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Immunization Financing Options

A Resource for Policymakers

GAVI Financing Task Force

Contents

Key Financing Concepts and Options

Overview and Comparison ofFinancing Options

Domestic Public Finance: General Revenues (Central)

Domestic Public Finance: General Revenues (Subnational)

External Public Finance: Project Grants from Bilateral or Multilateral Agencies

External Public Finance: Debt Relief through HIPC II

External Public Finance: Sector-Wide Approach (SWAp)

External Public Finance: National Budget Support

External Public Finance: Vaccine Fund

Mixed Domestic and External PublicFinance: Development Loans

Domestic Private Finance: User Fees

Domestic Private Finance: Cross-subsidies

Domestic Private Finance: Health Insurance

Financing Instrument: National Trust Funds

Financing Instrument: Revolving Funds(including PAHO and VaccineIndependence Iniative)

Key Concepts: Essential Immunization Services

Key Concepts: Costing of NationalImmunization Programs

Key Concepts: Economics of Vaccine Production

Key Concepts: Tiered Vaccine Pricing

Key Concepts: Information Sources

Acknowledgements: Immunization Financing Options: AResource for Policymakers has been pre-pared principally by Ruth Levine (TheWorld Bank), Sarah England (WorldHealth Organization), and ViolaineMitchell (GAVI Financing Task Force)on behalf of the Financing Task Force ofthe Global Alliance for Vaccines andImmunization (GAVI). This documentand the background papers prepared forthis report have been generously sup-ported through the contributions of theChildren’s Vaccine Program at PATH,United States Agency for InternationalDevelopment through its Partnershipsfor Health Reform (PHR) project, TheWorld Bank, and World Health Organi-zation. The authors are grateful to thenumerous individuals who have pro-vided helpful comments and contribu-tions especially Amie Batson, AlanBrooks, Richard Bumgarner, BrendaCandries, Grace Chee, Brandao Co,Laura Cooley, Sarah Glass, ChristyHanson, Keith Feldon, Pirrko Heinonen,Marianne Hooper, Jim Jones, MiloudKaddar, Daniel Kress, Patience Kuruneri,François Lacapere, Steve Landry, AnnLevin, Xingzhu Liu, Julie Milstien,Osman Mansoor, Germano Mwabu,Prosper Nyandagazi, Aviva Ron, BrynSakagawa, Sally Stevenson, WalterVandersmissen, and Scott Wittet. Thejudgments made herein do not neces-sarily reflect the views of the partners ofthe Global Alliance for Vaccines andImmunization nor The World Bank’sBoard of Executive Directors or thecountries they represent. The manycontributors to this document may notendorse every point, and they bear noresponsibility for any errors that remain.

For additional informationplease contact:

GAVI Secretariatc/o UNICEF, Palais des Nations CH 1211 Geneva 10, Switzerland

Tel: 41.22.909.5019 Fax: [email protected] www.vaccinealliance.org

Immunization Financing Options

An overview of the briefing sheets and an inventory offinancing options and their characteristics.

What are immunization financing options?Immunization Financing Options areshort, user-friendly briefing sheets thatoutline options for financing nationalimmunization services. Principallyintended for policy makers in Ministriesof Health, Finance, and Planning andInvestment, the briefing sheets bringtogether up-to-date knowledge about themajor advantages and drawbacks ofavailable financing options.

The briefing sheets present a workingdefinition of the financing option, asummary of relevant international poli-cies and practices, essential features ofthe financing mechanism, and sources ofadditional information. In severalinstances, the briefing sheets provideinformation about keys to successful useof the funding mechanism. The briefingsheets also introduce key conceptsrelated to the financing of immunizationservices, such as the economics of vac-cine production and pricing.

Why is understanding financingoptions important?Immunization services can realize theirpotential for improving the health ofchildren only with adequate and reliablefunding. Solid financing is one of theseveral elements required to ensurecontinuity in services, and to fundcontinuous increases in coverage, qualityand access to both traditional and newervaccines. It is an essential contributing

factor to an immunization program’sability to achieve current and futuregoals for access, utilization, quality, safe-ty, and equity. Therefore, identifying andchoosing among financing alternatives isa fundamental task of leaders in thehealth sector, and should be fully inte-grated into the planning and manage-ment of immunization services.

Decisions about financing arrange-ments can be complex ones: each sourceof funds (public, private, domestic andexternal), and each financial instrumentthat can be employed to access and usethe funds (such as trust funds andrevolving funds) carries with it a set ofimplications. For example, dependenceon user fees (private, out-of-pocket pay-ments) to finance immunization servicescan burden the poor. And creation oftrust funds, while generating a steadystream of resources that can be ear-marked for immunization, may beadministratively costly under certaincircumstances. Understanding theimplications—and accessing inter-national knowledge about what worksand what doesn’t work—can improvedecision-making, and ultimately benefitimmunization program performance.

What are the main options forfinancing immunization services?As shown in the table on the followingpage, there are four basic sources offinance for immunization (and all other)health services in any given country:

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• domestic public—funds derivedfrom taxation or other sources ofpublic revenues at the central and/orsubnational level, and allocated through a formal budgetary process;this may be current spending, ordomestically or internationally held loans, which imply futurespending;• domestic private—resources fromhouseholds, employers and/or localphilanthropists;• external public—official developmentassistance, typically funds derived fromtaxation in donor countries, allocatedaccording to the policies and practices ofbilateral and multilateral internationalaid agencies; this includes the grant (alsocalled concessionary) portion of devel-opment loans offered at below-commer-cial interest rates; and• external private—resources frominternational philanthropists and/or

commercial enterprises, such as pharma-ceutical manufacturers.

The distinction between public andprivate sources is somewhat artificial. Itis important to note that tax revenues,while collected and administered bypublic agencies, are fundamentally theproduct of individual citizens’ labor andownership of property. And while theVaccine Fund forms part of the land-scape of international public entities, it issupported in large part by private phil-anthropic contributions.

