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) Antigen birth1 st d2 nd d3 rd d9 m BCG (Bacillus Calmette-Guerin)x DTP (Diftheria, tetanos, pertusis)xxx OPV (Oral polio vaccine)xxx Measlesx HepB (Hepatitis B) monoxxx Hib (Haemophilus Influenza Type b)xxx Tetravalent (DPT – HepB)xxx Pentavalent (DPT - HepB - Hib)xxx Pneumococcal Conjugate Meningococcal meningites (A & C) Japanese encephalitis Others: Rubella, Yellow fever, Rotavirus

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 1 st 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. GAVIs new co-financing policy for new vaccines (2007-2010) Country co-payment price per dose Vaccine 1 Poorest 2 Intermediate 3 Least poor 4 Fragile states 5 1 st vaccine$0.20$0.30 $0.10 2 nd additional vaccine$0.15 3 rd additional vaccine$0.15 4 th additional vaccine$0.10 to $0.15 cents

15. Conclusions and reflections (1) GAVIs 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 www.gavialliance.org Other potential useful sources: http://www.who.int/immunization_financing/tools/en/ www.gavialliance.org