Sustainably graduating – so they don’t come home to live with us

By Robert Steinglass, Immunization Senior Advisor for JSI

Have we been kicking the can down Sustainability Street?

I have never forgotten his irritated impatience, or my surprise, when a senior WHO Immunization Officer told me 25 years ago, just as the resource-intensive and externally-driven UNICEF rush to achieve Universal Child Immunization (UCI) goals by 1990 was at its height, “We’ll worry about sustainability later when the money runs out.”

A few years earlier in Nepal, in 1986, where I was the WHO Technical Officer for the Expanded Program on Immunization, a colleague from the Ministry of Health working with UNICEF, had also dismissed my concerns that coverage would surely drop after 1990 (as it subsequently did in almost all UNICEF-supported countries) once the UCI initiative ended and finances dried up. He tossed out this ominous conversation-stopper, “None of us may even be here in 1991.”

These comments contradicted my past (and current) view that the time to think about sustainability is from the start, during program design and continuously during implementation.   But a mandate for sustainability is often absent when major global initiatives are cooked up and the focus turns to rapid, short-term achievement. The topic of sustainability seems highly-charged.

What is GAVI doing to promote financial sustainability? 

In the recently published article by Saxenian et al., Overcoming challenges to sustainable immunization financing: early experiences from GAVI graduating countries, we learn about the systematic steps now being taken by the GAVI Alliance to wean some lower middle income countries from external financial and technical support in planning for graduation after GAVI support ends. Saxenian et al. describe the multi-agency country visits to assess readiness to graduate and consultation with national authorities and partners to facilitate a smooth transition.

Whether or not these GAVI efforts succeed, as I certainly hope, or turn out to be a case of ‘too little, too late’ remains to be seen. Countries have taken out heavily subsidized ‘mortgages’ to introduce new and costly, life-saving vaccines; and these mortgages are now coming due as some countries’ economic levels have surpassed eligibility thresholds for continued GAVI support.

Since its inception in 2000, GAVI’s definition of financial sustainability, different than self-reliance or self-sufficiency, has emphasized ‘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.’ GAVI and  many countries were not overly concerned in those early days about creating dependency. But now the mortgage crisis is hitting home and finding cramped public fiscal space to deal with it.

So haven’t we been here before and what did we learn?

Saxenian et al. wisely call for a synthesis of experience across programs and initiatives to learn what works to ensure successful graduation.  But we have been down this path before, or at least I have, and I bet you have too.

Whether it was UNICEF’s Vaccine Independence Initiative in the mid-1990’s or GAVI’s primary focus since 2000 on introducing new vaccines, the issue of who was paying for vaccines has always grabbed center stage and could concretely be measured. The need to sustainably cover the recurrent costs of operating a vaccination program, beyond the costs of just vaccines, received insufficient attention.

Efforts to increase the likelihood of sustainable immunization programs, processes and outcomes have a long history of debate. A good starting point might be ‘Sustainability of Achievements:  Lessons Learned from Universal Child Immunization.  Report of a Steering Committee’ (UNICEF, 1996). This introspective and candid UNICEF-commissioned report sought lessons about factors influencing the achievement and sustainability of UCI by 1990 and which would contribute to achieving and sustaining mid-decade (1995) and year 2000 goals.

This UNICEF report concluded that ‘The internal structures, leadership, mandates, advocacy and fund-raising activities of donor organizations have an important influence on sustainability of country programmes. Leadership within donor organizations influences internal operations and approaches taken in countries. Mandates form the boundaries within which donor agencies work, and they are used to justify the focus and emphasis of what will be supported in countries.’

‘The procurement of vaccine is now a key focus of donors and governments that are moving to government responsibility. This will help to ensure one critical input, but does not address the equally critical availability of operational funds for reaching children. The funds needed for supervision and transport are declining as donors withdraw funding and governments and communities fail to take them over. This has decreased outreach and undermined credibility, decreasing coverage in some places for the short term.’

Fast forward 18 years since the UNICEF report and read a timely article appearing this week on ‘Health system cost of delivering routine vaccination in low- and lower-middle-income countries: What is needed over the next decade?’ by Lydon et al. reinforcing a similar point, ‘in addition to investing in vaccines, it is critical to renew investments in strengthening the ability of health systems to deliver vaccines and vaccination services and in ensuring that systems are sufficiently resilient. The findings from this WHO and UNICEF analysis clearly highlight the need for substantial front-loaded investment beyond the vaccines themselves if the goals established for this decade are to be met.’ And perhaps surprisingly, they go on to state that ‘system investments for vaccination delivery will supersede investments in the vaccines themselves, despite the higher cost of many new vaccine products.’

So, there is a long history of coming to grips, sometimes belatedly, with sustainability in all its dimensions. Now Saxenian et al. add to this body of work by rightly emphasizing that transition planning must extend beyond financing of GAVI vaccines to all vaccines and indeed more broadly to the non-vaccine costs of delivering routine vaccination services.

What else would we like to know about GAVI’s work on financial sustainability?

Are GAVI-supported countries making headway in purchasing the older, inexpensive, ‘traditional’ vaccines, and are country co-payments to GAVI for newer, expensive vaccines displacing domestic financing of vaccines not supported by GAVI? I would have liked to have learned more from Saxenian et al. about this. For example, in Kyrgyzstan several years ago, I learned that their limited national budget could no longer cover procurement of the inexpensive, monovalent hepatitis B vaccine birth dose, which had been introduced and discontinued by GAVI, because of high-profile political pressure to meet GAVI’s co-financing requirements for the more expensive pentavalent vaccine. I also would have appreciated discussion on their almost offhand comment that lower GAVI vaccine prices for graduating countries might be conditioned on using UNICEF Supply Division procurement services. Why? What are the arguments, pro and con?

I was taken aback by the comment of Saxenian et al. that most countries do not request a particular presentation of vaccine (e.g., number of doses per vial) when applying to GAVI. In providing technical support to a dozen countries in applying to GAVI for new vaccines, our experience at the USAID-funded Maternal and Child Health Integrated Program (MCHIP) has been the exact opposite.

In my experience, countries know what they want; but they are often frustrated by what is offered to them, with political pressures and donor politics usually trumping technical needs. And yet vaccine presentation, formulation and packaging have important technical and financial implications for optimal vaccine introduction, co-financing and affordable long-term use. What an indictment of the technical support made available to countries by GAVI and its technical partners that, if accurate as stated, ‘most countries visited were not well informed about the multiple presentations (number of doses per vial, cold storage requirements, recommended doses per child, etc.) available for a given vaccine and their financial implications.’

So how well does the GAVI Alliance manage to meet country preferences for programmatically suitable vaccine products that fit well within country immunization programs?  Different institutional players with a role to play in the decision concerning which vaccine product to provide may have varying and sometimes competing perspectives on the relative importance of meeting the needs defined by the countries themselves. What percent of countries receive GAVI support for their first choice of vaccine product?  Is this even tracked?

Should the broader dimensions of immunization sustainability also be examined by GAVI?

And of course sustainable immunization financing, as recognized by Saxenian et al., is but one dimension of overall sustainability which must include institutional, legal, financial, governance, ownership, managerial, supply, demand, cultural and technical elements. Do you agree with Saxenian et al. that these broader dimensions of immunization sustainability should also be examined by GAVI and its partners?  If this expanded scope is not already included in future country analyses concerning graduation, then it seems to me as a global community we have been slow to learn the lessons of sustainability. Do the donor community and its partners have to repeat these lessons, before they too can qualify for graduation?