Similarly, the line between internaland external sources of funds sometimesis blurred. In particular, loans from glob-al and regional development banks havea mix of “external” and “domestic” fea-tures: Loans can be conceptualized as“external” because they represent asource of funds outside of the currentnational tax revenues, and are oftenstructured like grants from bilateral and

multilateral aid agencies. In addition,loans to low-income countries that carrybelow-commercial interest rates imply asignificant grant component. At thesame time, development loans can beconceptualized as “domestic” becauseeventually domestic resources are used torepay the capital plus any interest.Therefore, in the briefing sheet on devel-opment loans, they are referred to as“mixed domestic and external.”

In addition to the major sources offinancing, there are financing mecha-nisms or instruments—national trustfunds and revolving funds—that do notinject monies into the immunizationprogram, but rather structure and usethe existing funds in specific ways. Aswith the financing sources, the financingmechanisms have important characteris-tics that determine how well they meetthe needs of a given country and itsimmunization program.

Sources of Financing for Immunization Services

Domestic External

Public • Tax revenues (central or subnational) • Project grants from bilateral or multilateral for current spending agencies

• Tax revenues (central or subnational) for • Grant portion of development loansrepayment of domestically or internationally held debt • Budget support

• Social health insurance (compulsory) • Debt relief proceeds

• Sector-wide approach (SWAps)

Private • User fees • Vaccine Fund

• Cross-subsidies • Project grants from philanthropic institutions

• Health insurance • Contributions (often in-kind) from vaccinemanufacturers

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What are the maincharacteristics of goodimmunization financing?Different countries have different goalsfor their immunization program. Forsome, achieving higher levels of coveragewith traditional vaccines is the highestpriority. For others, which have alreadyachieved high coverage for the basicvaccines, the primary aim may be toimprove quality, enhance program efficiency and/or expand the immu-nization schedule.

Whether an immunization programachieves its goals for population cover-age, quality and access to both tradition-al and newer vaccines depends on manyfactors, ranging from the quality controlin national laboratories to the outreachstrategy to the maintenance of coldchain equipment. Solid financing is onepart of the overall challenge: necessaryfor the rest of the system to work, butnot sufficient to make it work well.

In general, the source of funds and thefinancing mechanisms do not directlydetermine how well the program willperform, but can have a powerful indi-rect effect. For instance, funds from gen-eral tax revenues are not necessarilymore or less likely to lead to high levelsof coverage than are funds from interna-tional development agencies. But if thereis a higher degree of attention to efficientuse of funds for domestic resources thanfor external ones—or vice versa—thenthe choice has important implications.Similarly, the application of user fees tomobilize private resources for immu-nization can have a negative effect onequity and coverage.

The selection among financing optionsshould be made in part on the basis ofan estimate of the volume of resources

required to achieve the immunizationprogram goals of access, utilization,quality, safety and equity. As importantly,however, the choice of financingarrangement should be made with anunderstanding of the specific character-istics of different options.

Immunization program goals are sup-ported by the mobilization of funds in away that (a) does not burden the poor;(b) minimizes administrative costs andpromotes high levels of program effi-ciency; (c) ensures that necessaryresources are available in a timely andreliable manner; (d) engenders accounta-bility in resource use; and (e) encouragesthe highest level of self-sufficiency. Inselecting among the range of financingoptions, decision makers may wish toevaluate how well the options performrelative to several criteria:• Promotes equity—the financingarrangement ensures that, across thesociety, the poor are not disproportion-ately burdened with the responsibilityfor financing immunization services; andthat individuals are not denied access toessential immunization services due toan inability to pay;• Achieves efficiency—the financingarrangement minimizes costs of obtain-ing and accounting for funds and/orstimulates efficient production of immu-nization services;• Provides resources in an adequate,timely and reliable manner—thefinancing arrangement ensures that re-sources are available in the volume and atthe time and place where they are neededto have the greatest health benefits;• Engenders accountability—thefinancing arrangement is compatiblewith procedures and documentation that

allow for transparency in the allocationand use of funds; and• Encourages the highest level of self-sufficiency—the financing arrangementmaterially advances movement toward ashigh a level as possible of financial, tech-nical and logistical self-reliance inobtaining vaccines and related healthproducts and services of assured quality.

In the immunization finance briefingsheets, to the extent possible each fund-ing source and instrument is assessedagainst these characteristics. Plus (+) andminus (-) symbols are used to denotepositive and negative features. In somecases, a combined symbol (+/-) is used toindicate that there are both positive andnegative features to be considered, de-pending on country circumstances. Thenull symbol (o) indicates that the financ-ing arrangement has a neutral effect.

What topics are covered in thebriefing sheets?Financing options presented in color-coded briefing sheets are as follows:

For domestic public financing options:• General revenues (central level)• General revenues (subnational level)

For external financing options:• Project grants from bilateral or mul-tilateral agencies• Debt relief proceeds through HIPC ll• Sector-wide approach (SWAp)• National budget support• Vaccine Fund

For “mixed” external and domesticfinancing options:• Development loans

For domestic private financingoptions:• User fees• Cross-subsidies• Health insurance

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For financing instruments:• National trust funds• Revolving funds (including PAHOand VII)

In addition, supplementary briefingsheets cover the key concepts of:• Essential immunization services• Costing of national immunizationprograms• Economics of vaccine production• Differential pricing• Sources of additional information

How will the ImmunizationFinance Resource Kit briefingsheets be made available?While individual background papers thatform the evidence base of the may bepublished by the commissioning agen-cies, the set of briefing sheets is pub-lished by GAVI as a cohesive entity. Thebriefs will be available in English, French,Spanish, and Russian.

The briefs will be posted on the GlobalAlliance for Vaccines and Immunizationweb site, www.vaccinealliance.org,ultimately as a hypertext document with links among the fact sheets, back-ground papers, and other sources ofinformation on health sector financingand related issues.

