coordinating interventions

Action 5.1: Monthly meetings for assessing and promoting
vaccination prioritization within all levels of the Ministry

General Secretary of the MoH

Action 5.2: Obtain the commitment of all for the

implementation of the Action plan on sustainable financing of
the vaccination

General Secretary of the MoH

6. Strengthen appeals to and partnership with the private sector and civil society.
Action 6.1: Make copies of the cMYP document for in order to
EPI service, MoH
use it as advocacy document
Action 6.2: Advocacy meetings including private sector and
MoH, Ministry of Budget, Parliament
employers

UNICEF study on SubSub-national financial bottlenecks

Challenges to the sufficiency and predictability of financial flows, as well as contracting fiscals space for
health overall, pose substantive challenges to ensuring immunization services, including implementation
of pro-equity strategies such as Reaching Every District (RED) and Reaching Every Community (REC).
Build upon an immunization platform, RED/REC is a results-focused strategy to identify where
underserved population live, support innovative ways to bring services to those communities and
households, whilst also remove barriers to service access, both financial and non-financial, that
constrain the demand for services. If Universal Health Coverage is to be achieved, integrated RED/REC as
a core component of Health Systems Strengthening, must be fully implemented with sufficient quality to
achieve impact.
Despite the challenges from recent political changes, the government has remained steadfast in its
efforts to maintain and increase immunization coverage, as well as support introduction of new
vaccines. The 2012 joint WHO/UNICEF report (JRF) estimates that the countrys DTP3 coverage is 82%, in
comparison with an average rate of 47% in the Africa region, reflecting a commitment to fund service
provision. However, there are increasing signs that the resources gap is impacting service delivery.
Budget delays and insufficiencies, which materially impacted service provision, were reported in 5/20
districts and 7/99 health facilities. In response, UNCIEF worked with the MoH to implement bottom-up
planning and budgeting, to move towards needs-based allocation of resources. To assist in diagnosing
systemic challenges to timely and efficient use of resource, UNCIEF assisted the MoH to carry out an

analysis of how sub-national financial bottlenecks impact efforts to implement health strategies such as
RED/REC, and how such bottlenecks hinder attainment of high coverage rates.
The rapid assessment approach used for this study was adapted from a methodology and set of tools
developed by UNICEF, which were previously field tested in Uganda and Indonesia. A desk review and
initial meeting with government and partners led to the development of a protocol for implementing
the assessment in Madagascar. Subsequently, the Institut Pasteur of Madagascar (IPM) was engaged to
facilitate further adaptation and implementation of the rapid assessment methods and tools were
adapted to the Madagascar context in an iterative process between the government, UNICEF, IPM, and
development partners.

Aim
This case study describes the main components of a country-tested rapid assessment, designed
primarily for the use of national and sub-national managers, and their development partners, wishing to
diagnose barriers and bottlenecks to the timely flow, appropriate use, and reliable tracking of financial
resources from national to all sub-national levels. The objective of the rapid assessment tool is to quickly
identify critical issues, with a goal of catalysing effective actions to address and resolve them.

Four areas of assessment

With the perspective of this diagnostic being primarily for the generation of reliable data, useful for
policy and management decision making rather than for academic rigour, a non-probability purposive
sampling methodology is proposed for the collection of data. This rapid assessment focuses on four
main areas of potential bottlenecks for financial flows.
First, the approach seeks to generate information on delays in receipt of Routine Immunization (RI)
and health funds at each sub-national administrative level, relative to start of fiscal year. The aim is to
assess the date when funds are delivered and when they are available for use. Data on funds are
disaggregated by funding source, such as domestic, GAVI cash grants, other donor funds, user fees (if
applicable); and by funding level (national, sub-national), and any other categories relevant to a
particular countrys context.
Second, the assessment of fund diversion by the transferring administrative level are examined, as
well as other factors that reduce the actual amount of funds received by the sub-national level, if
compared to the amount of funds expected by that level, according to its approved health and
immunization budgets.
Third, each administrative level is examined to assess the scope and causes for any reallocations of
funds planned for RI spending, due to a decision being made by that implementing level. This seeks to
measure the ability of each level to ring-fence or guarantee that health funds are used as planned.
The fourth areas is assessing problems with systems and capacities for accurate tracking of the receipt
and use of immunization and health funds from donors and domestic sources. This not only includes
accurate accounts of receipts and expenditures, but an assessment of systems to accurately record the
true outputs purchased. coverage.

