1. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum Philadelphia, USA Reflections on the Ethics of Sustainable Immunization Financing Mike McQuestion, PhD MPH Director Sustainable Immunization Financing Ciro de Quadros, MD MPH Executive Vice President Sabin Vaccine Institute

2. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA Ethics  Life-saving immunization is increasingly being provided but for what reasons? –Humanitarianism –To create new markets –Exercise in clientelism –Empire building –Rent-seeking opportunity

3. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA Ethics  The current global immunization equilibrium is fraught with dependencies and ethical dilemmas –Little vaccine production, regulatory technology transfer –GAVI financing uncertainty –Atomized markets, vaccine price inelasticity –Fungibility: Spending other peoples’ money –EPI: $30/child -> Other health needs go unmet

4. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA Ethics  Immunization is among the first public goods any government should provide  Rationales –Economic  Cost-effectiveness, cost-benefit  Profitability, capacity building –Institutional  Cooperation, collective bargaining (eg,Revolving Funds)  Global citizenship

5. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA Ethics  In a counterfactual world –Needed vaccines would be manufactured and put into universal use –Costs would be borne equitably –External partners would not use power relationships to influence country decisions –Publics would actively participate, be part of the decision-making process –Numerous diseases would be eradicated

6. Current equilibrium  New vaccines undersupplied  Programs highly donor dependent  Donor inputs are too far downstream  Weak political support  Rent seeking Higher equilibrium  All effective vaccines are on offer  National institutions own, direct programs  Donor inputs move further upstream  Protective legislation  Pooled procurement CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA

7. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA S USTAINABLE I MMUNIZATION F INANCING P ROGRAM  $9.2 million USD, (2008-2013), funded by Bill & Melinda Gates Foundation  Fifteen pilot countries chosen in consultation with GAVI and partners (WHO, UNICEF, World Bank)  Five full-time Program Officers based in selected countries  Innovation: rather than funding or technical assistance, SIF Program acts as an agent to the principals, facilitating and connecting agendas

8. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Pilot Countries  Senegal, Mali, Cameroon*  Liberia, Sierra Leone*, Nigeria  Madagascar, DR Congo*, Rwanda  Ethiopia, Uganda*, Kenya  Cambodia, Nepal*, Sri Lanka * Resident SIF Program Officer

9. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Measurable Objectives  Increase the proportion and amount of government financing for immunization  Assure that countries find new, diversified, long-term financing for immunization  Document innovative and effective financing strategies and mechanisms

10. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Program theory: Development  Immunization is often the leading edge, the first formal government health program populations receive  Ensuring immunization programs are well managed and that clients are satisfied with services leads to generalized trust in the health system (Gilson 2003)  Generalized trust paves the way for greater participation in other government programs, ie, it has a democratizing effect

11. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Program theory: Institutions  To reach financial sustainability, key national institutions (ministries of health and finance, parliaments) must appropriate their immunization programs by investing more and reducing donor dependency  Appropriation requires organizational innovation- new business practices, a shift in decision-making power- by both national institutions and external donors

12. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Program theory: Institutions  Organizations innovate not to improve effectiveness but to adjust to changing environments in order to legitimize themselves (DiMaggio and Powell 1983; Andrews 2009)

13. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Methods  Sabin changes organizational environments by engaging new stakeholders in immunization programs –Elected officials –Private firms –Community service organizations –Media  Engagement is through periodic parliamentary briefings, peer exchanges and presentations at international meetings  Collective action is supported through inter-country meetings, a quarterly newsletter, an SIF Program blog

14. S USTAINABLE I MMUNIZATION F INANCING P ROGRAM

15. CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA S USTAINABLE I MMUNIZATION F INANCING P ROGRAM Results to date Six pilot countries increased their routine government 2010 EPI budgets (Cambodia, Cameroon, DR Congo, Mali, Nepal, Sierra Leone) Six pilot countries have begun drafting immunization financing legislation (Cameroon, DR Congo, Kenya, Liberia, Mali, Nepal)

16. S USTAINABLE I MMUNIZATION F INANCING P ROGRAM CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA

17. Summary  Universal immunization is both a societal and a global public good, the provision of which strengthens institutions and societies  Pareto optimality: immunization gets its fair budget share, within countries and globally –Market forces alone are insufficient  As with all foreign aid, immunization inputs must meet a set of ethical criteria –Minimize dependencies –Build capacity, transfer technology CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA

18. Thank You for Your Attention! CVEP Symposium: Global Vaccines 202X: Access, Equity, Ethics 2-4 May 2011 The Franklin Institute Science Museum. Philadelphia, USA