We want to hear from you . . . The briefing sheets are intended to beflexible, evolving information resources.They can be read in any order, and willbe updated periodically as new findingsbecome available.

Feedback and suggestions on theImmunization Finance Resource Kit aremost welcome and can be directed to theattention of the Financing Task Force atthe GAVI Secretariat through the webpage (www.vaccinealliance.org) or as follows:

Directly to the WHO or UNICEFoffice, to the attention of the GAVISecretariat in countries with WHO orUNICEF offices, or by post or e-mail tothe GAVI Secretariat:GAVI SecretariatAttn: Financing Task Forcec/o UNICEFPalais des Nations1211 Geneva 10Switzerland Tel: 41.22.909.50.19Fax: 41.22.909.59.31Email: [email protected]




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A comparison of the characteristics of the immunizationfinancing options.

Overview and Comparison of Financing Options

acteristics: promoting equity; achievingefficiency; providing resources in an ade-quate, timely and reliable manner;engendering accountability; and encour-aging the highest level of self-sufficiency.It also provides a guide to the financingoptions that may be most appropriate indifferent country contexts.

The table at the end of this sectionpresents the strengths and weaknesses ofeach financing option, in general terms.Good public policymaking depends on amore in-depth look at the characteristicsof these options within specific settings,but the table provides an initial perspec-tive on options to consider or to rule out.

How do countries differ?The most appropriate package of

financing options will differ dependingon specific country conditions including:• Public health policy context: thepriority placed by the government onchildhood immunization and other pre-ventive actions, relative to pediatric cura-tive care and/or services for adults.• Quality of governance and regulato-ry structure: the degree to which finan-cial management is transparent and rig-orously monitored.• Culture of solidarity: the level of sup-port from the community for an inter-vention like immunization that has socialbenefits, in addition to private ones; andsociety’s willingness to redistributeresources from better-off to poorer com-

No easy choicesEach nation must determine the volumeof resources to devote to its immuniza-tion services—and where to find thoseresources. The amount of resources to beallocated depends on the population sizeand structure, incidence of each vaccine-preventable disease, size of non-immu-nized age cohort, special demographicand geographic features, as well as avail-ability of resources and competing socialpriorities. While complete coverage ofthe at-risk population may be unattain-able, sound public health practice, as wellas fundamental principles of publicfinance, demand that countries strive tomobilize sufficient resources to achieve ahigh level of vaccination with traditionalantigens, and with newer antigens whenand where they are found to be cost-effective.

Determining the source of funding is acomplex exercise in which the advan-tages and disadvantages of all potentialfinancing options are weighed. Everypotential source of financing—from thedonor funds that may have policy condi-tions attached, to the tax revenues thatare never able to stretch to meet allneeds—has benefits and costs. The deci-sion among financing options dependson availability and appropriateness forspecific country conditions.

This overview provides a rapid com-parison of the different financingoptions with respect to the desired char-

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munities. This is reflected partially in theprogressivity of the tax code.• Macroeconomic context: nationalincome level (which affects eligibility forvarious types of external funding), thepotential for economic growth, thedegree of indebtedness, availability offoreign exchange, the stability of the eco-nomic system, and inter-regionalresource inequities.• Relationship with bilateral or multi-lateral donors: the historical and con-temporary nature of the negotiated rela-tionship between national authoritiesand decision-makers in donor agencies

While it is difficult in the extreme toprovide generic recommendations aboutthe “correct” financing mix for a given

country, it is possible to derive some verybroad guidelines.• First, both countries in strong macro-economic positions and those facingsome degree of economic instability havegood options for financing immuniza-tion services, ranging from general rev-enues at the central level (important inall countries), to budget support fromaid agencies, to development loans atcommercial or lower-than-commercialinterest rates. Some collective forms ofprivate financing—for example, healthinsurance—may have some limitedpotential, but point-of-service user feescan be counterproductive for immuniza-tion financing. On the other hand,revolving funds and national trust fundscan all be useful ways of organizing

financing for immunization services innon-emergency settings.• Second, for countries that are econom-ically vulnerable (but not in a state ofeconomic or social emergency), there areimportant additional sources of supportthat can be tapped, such as the proceedsfrom debt relief and resources from theVaccine Fund.• Third, even for countries that are inemergency conditions due to economicand/or social upheaval, there are viableoptions for mobilizing resources to sus-tain the immunization services. Theseinclude project grants from aid agenciesand resources from the Vaccine Fund. Intimes of emergency, development bankssometimes can mobilize assistance,as well.

Characteristics of financing options: A summary

Provides adequate,Financing option Promotes Achieves timely and reliable Engenders Encourages or mechanism equity efficiency resources accountability self-sufficiency

Domestic public

General revenues +/- + -/+ +/- +(central level) depends on requires no allocation is often depends on

tax structure additional lower than program quality of public resources requirements; delays administration

to manage in accessing funds;potential exists for

high levels of funding

Table continues on next page

+ = generally positive effect- = generally negative effecto = no clear positive or negative effect; depends on country conditions

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General revenues - + - +/- +(subnational) depends on tax requires no allocation is often depends on

structure; poorer additional lower than program quality of public subnational units resources requirements; delays administrationare disadvantaged to manage in accessing funds

Social health +/- - + + +insurance depends on may have high (compulsory) solidarity administrative

of system costs

External public

Project grants o - +/- + -requires additional year-to-year

resources allocations can to manage vary greatly

Debt relief proceeds + + + +/- +requires no depends on howadditional procedures are resources established for

to manage tracking

Sector-wide approach + + + + -(SWAps)

Budget support o + + + -/+requires few can contributeadditional to betterresources sectoral

to manage planning


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GAVI/Vaccine Fund o + + + -/+requires few accountability additional based on resources program results

to manage

Mixed external and domestic public

Development loans +/- - + + +(no interest) depends on requires

future tax additionalstructure resources

to manage

Domestic private

User fees - - + - +requires positive, though

additional small, contribution resources to to volume

manage of resources

Cross-subsidies +/- - + - +depends on requires positive, thoughwho pays additional small, contribution

the subsidies resources to volumeto manage of resources

Health insurance - - + o +may have high administrative

costs


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Financing Instruments

National trust funds o - + + +may have high steady availabilityadministrative of funding

costs

Revolving funds o + + + +typically reduces access to foreign

management exchange on a burden reliable basis




Domestic Public Finance: General Revenues (Central)

Using national resources to finance immunization.