Methods
The study used a non-probability purposive sampling methodology. This study selected 10 out of 22
regions in Madagascar. Every region developed health sector annual work plans using the same bottomup approach, except for Analamanga. All regions benefitted from the Health System Strengthening
Programme (PASSOBA) and had a UNICEF field presence. In each district, two strong EPI performers
and two weak EPI performers were selected using DTP3 coverage rates. Numerous health centres lack
copies of reports and files, and subsequently, are missing data on the funds allocated to them.
Therefore, only 42 health centres out of 80 in the study were considered for the assessment of financial
flows.
In order to assess financial flows and bottlenecks for immunization services, the study used timeframes,
for establishing delays in the flow of financial resources, funding gaps, funding reallocations and barriers
to financial monitoring and tracking systems to identify potential bottlenecks. The study then defined
factors constraining the flow, use and tracking of immunization financing. Strategies for overcoming
each of the constraining factors were suggested by health officials and other immunization services
stakeholders. In some cases health officials were already applying these strategies. The economic
analysis was based on financial data for fiscal year 2013 and on the two first trimesters of fiscal year
2014. The data on vaccination coverage are from 2013.
The survey data were transcribed into Excel 2010 and then cleaned and analysed using Excel 2010 and
STATA 13. Tables and figures were created through Excel 2010. To generate descriptive statistics, the
study calculated the absolute and relative frequencies (percentages) for qualitative variables, and the
median, mean, maximum and minimum for quantitative variables. The study used simple and multiple
linear regressions to determine correlation between quantitative variables. For testing statistical
significance, the study used the 5% significance level.

Findings
The regional and district health teams manage most of the public funding for health that is allocated to
their respective levels. The district is responsible for distributing funding equitably among health
centres. The district considers the type of health centre (HC1 or HC2), total catchment population,
geographic accessibility and health centre needs in their allocation process. The regional health team
receives funds for operational costs directly into its bank account.
However, the district health team receives funds for the districts operational costs and the health centre
operations in their jurisdiction. Health centres do not have financial management responsibilities;
rather, their focus is primary on healthcare delivery major constraint to implementing RED/REC is lack of
formal mechanisms for securely distributing funds to CSBs. Most disbursements to CSBs (and even to
some districts) are made in cash, as there are no government-approved banks nearby that are
authorised to accept and disburse funds from government accounts. This creates substantial problems
with tracking use of funds, and hinders the ability of managers to ensure compliance with approved
health plans and budgets.
The study was able to identify the major sources of immunization funding at the national, regional and
district level. However, financing details at the health centre level were difficult to assess due to lack of
data, archives or copies of reports to cite sources. Overall, Madagascar is heavily dependent on partners

