Financing ownershipAn international perspective: Immunization and

broader issues in healthMike McQuestion PhDSabin Vaccine InstituteWashington, DC USA

AMASA-10Entebbe, Uganda

10-12 November 2014

$8 $6 $4

$11 $12 $11

$5 $7

$16$21

$17

$35 $34

$21 $19

678

785

646

1116

1274

764 739805

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90

$100

$0

$250

$500

$750

$1,000

$1,250

$1,500

2006n=27

2007n=34

2008n=27

2009n=29

2010n=30

2011n=28

2012n=27

2013n=33

Les d

épen

ses d

u go

uver

nem

ent (

US$

)

Le re

venu

nati

onal

bru

t (RN

B) p

ar h

abita

nt U

S$

Les Dépenses du Gouvernement sur la Vaccination de Routine, sur la Santé, et le Revenu National Brut par Habitant du Pays Africains

dépenses pour la vaccination de routine par nourrissons survivantsdépenses pour la santé par habitantRNB (US$) par habitant

Tous les valeurs sont exprimées en dollars constants et sont pondérées selon la population. Les dépenses publiques pour la vaccination de routine ont été extraites de la base des donnés sur le financement de la Vaccination de l'Organisation Mondiale de la Santé -formulaire conjoint, indicateur 6500. Les dépenses ont été énoncées en dollars américains ou en monnaie locale. Celles qui étaient énoncées en monnaie locale ont été converties en utilisant le taux établi au 30 de Juin de l'année du rapport. La population des nourrissons survivants est prise de la base de données en ligne de la Division des Nations Unies pour la population et a été ajustée en prenant en compte la mortalité infantile. Le revenu national brut par habitant, exprimé par la méthode Atlas en dollars américains provient de la Banque mondiale. Les dépenses de santé des gouvernements ont été obtenues de la base de données des Comptes nationaux de la santé de l’OMS.

Dependency• In the current, dependent equilibrium

Work is done through patron-client relationships, not institutional engagement

Technical decisions such as new vaccine introduction are based on external expertise

External financing dominates and is generally off-budgetGovernments underinvest (substitution effect)Public does not credit government

Change scenario• How can we move from the current dependent

situation, where countries rely on outside funding for immunization, to the goal of sustainable country ownership?• Focus on the key public institutions: MoH, MoF,

parliament, subnational governments• Induce institutional changes through targeted

advocacy efforts

Change scenario• Institutional change (innovation) means developing

new ways of working, ie new best practices• Each institution must innovate

Ministry of health begins to monitor and report program efficiency (ie, expenditures per fully immunized child), allowing a stronger immunization investment case to be made

Change scenarioMinistry of finance considers these efficiency estimates when it recommends and follows the execution of the immunization budget

Subnational governments, elected bodies form realistic immunization budgets, actively follow EPI performance

Parliament scrutinizes the annual health and EPI budgets, follows program execution (technical and budgetary), helps mobilize constituents, approves vaccine legislation

Government, parliament write or update laws

Institutional innovation• Expected results of these innovations• Larger, more efficient immunization budgets• Up-to-date legislation guaranteeing those budgets

(earmarking) and providing for other aspects of vaccination• More domestic stakeholders actively supporting

immunization• Public comes to expect a high-performing national

immunization program provided by their government (public good)

Institutional logics• The state institutions- government and parliament-

must work together• But these institutional actors follow different logics• For those who follow a welfare logic, one might argue

that immunization is a basic human right

Institutional logics• According to the logic of medicine and public health,

no one should be left unvaccinated• Economic logic holds that immunizations are a

justifiable investment provided the data show they are cost effective or cost savings

Institutional logics• According to the logic of public finance, the EPI

program deserves a bigger budget provided there is unmet need, adequate revenues and the program meets three criteria: absorptive capacity, allocative efficiency and value for money

Institutional logics• Political logic maintains that inmunizations are part of the social

contract, something the state should provide as a public good• In addition, to assure a well functioning EPI program is to deserve

more votes!

Institutional innovation

• Innovation comes through advocates (champions) who do the necessary institutional work• They explain their case in rational terms• They use different techniques

Mimicry: associate the change with other, existing practices

Theorize: elaborate causal argumentsEducate: impart the new skills needed (Lawrence and

Suddaby 2006)

Institutional innovation• These are observable processes

Champions and those they engage produce texts- written, spoken, symbolic- for or against the innovation

Connecting these texts, actors construct the innovation, arriving at a common understanding of the meaning of the new idea or practice (Phillips and Malhotra 2008)

Thank you!