What are general revenues atthe central level?They are any funds allocated from gener-al tax or other public revenues at thenational level. The resources may be innational currency and/or in foreignexchange, as is required in manyinstances for the procurement of vac-cines and other supplies obtained on theinternational market. They typically areadministered by a sectoral ministry (e.g.,the central Ministry of Health), whichobtains the funds as an annual transferfrom the general treasury (Ministry ofFinance). Or they may be transferreddirectly to local jurisdictions (provinces,districts) by the Ministry of Finance. Thetransfers may be earmarked for specificprograms, or sent as a block.

National governments raise revenuesthrough a variety of taxes, includingincome, property, value-added and oth-ers. Depending on the specific tax code,the enforcement regime, and taxpayers’patterns of earning and consumption,each type of tax can be progressive orregressive in nature. (A progressive tax isone in which higher income individualspay a larger fraction of their income thanlower income individuals. A regressivetax is one in which higher income indi-viduals pay a smaller fraction of theirincome than higher income individuals.)As noted later, the degree to which thegovernment’s revenue source is progres-sive or regressive is a strong determinant

of whether the use of general revenuesfor immunization services is inherentlyequity-enhancing or not.

What are common internationalpolicies and practices infinancing immunization serviceswith general revenues at the central level?While countries have individual perspec-tives on the relative importance of publicand private financing for immunization,general revenues from central or subna-tional levels are the most commonsource of financing for immunizationservices in industrialized, transition anddeveloping economies. Central-levelfunds are often used for the procurementof vaccines (if this is done with domesticfunds), and may also be used to reduceinequalities in funding across sub-national units, or promote special initia-tives, such as National ImmunizationDays. In some cases, all immunization-related inputs are financed by nationalrevenues, through the central Ministry of Health.

Over the past decade, there has been atrend toward decentralization in thehealth sector (and other sectors), with ashift of both financing and managementresponsibilities from central to subna-tional authorities. As part of this trend,in many countries, funds for many pri-ority health programs are no longeradministered at the central level, but

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rather have been transferred to provin-cial and/or district levels. Experience hasshown that unless immunization isexplicitly protected during this process—through either the earmarking of budg-etary transfers or outcome-related per-formance agreements with subnationalauthorities—funding for immunizationservices loses out to other activities forwhich demand is more active (e.g., cura-tive services).

What are the maincharacteristics of fundingimmunization services withgeneral revenues from thecentral level?• Promoting equity (+/-). The equity-related implications of using general rev-enues to finance immunization dependon the country conditions. To somedegree, whether using general revenuesto finance immunization services is equi-table or not depends on whether the taxcode and its enforcement are progressiveor regressive—and whether fundingimmunization implies an increase in thetax burden, or a reallocation of existingrevenues. If the poor already are dispro-portionately burdened by taxes (i.e., thesituation is regressive), then puttingadditional demands on the tax revenuesdoes not enhance equity. On the otherhand, given that immunization serviceshave a strong potential to provide bene-fits to poor households, paying forimmunization services out of generalrevenues may be an effective way ofincreasing the returns that the poor geton their tax payments. Thus, equity canbe enhanced by a reallocation of existingtax revenues from hospital-based cura-tive services to immunization and otherpreventive services.

Equity is also affected by the pattern oftransfers from the central to subnationalgovernments. If equity-related considera-tions, such as the poverty rate, are used toallocate transfers, then using general rev-enues can substantially enhance equity.• Achieving efficiency (+). While thereis variation across countries, in conceptgovernment funds from the central levelcan be made available to immunizationservices with relatively low administra-tive costs, through routine procedures.No additional resources are required.• Providing adequate, timely and reli-able resources (-/+). In many low-income countries, the central govern-ment does not allocate sufficient fundsto achieve its immunization programgoals, and the funding has been unpre-dictable. In many cases, there is littlecorrespondence between the programrequirements and the amount allocatedin national budgets. As a preventivehealth service for which organizeddemand is relatively weak, immuniza-tion tends to lose out in the politicalprocess of resource allocation. In theabsence of a concerted advocacyeffort—and, in some cases, creation andenforcement of legislation guaranteeingresources for priority health programs—funding levels rise and fall erratically,depending on the political environment.

With respect to timeliness of the avail-ability of central-level funds, the recordis also not good. Typically, there are longdelays between the time resources areallocated by the legislature and the timethey are available to program managers.In addition, in some countries, nationallegislation and regulations regardingprocurement of goods (including vac-cines) imply a cumbersome process,which may reduce the immunization

program’s ability to respond to out-breaks, or sudden increases in demand.

On the other hand, most middle-income countries (e.g., many in LatinAmerica) have been able to mobilize suf-ficient funding from national sources toachieve good results for their basicimmunization programs. Immunizationservices require a small share of the over-all health budget, and full funding can beeasily justified on the basis of cost-bene-fit and cost-effectiveness arguments. Insome middle-income countries, reliabili-ty of funding for immunization serviceshas been assured with national legisla-tion that guarantees baseline allocations.• Engendering accountability (+/-).Again, the specific country conditionsdetermine whether use of general rev-enues helps or hinders the achievementof high levels of accountability. Depend-ing on the sophistication of the publicbudgeting, accounting and auditing prac-tices, central-level public funds can bemonitored through standard procedures,ensuring that they are used for theintended purposes. However, many coun-tries have significant weaknesses in theirpublic administration and accounting.• Encouraging self-sufficiency (+). Acentral-level budget allocation for animmunization program represents thenational government’s commitment toan essential and cost-effective publichealth intervention that has large social(as well as individual) benefits—a coreresponsibility of the state. If politicalcommitment to immunization is fos-tered and continuously reinforcedthrough advocacy and good programperformance, central-level funding is themajor element in movement toward self-sufficiency.