and donors for immunization funds with 92% of Expanded Programme of Immunization (EPI) coming
from technical and financial partners. At the district level, a little more than half (54.73%) of the total
funds received by the district are used for immunization activities of which 24% comes from the state
and 61.9% from technical and financial partners. Additionally, for a good number of districts, the
amount received is greater than the amount planned (budgeted) and requested from partners outside
the activities of the Annual work plan (AWP) (46.8%). The study was also able to uncover the major
immunization activities undertaken, which were overwhelmingly for mother and child health weeks
(MCHW), Reach Every District (RED), and intensified routine immunization days (68.72% at district level
and 83.45% at health centre level).
Delays had an impact on utilization rates, which were lower due to delays in credit allocation.
The utilization rate is about 35.1% at the level of the regional directorate of health and 41.9% at
the level of the district. The second and third quarters are the only periods during which state
funds can be used and vaccination activities funded by the state are implemented during these
quarters. Thus, a large part of the state funds not to be utilized. Furthermore, delays caused
some bottlenecks at the district and health centre level. At the district level, the date
information for reports is sent can cause delays in the date funds are received. For health
centres, the date funds are received overlapped with the planned date for implementation of
activities causing a delay in activities.
The results also indicated that the number of monitoring and evaluation supervisory visits and financial
management checks vary largely with regional health directorates, districts or health centres. These
activities are generally integrated with other activities.
The findings were first reviewed by the MoH and partners. Subsequently, the findings and their
significance were reviewed during a meeting of health managers form all levels in late 2014. The main
outputs of the discussion were.
1. Investment in maintaining health system records and archives is important for improving the
availability and quality of data on financial flows for immunization. This would include making
the health centre manager accountable for record-keeping. Community surveys can also
contribute to validating data on immunization financing.
2. Budgetary reviews at every level are necessary for contrasting rates of expenditures between
cost centres. In some instances, budgetary controls (spending limits) e.g. in the first two
trimesters may be warranted.
3. Investment in bottom-up planning would strengthen the approximation of budgets with
planned activities. Methods for ensuring compliance to activities and timelines of the annual
work plans would also limit the number of off-budget activities.
4. Coordination between the central government and donors and development partners. The
aim hers is to better guarantee timely funding for the implementation of activities contained
in the annual work plan of districts and CSBs.
Overall, findings indicate that the approach used in this study can adequately capture financial
information in districts and facilities for which some effort to track immunization resource use are
routinely followed. The tool is equally useful in helping identify those facilities and districts where such

information is not available, and provides evidence to support building stronger sub-national capacity
for more effective financial management systems.

Acceptance, value add, and cost effectiveness requires avoidance of creating parallel processes,
such as generic approaches and tools that cannot be adapted to build up support in-country
financial management systems.

Information point: based on above, each application of rapid financial bottlenecks assessment
will require careful local adaption to enable it to build upon and become embedded in local
financial management systems used for tracking financial flows and use of funds for
immunization and other health services.

Acceptance of approach is very high amongst governments in the pilot countries, including
Madagascar, in large part because it is perceived as being a tool that can help authorities
improve their financial management of immunization and health resources (instead of being
perceived as a vehicle for donors to audit the use of funds).

A rapid but thorough pre-mission assessment is required to map out major systems for
channelling immunization and health funds (both domestic and external), plus reviewing
strength and completeness of systems to track use of funds, as well as the outputs truly
obtained: i.e. the quantities of outputs actually purchased. It is also vital to record any planned
major changes to financial management systems.

Taking action
The information from the Financing Review mission and the assessment of sub-national bottlenecks to
financial flows is being used by the government and its partners to identify practical approaches to help
prioritize and overcome major financial bottlenecks that constrain achieving equitable and universal
immunization coverage.

Annex 1 Mission
Mission to Madagascar to assess fiscal space requirements for
successful graduation from GAVI Alliance support.
Terms of Reference (ToR)
Over the years, country Immunization Programmes have grown in terms of service delivery so has been
the Immunization Financing Investment portfolio in order to sustain coverage and introduce new
vaccines and available technologies. The developing vaccines landscape suggests that investment
requirements by countries might increase over time. One area of concern for Governments and partners
alike is Immunization financing sustainability which is the ability of a country to mobilize and efficiently
use domestic and supplementary external resources on a reliable basis to achieve current and future
target levels of immunization performance in terms of access, utilization, quality, safety and equity.

In 2012 WHO provided country tailored technical support to countries in order to review immunization
financing through an analysis of financial and programmatic difficulties to strengthen immunization
systems and outline the prospects for financing immunization programs, including vaccines, operational
costs and GAVI co-financing requirements. This has proven to be useful as countries were supported to
develop a practical action plan with the key stakeholders and officials to overcome the identified
obstacles and create a dynamic environment in favour of accountability, ownership and financial
responsibility.
A framework has been developed to guide the work which consists of desk review and a one week in
country mission by partners including WHO, UNICEF, GAVI, SIF and others as may signify. There will be
focus on the macro-economic context and health, with a dig deeper into the challenges of immunization
financing.
In the current stream of work, the mission will review and document a time series of data (2006 2012)
focusing on Health financing in general and immunization financing in particular.

