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Financial Sustainability of GAVI funding for immunisation programmes

Financial Sustainability of GAVI funding for immunisation programmes. Marianela Castillo-Riquelme Marianela.Castillo-Riquelme@uct.ac.za Health Economics Unit- University of Cape Town HEPNet workshop on Donor Funding Livingstone, Zambia 26-28th May 2008. Outline of the presentation .

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Financial Sustainability of GAVI funding for immunisation programmes

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  1. Financial Sustainability of GAVI funding for immunisation programmes Marianela Castillo-Riquelme Marianela.Castillo-Riquelme@uct.ac.za Health Economics Unit- University of Cape Town HEPNet workshop on Donor Funding Livingstone, Zambia 26-28th May 2008.

  2. Outline of the presentation • Background on immunisation programmes • Global Immunisation Vision and Strategy (GIVS) • GAVI funding model • Phase 1 (ended) • Trends in expenditure on immunisation programmes after GAVI • Phase 2 • Challenges on sustainability (new vaccines) • Conclusion and reflections

  3. Background information on immunisations • One of the basic healthcare prevention programmes => Considered very cost-effective • Phenomenon of various new vaccines (Hep B & Hib, then rotavirus, Japanese Encephalitis, meningococcal A/pneumococcal conjugate, HPV, and rubella) • New vaccines including combination vaccines are much more expensive • WHO-UNICEF Global Immunization Vision and Strategy, 2006-2015 • Many developing countries rely on donor funding to conduct immunisations programmes – mainly GAVI

  4. Immunisation schedule (generic)

  5. Global Immunization Vision and Strategy (GIVS) for the period 2006-2015 • UNICEF/WHO initiative • Reduce mortality due to vaccine-preventable diseases by 2/3 by 2015 • Reach 90% coverage by 1015 • Introduce new vaccines (which?) • Can we afford GIVS? Wolfson et al. (2008) try to answer this!

  6. Global Alliance for Vaccines and Immunisations (GAVI) • Created in 2000 (initially for 5 years) • Financial sustainability plans [FSP], 10 years • Definition of eligible countries • Grouping by income (4 groups using UN definition of less developed and income threshold of GNI $1000 per capita) • Three components of funding: • Immunisations services support (ISS) [DPT3<80%] • Injection safety support (INS) disposable syringe & safety boxes • New vaccines support (NVS) • 2 phases • First phase 2001-2006 $1.2 billion • Second phase 2006-2015 (around 5.5 billion committed)

  7. GAVI experience 1st phase • 71 out of 75 eligible countries have benefited • Vaccine introduction grant ($100.000 one time) • Immunisation coverage has increased • Injection safety component very well evaluated • ISS with a performance based component $20 for additional FVC But • Financial sustainability not achieved in 5 years • New vaccines’ prices have not decreased as expected • Donors unable to make multi-year commitment • Therefore second phase was needed

  8. Evaluation of GAVI funding (1)Lydon et al. 2008 • Some findings • Total cost of $153 million (baseline) to increase to $500 million in 2010 (to sustain and gain scale-up) • Cost per child $6 (baseline), $9.2 (GAVI) and $17,5 (2010) • Cost profile of immunisation services changing=> vaccines 20% (baseline) and expected to reach 50% (new vaccines) • Other cost of introducing new vaccines: training and social mobilisation • Increase in recurrent expenditures of 22% (cold chain equipment and maintenance, training, additional human resources, vehicles, transportation, and surveillance activities)

  9. Evaluation of GAVI funding (2)Patrick Lydon (WHO) • Unknown trends in the absence of the new vaccines (Hep B and hib) • Immunisations services strengthening (ISS) would account for 11% increase on non-vaccine expenditure • Variability in costs across countries respond to vaccine schedule, HR costs, economic development, demographic, performance and delivery strategies • Supplemental activities (mass campaigns, NID, mop-up activities & outbreak responses) can be a considerable part of total costs (25%). Normally these costs exceed those of routine delivery services

  10. GAVI phase 2 • Period: 2006-2015 • Countries consultative process • Introduction of co-financing also called bridge-funding • ISS continues • International Finance Facility for Immunisation (IFFIm) [4 billion] borrowing from international capital markets • [Pneumo] Advance Market Commitment (AMC) [1.5 billion] from Feb 2007

  11. Challenges for phase 2- Cost of new vaccines Very high! e.g. Pentavalent account for 92% of the overall cost on vaccines in Malawi (GAVI, 2005) – no secure funding after 2007 • Rotavirus projected price $5.75 per dose in 2010 and $1.88 in 2015 (Wolfson et al, 2008) • Meningococcal Conjugate $0.44 (2010) & $0.58 (2015) (Wolfson et al, 2008) • Japanese Encephalitis $3.02 (2010) & $2.96 (2015) (Wolfson et al, 2008) • Pneumococcal Conjugate $5 (2010) & $4 (2015) (Wolfson et al, 2008) • Plus costs of introduction • Plus other recurrent costs associated to delivery

  12. Cost of reaching GIVS, Wolfson et al.2008 Methods • 117 low and middle income countries included • Using country planning documents • Botton-up ingredients approach to scale-up • Introducing: Rotavirus, Conjugate Meningococcal A, Japanese Encephalitis and Pneumococcal Conjugate Findings • The 72 poorest countries spent $1.1 billion in 2000, which increased to $2.5 b in 2005 and it is projected $4 b for 2015. • Total costs between 2006-2015 = $35 b: • $19.3 b to maintain current level, • $8.7 b for vaccines & • $5.6 b for system scale-up • These costs almost double for the 117 countries

  13. From Report to GAVI secretariat, July 2005 (page 17)

  14. GAVI’s new co-financing policy for new vaccines (2007-2010)

  15. Conclusions and reflections (1) • GAVI’s aim of increasing coverage has been achieved • Increased awareness of financial sustainability at country level • Sustainability of the current level of immunisations is challenging • Introducing new vaccines is even more challenging • Some new vaccines have been introduced on cost-effectiveness results basis, however CE does not guaranty affordability • Sustainability was not achieved at the end of phase 1 (due to wrong assumptions). Can this happen again with phase 2?

  16. Conclusions and reflections (2) • More research is needed at country level prior introduction of a new vaccine • Introduction of combination & new vaccines need to be evaluated in relation to other non-vaccine preventable disease interventions • Question on allocative-efficiency => Do we really know the opportunity cost of introducing pentavalent vaccine? Or rotavirus? Or other vaccine? • Are GIVS unrealistic? • Changing donor behaviour SWAp versus specific disease programmes (in-kind v/s budget donation)

  17. Thanks! References Lydon P at al (2008) New Vaccines in the Poorest Countries - What did we learn from the GAVI experience with financial sustainability? Submitted to Vaccine Wolfson et al (2008). Estimating the costs of achieving the WHO-UNICEF Global Immunisation Vision and Strategy, 2006-2015. Bulleting of the World Health Organisation, 86(1):27-39 GAVI, Lessons learned from GAVI Phase 1 and design of Phase 2; Findings of the Country Consultation Process. Available at www.gavialliance.org Other potential useful sources: http://www.who.int/immunization_financing/tools/en/ www.gavialliance.org

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