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Domestic Public Finance: General Revenues (Subnational)

Using local government resources to finance immunization.

What are general revenues atthe subnational level?

They are any funds allocated from sub-national budgets. The original source offunds may be from taxes levied at thelocal level or other local sources of rev-enue, and/or from non-earmarked trans-fers (known in some cases as “blockgrants”) from the national treasury.1

Local governments raise revenuesthrough a variety of taxes, includingincome, property, value-added and oth-ers. Depending on specific tax code, theenforcement regime, and taxpayers’ earn-ing and consumption patterns, each typeof tax can be progressive or regressive innature.

What are common internationalpolicies and practices infinancing immunization serviceswith general revenues at thesubnational level?Across countries, there is tremendousvariation in the proportion of totalimmunization program funding comingfrom the subnational level—largely

depending on the extent of political andfiscal decentralization. In some coun-tries, for example, states, provinces,departments and/or municipalities haveprimary (or sole) responsibility for fund-ing immunization services for their resi-dents. In many others, the central gov-ernment provides key inputs, such asvaccines and infrastructure for surveil-lance and service delivery; salaries andother recurrent expenditures fall undersubnational budgets. In still other coun-tries, even those where most health serv-ice are funded by the national govern-ment, central authorities may have fullcontrol (and financing responsibility) forimmunization and other priority publichealth programs.

Even within countries, some regionsmay benefit from substantial transfersfrom the central government, ear-marked for immunization services,while other regions must finance serv-ices independently.

With the trend toward increasingpolitical and fiscal decentralization,immunization programs face the need toclosely examine the financing capacityand decision making process at the sub-national level. Experience has shown thatunless immunization is explicitly pro-tected during the decentralizationprocess—through either the earmarkingof budgetary transfers or outcome-related performance agreements with

1 Readers will note that transfers from the cen-tral level are also discussed in the briefing sheet,“Domestic Public Finance: General Revenues(Central).” Some observers consider these fundsto be central-level funds, while others considerthem to be subnational funds. Thus, they areincluded in both of the briefing sheets.

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subnational authorities—funding forimmunization services loses out to otheractivities for which demand is moreactive (e.g., curative services).

What are the maincharacteristics of fundingimmunization services withgeneral revenues from thesubnational level?• Promoting equity (-). Heavy relianceon subnational revenues to financeimmunization services often has unfa-vorable equity implications. Typically,the subnational entities with the lowestcapacity to finance immunization servic-es also are the ones most in need of goodpreventive services, and where the unitcosts of providing services are the high-est—that is, poorer and more geographi-cally and/or socially marginalizedregions of a country. In addition, taxeslevied at the local level are often are lessprogressive in nature than central-leveltaxes. To counter these tendencies,equity-enhancing policies include redis-tributive transfers from the central level,and reform of local tax laws to increasetheir progressivity.• Achieving efficiency (+). While thereis variation across countries, in conceptgovernment funds from the central levelcan be made available to the immuniza-tion program with relatively low admin-istrative costs, through routine publicadministrative procedures. No additionalresources are required.

• Providing adequate, timely and reli-able resources (-). Subnational entitiescan make an important contribution tofinancing immunization services, butrarely can take on the challenge of fund-ing all inputs. As noted earlier, the localareas where the immunization costs arehighest typically are precisely those withthe most limited ability to generate taxrevenues. In addition, local entities areunable to mobilize the foreign exchangerequired for some inputs, such as thevaccines.

Given the many demands for fundingacross sectors, and within the health sec-tor, services that are deemed a priority atthe national level may not be seen in thesame light by subnational authorities,who are in direct contact with manyconstituencies. Immunization may loseout in the political process of resourceallocation. Thus, in many geographicareas funding for immunization ischronically inadequate to meet programgoals, and may rise and fall erratically,depending on the political environment.




External Public Finance: Project Grants from Bilateral orMultilateral Agencies

Using grant resources to finance immunization.

What is a project grant from abilateral or multilateral agency?A grant is a set of resources—money,technical assistance and/or goods in-kind—typically transferred from indus-trialized nations to poorer ones. There isno expectation that they will be repaid.Grants may come directly from individ-ual countries as part of a bilateral assis-tance package, or may be channelledthrough multilateral agencies of theUnited Nations, or the European Union.The World Bank and regional develop-ment banks also offer limited grantmonies, primarily for pre-investmentstudies and institutional capacity build-ing. The volume and type of grantsoffered is the outcome of a combinationof technical analyses and political choicesby donors and beneficiary countries.

What are common international policies andpractices in using grants forimmunization financing?Grant monies constitute a vital source offunding for immunization services, par-ticularly in low-income countries.Grants typically provide a share (or insome cases all) of the financing foressential vaccines, and may also supportinfrastructure investments, technicalassistance, information systems andother inputs. Grants rarely pay healthworker salaries, although historicallythere has been a practice of “topping

up” low government salaries to encour-age workers to deliver certain services,such as immunization.

What are the maincharacteristics of using grants to finance immunization services?• Promoting equity (o). Grants canenhance global equity by redistributingfunds from richer to poorer countries.However, their effect on equity within acountry depends entirely on program-matic actions, such as whether they areused to improve strategies to deliverservices in hard-to-reach areas.• Achieving efficiency (-). Grant financ-ing of immunization services can haveimportant efficiency-related impacts. Onthe narrow question of the efficiency offinancial management, grant financingmay be associated with a lengthy andbureaucratic process. Administrative,accounting and auditing resources aboveand beyond those required for routinegovernment financing often are requiredby granting agencies.