Specifically:
The mission will, based on the framework for analysis of countries in difficulties of immunization
financing and co-financing in particular,

Collect and analyse relevant documents and data (e.g. cMYPs, JRF, APRs, GAVI decision letters,
UNICEF procurement and co-financing data, PRSPs, MTEFs, health sector strategies, IMF
economic growth forecasts) to determine the appropriateness of fiscal space for immunization
financing .
Perform a desk review of available documents and data to show:
o Trends in Health financing, gaps and bottlenecks
o Trends in immunization financing, gaps and bottlenecks
o Trends in GDP (total and GDP growth, annual estimates and averaged over the period)
o Trends in GGHE (totals and growth, annual estimates and averaged over the period)
o Trends in share of OOP expenditures (annual estimates and averaged over the period)
o Relationship between GDP, GGHE, and DTP3/Penta3 coverage
o Document stress level occasioned by the GAVI co-financing payment (if any)
Fill gaps in data from the desk review by conducting interviews with key NIP, MOH, MOF, and
external development partner personnel to determine the landscape for immunization
financing.
Develop a practical action plan with the key stakeholders and officials to overcome the
identified obstacles and create a dynamism in favour of accountability, ownership and financial
responsibility.
Write country report to present findings, lessons learned and ways forwards at global, regional
and country level.
Feedback to country: Government and partners through advocacy for improved and sustained
funding of immunization vaccine procurement and service delivery

Annex 2 ToR for UNICEF subsub-national Bottleneck Analysis of immunization

financing
Overall approach:
1. Review existing data, literature and tools (including the results of reviews of Public Financial
Management with the IMF and Public Expenditures with the World Bank) on existing
approaches to assessing sub-national enablers and bottlenecks to effective funding and use of
resources for routine and supplemental immunization services. The aim is to identify useful
current national practices and methods relevant that can be incorporated into the generic
approach described below. .
2. In ten regions, assess enablers and bottlenecks to timely and full disbursement of budgeted
funds to Regions, From Regions to Districts, and from Districts to Health Centres I and II.
a. The ten Regions in the study were selected because they have already fully implemented a
new bottom up planning and budgeting approach that will be rolled out by the government
in all 22 Regions with the support of UNICEF and partners.
b. In each Region, two Districts will be chosen: one with the highest total DTP3 + OPV3
coverage, one with the lowest DTP3 + OPV3 coverage. In case of security concerns, the next
lowest or highest district would be chosen.
c. In each District, two Health Centre 1s and two Health Centre 2s will be chosen: one each
with the highest total DTP3 + OPV3 coverage, one each with the lowest DTP3 + OPV3
coverage. In case of security concerns, the next lowest or highest HC would be chosen.
3. At each level, key informant interviews and review of local records will be used to, assess the
presence of issues impacting the accurate flow, use and tracking of immunization resources, and
how each of these contribute to financial bottlenecks impacting the flow of funds subnationally.
4. Based on the literature review and findings:, :
a. Provide a synthesis report on the major identified bottlenecks to the flow, integrity and
use of financing for EPI at each level, along with the options provided by key informants
for their resolution;
b. Propose system strengthening components that could be financed through government,
GAVI HSS and other funding sources, that would help overcome bottlenecks to
equitable coverage;
c. For the near term, offer specific ways to catalyse and inform in-country policy dialogues
to catalyse the political commitment needed to implement actions to resolve specific
bottlenecks identified;
d. Provide feedback on how to improve this rapid assessment tool, to periodically monitor
progress towards resolving major sub-national financing bottlenecks to the flow, use
and tracking of funds that impact on the ability to achieve universal immunization
coverage.

e. Provide options for how the findings could be incorporated into the guidelines for
health sector budget allocations, which will inform the planned development of the
Medium Term Expenditure Framework 2015-2018.
f.

For the longer term, provide recommendations for policy dialogues to assist the
government and its partners to make more efficient use of immunization funds to
achieve more equitable outcomes.
i. Note: in some cases, local reprogramming of funds could be an adaptive response to
cope with financial flow bottlenecks or other emerging issues, consistent with the
authority provided under decentralised district management.
ii. While beyond the scope of this study to investigate at length, data suggesting that
such factors potentially drive at least some of the sub-national reprogramming that
is occurring will be an important finding for assessing the adequacy of financing
amounts and priorities for provision of EPI as key foundation of integrated primary
health care.