On the broader question of programefficiency, grant funding can also havenegative consequences. Because grantstend to reflect donor priorities, theysometimes distort program budgetingand activities, leading to inefficiencies. Asa simple example, if grant funding isavailable for four-wheel drive vehiclesbut not motorcycles, total fuel costs may

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end up higher than they otherwisewould be, and/or outreach activities maybe more limited.• Providing adequate, timely and reli-able resources (-/+). The availability ofdevelopment aid is subject to a variety ofpolitical and other forces that may resultin substantial and unpredictableincreases and decreases in funding levelsover a short period of time. There is littlecorrelation between need and the avail-ability of grant funding. Many observersbelieve that the contribution of externaldevelopment assistance to immunizationprograms could be enhanced by multi-year commitments, tied to specific pro-gram goals.

With respect to timeliness, grants canprovide important supplementaryresources that permit program benefitsto be sustained, particularly during peri-ods when there is a shortfall in govern-ment resources due to macroeconomicor other crises.

• Engendering accountability (+).Accounting and oversight proceduresrequired by development agencies canincrease the level of accountability inprocurement and financial management.• Encouraging self-sufficiency (-).Seeing that donors are willing to pay forimmunization services, governments maydevote national resources to other needs.Over the long term, there may be—andin some countries has been—an erosionin the national commitment to immu-nization. In addition, extensive relianceon foreign technical assistance may comeat the price of decreasing domestic tech-nical and managerial capacity.

It is important to note that, in concept,external funds could promote self-suffi-ciency if, for example, they required anincreasing “match” of domestic funds overtime, and/or they financed efficiency-enhancing improvements in organizationand management of the program.




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Using the proceeds from debt relief to finance immunization.

External Public Finance: Debt Relief through HIPC II

hensive and participatory fashion. (TheI-PRSPs are simpler, shorter versions ofPRSPs and can be developed morequickly than PRSPs, allowing debt reliefproceeds to be programmed in theshort-term while the longer PRSP docu-ment is in preparation.)

Countries that qualify for debt reliefunder HIPC II may:• Significantly reduce their long-termdebt service, transitioning from unsus-tainable indebtedness into sustainableindebtedness thereby improving theircredit rating and encouraging greaterforeign investment; and• strengthen development efforts morequickly through an increased allocationof funds to the social sectors.

What are the maincharacteristics of using HIPCfunds for immunization services?• Promoting equity (+). Whether thefunds freed-up through debt relief havean equity-enhancing effect depends en-tirely on how they are used. If used asintended—for investments that alleviatepoverty—HIPC does have the potentialto improve conditions for the poorest ofthe poor.

What is HIPC?The Highly Indebted Poor Countries II(HIPC II)1 is a program of accelerateddebt relief introduced by the Group ofSeven (G7) countries in 1999. Countriescan use HIPC II debt relief proceeds tohelp support and strengthen programsin social sectors, including immuniza-tion services.

What are international policiesand practices related to HIPC?To be eligible for HIPC II debt relief, acountry must: have a low enough percapita income to be eligible for conces-sional/grant support from the Interna-tional Monetary Fund (IMF), WorldBank and regional development banks;face an unsustainable burden of debt;and have a track record of reform andsound policies through IMF- and WorldBank-supported programs.

Under HIPC II, debt relief proceedsmust be used for poverty reduction. Howcountries plan to attack poverty utilizingboth national and external resources isoutlined in a Poverty Reduction StrategyPaper (PRSP) or an interim PovertyReduction Strategy Paper (I-PRSP), bothof which must be produced in a compre-

1 As of October 2001, the following countries are eligible to receive HIPC II support: Angola,Benin, Bolivia, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Comoros,Congo, Cote d’Ivoire, Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Guinea,Guinea-Bissau, Guyana, Honduras, Kenya, Lao PDR, Liberia, Madagascar, Malawi, Mali, Maurita-nia, Mozambique, Myanmar, Nicaragua, Niger, Rwanda, Sao Tome and Principe, Senegal, SierraLeone, Somalia, Sudan, Tanzania, Togo, Uganda, Vietnam, Yemen, and Zambia.

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• Achieving efficiency (+). Debt reliefdoes not imply significant additionaloutlays for administration or manage-ment of funds.• Encouraging self-sufficiency, andproviding adequate, timely and reliableresources (+). The HIPC II debt reliefinitiative provides countries an opportu-nity to increase national financial sup-port for health and immunization pro-grams by reducing the drain of nationalfunds for debt servicing.

It is important to note, however, thatthe actual volume of funds made avail-able for social programs through theHIPC process may in reality be small.This is the case, first, because much ofthe savings accrues over time, ratherthan in terms of current budgets.Second, there are a tremendous numberof competing demands on the resourcesthat are freed up, and if a country cur-rently is in deficit spending, those fundshave already been committed. In addi-tion, although debt relief can cut a coun-try’s external debt by more than 60 per-cent, many countries will continue tohave large outstanding external debt.

While potentially useful, the incre-mental increase in national health budg-ets as a result of debt relief is expected tobe modest. A World Bank analysis on thefinancial impact of the HIPC initiativenoted that average social spending as apercent of GDP is expected to increaseby less than one percentage point inAfrica, from 4.4 to 5.1 percent over theperiod 1999-2003 and by about 3 per-centage points, from 10.8 to 13.5 percentin Latin America. Average social spend-ing as a percent of national revenues isonly expected to increase by less than 5

percentage points in both Africa andLatin America regions.• Engendering accountability (+/-).With respect to the transparency of useof debt relief proceeds, the track recordso far is mixed. Many HIPC countriesare establishing poverty funds, designedto be transparent and accountable mech-anisms to administer funds gainedthrough debt relief efforts. At the sametime, some country experiences indicatethat it has been extremely difficult totrack the funds made available underdebt relief, and there are chronic ques-tions about whether funding for socialprograms has been positively affected.

What are some keys to success for using the HIPCprocess to supportimmunization financing?Countries and development partners canmake a strong case within the I-PRSPs/PRSPs for focusing resources releasedthrough the HIPC process on immuniza-tion. Arguments include the following:• Vaccine-preventable diseases are bothcauses and effects of poverty.• Essential immunizations are highlycost-effective.• Poor children are less likely to haveaccess to high quality curative care sopreventive services are particularlyimportant for this age group.• Immunization costs are a very small share of government and health-sector spending.• Immunizations can help break thecycle of poverty and ill health.

For each program element I-PRSPsand PRSPs require:

• The identification of a developmenttarget and strategy (e.g., increase immu-nization coverage for the poor).• Establishment of a program indicator(e.g., increase immunization coverageusing DTP3 as an indicator).• Choice of an impact indicator (e.g.,reduction of infant mortality rate inthe lowest two income quintiles by agiven percent).

For more information . . . Financial Impact of the HIPC Initiative:First 22 Country Cases, March 2001. TheWorld Bank, Washington, DC.

Fairbank, A., M. Makinen, W. Schottand B. Sakagawa. (2000) Poverty Reduc-tion and Immunizations. Abt AssociatesInc. Bethesda, MD. This document isalso posted on the Global Alliance forVaccines and Immunization web site at:www.vaccinealliance.org

Poverty Reduction Strategy PaperSourcebook—Health, Nutrition and Pop-ulation chapter. The World Bank, Wash-ington DC. Available on-line in English,French, Russian, Spanish and Portugueseat: http://www.worldbank.org/poverty/strategies/sourctoc.htm.

See the HIPC website operated by theWorld Bank, http://www.worldbank.org/hipc/




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External Public Finance: Sector-Wide Approach

Using pooled external support to finance immunization.

What is a “Sector-WideApproach”A sector-wide program of external sup-port, commonly known as a Sector-wideApproach (or by the acronym SWAp), isa relatively new way for donor and lend-ing agencies to organize their support toa developing country’s health sector. Thefundamental idea is that developmentpartners work with the beneficiary gov-ernment to agree upon a comprehensivevision and strategy for the health sectoras a whole, and then provide all externalsupport within that framework—ratherthan as isolated categorical programsdetermined solely by external interestsand priorities.

What are international policies and practices related to SWAps?In concept, a fully evolved SWAp has thefollowing characteristics, among others:external funds are not earmarked; exter-nal financing does not go directly to aproject unit, but rather to an overallbudget; the government sets priorities;and reviews and reporting processes are consolidated.

In many instances, SWAps are associ-ated with sectoral reform processes—that is, the development partners seek towork with the government to define avision and implement a strategy formore efficient and equitable functioningof the sector, rather than maintenanceand expansion of the government’s cur-

rent “way of doing business.” That said,there is not necessarily a one-to-onecorrespondence between a SWAp andsector reform.

There currently are no examples offully-evolved SWAps—i.e., where unear-marked budget support is provided by alldonors, based on an agreed-upon frame-work. However, in several countries (e.g.,Ghana, Bangladesh, Zambia, Tanzaniaand others) there is a range of variants ofthe concept, and popularity of sucharrangements appears to be increasing.

What are the maincharacteristics of using a SWApfor immunization programs?• Promoting equity (+). Grants frombilateral or multilateral agencies, whetherpart of a SWAp or not, can enhanceglobal equity by redistributing funds fromricher to poorer countries. However, theireffect within a country depends on pro-grammatic actions, such as whether theyare used to improve strategies to deliverservices in hard-to-reach areas. The nego-tiations between the funding agencies andthe government, which form the basis fora SWAp, usually include discussions aboutactions to improve targeting of services tothe poor or other equity-enhancingapproaches.• Achieving efficiency (+). Compared totraditional project-specific external fund-ing, SWAps can imply lower transactioncosts to access funding: Once the frame-work and performance targets for a

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SWAp are agreed to, in concept the exter-nal financiers simply provide budget sup-port, which can be used through regularchannels. Few additional administrativeand accounting resources are required.

SWAps also have the potential toenhance program efficiency, if they pro-vide the government with greater flexi-bility in resource allocation than project-specific funding.• Providing adequate, timely and reli-able resources (+). In concept, a SWApfor external grants and loans can makean important contribution to healthsector funding, particularly in the poor-est countries, and therefore can help toensure adequate funding for all priorityprograms. There has been some concernamong the immunization communitythat shifting from a project-specific to aSWAp arrangement might reduce thefunding available for support of immu-nization programs. While it is certainlytrue that earmarking of donor funds—

for example, for vaccines or for coldchain rehabilitation—is anathema toSWAps, allocation of government fundsfor priority public health programs atthe national level is strongly encouragedby the SWAp process: All partners partic-ipate in negotiations about how publicspending patterns can be reoriented toimprove health conditions. Thus, aSWAp can ensure higher levels of fund-ing for immunization.• Engendering accountability (+). ASWAp can be negotiated around healthoutput and/or outcome targets.• Encouraging self-sufficiency (-).Potentially, external funds could promoteself-sufficiency if, for example, theyrequired an increasing “match” ofdomestic funds over time, and/or theyfinanced efficiency-enhancing improve-ments in organization and managementof the program. However, any injectionof external funding runs the high risk ofengendering greater dependence on aid.




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What is national budgetsupport?National budget support is financialinput from external sources (principallybilateral and multilateral donor agen-cies) delivered to the national treasuryor the account of a particular govern-ment ministry.

What are common international policies and practices on budgetsupport for immunization?Typically, funds are provided condi-tional on the creation of a budget linefor particular items, such as vaccines, ordonor consultation on a sector budget.For example, the European Union pro-gram of budget support for Sahelianountries—known as Appui au Renforce-ment de l’Indépendence Vaccinale enAfrique Sahélienne (ARIVAS)—requiresthat participating countries establishbudget lines for vaccines. In most cases,some form of reporting is required,although it is less detailed than for proj-ect grants. In some instances, foreigntechnical assistance in budgeting andfinancial management accompanies thebudget support.

Not all donors have the option ofusing budget support (rather than proj-ect support), although there is a trendamong international agencies toward thisoption, and away from project grants.

What are the maincharacteristics of using budget support to financeimmunization services?• Promoting equity (o). Whethernational budget support has equity-enhancing effects depends on program-matic decisions.• Achieving efficiency (+). In concept,national budget support requires rela-tively few additional resources to managethe funds.• Providing adequate, timely and reli-able resources (+). Budget support cantake years to implement as it oftenrequires the development of trust amongpartners, a structure for consensus build-ing on goals and priorities, and a moni-toring and reporting system. However,once established, national budget sup-port represents an important contribu-tion to ensuring that there are sufficientfinancial resources to achieve programgoals; it implies reliable, multi-year com-mitments by development partners.• Engendering accountability (+). Highlevels of accountability are required tomaintain donor confidence in the systemand to promote efficient and effectiveuse of resources.• Encouraging self-sufficiency (-/+).Whether long-term self-sufficiency isenhanced or hampered by nationalbudget support depends on how it isstructured and managed. On the posi-tive side, budget support is considered

External Public Finance: National Budget Support

Using national budget support from donor agenciesto finance immunization.

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to promote capacity building by puttingthe national government in control ofthe disbursement of funds and support-ing the development of accounting andreporting systems. In concept, underbudget support, donor priorities andproject reporting procedures no longerdominate the time of policy-makers.Governments can therefore concentrateon longer term strategic health policy-making that is incorporated into thebudgetary process of the country. Thefact that resource allocation decisionsare made by the government rather than by donors alone may increase thelikelihood that these allocations will bemaintained after the withdrawal ofexternal assistance.

On the negative side, whenever there is an external source of funding, thenational government may depend onthose external funds for priority pro-grams, and fail to take measures toincrease its own financial contribution.

What are some keys to successof budget support?Budget support works best when the fol-lowing conditions are in place or wherethere is a willingness to put them in place:• A positive policy environment.• A rigorous system of financialaccountability or the means to build one.• Strong program monitoring systemsor the means to build them.• A shared vision of the strategic direc-tion for the health sector.

• A willingness to view the budgetsupport as part of a process of im-proving health sector management and implementation.• A rigorous annual review process thatinvolves the main stakeholders.• Mutual trust, strong government own-ership of the program and agreement onthe “rules of the game.”• Flexibility on the side of donors and awillingness to take the broad view.• Donors’ willingness to deliver contri-butions on time.• Broad participation in planning and design.• An appreciation of the complexitiesand difficulties to be encountered inmoving from a project-based to sector-based program and a plan for dealingwith these challenges.

For more information . . . Foster, M. A. Brown, T. Conway.

(2000) Sector-Wide Approaches for HealthDevelopment. World Health Organiza-tion Strategies for Cooperation and Part-nership, Global Programme on Evidencefor Health Policy. World Health Organi-zation, Geneva, 2000. WHO/GPE/00.1

Kaddar, M, B. Sakagawa. (2001) Analy-sis of International Mechanisms Support-ing Immunization Programs: The Euro-pean Union’s ARIVAS. Abt Associates,Bethesda, MD. For additional information

please contact:



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External Public Finance: Vaccine Fund

Using Vaccine Fund resources to finance immunization.

What is the Vaccine Fund?The Vaccine Fund is a multi-milliondollar trust fund established to supportcountries to strengthen their immuniza-tion services and introduce new andunder-used vaccines. The Fund makes itsawards based on recommendations fromthe Board of the Global Alliance for Vac-cines and Immunization (GAVI). Coun-tries with a GNP per capita equal to orbelow US$1,000 are eligible for support.

The Vaccine Fund was established inJanuary 2000 with an initial grant ofUS$750 million from the Bill andMelinda Gates Foundation. Since thattime, there have been significant contri-butions from many national govern-ments. Total commitments for theVaccine Fund exceed US$1 billion for 2001-2005.

What are common international policies andpractices in using the VaccineFund for the procurement of new and under used vaccines and strengtheningimmunization services? There are three basic conditions for sup-port from the Vaccine Fund. Countriesmust have:• a fully functioning Inter-agencyCoordination Committee (ICC) or equivalent;• an assessment of immunization serv-ices conducted during last three years;

• a multi-year plan for immunizationprogram

The Vaccine Fund currently providessupport from two sub-accounts: immu-nization services, and new and under-used vaccines.

Immunization services sub-account:To access the immunization services sub-account, countries must have:• National DTP3 coverage < 80%• Annual targets for increasing numberof children to receive DTP3• Action plans as part of the multi-yearplan to achieve:

■ safe injections and safe managementof sharps waste■ a reduction of vaccine wastage andimmunization drop-out rates.The Vaccine Fund allocates support

from the immunization sub-accountthrough the awarding of shares. Eachshare conceptually represents the VaccineFund’s contribution toward immunizingone child. The initial share value is set atUS$20. Share values are divided into two parts:• Up-front investment in plans to reachadditional children for the first twoyears. The investment is calculated basedon the number of children the govern-ment plans to reach in the future.• Retrospective reward for additionalchildren having been immunized. Thereward is to be calculated at the end ofeach year based on the number of addi-

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tional children actually immunized withDTP3 by age 12 months during the pre-ceding year.

If countries do not show any increasesin numbers of children immunized aftertwo years, support from the immunizationservices sub-account will be suspendeduntil satisfactory progress is shown.

New and under-used vaccines sub-account:To access the new and under-used vac-cine sub-account for the procurement ofhepatitis b, Haemophilus influenzaetype b, (either as single antigens or incombination with DTwP) and yellowfever, countries must have a:• National DTP3 coverage >50%• Plan for the introduction ofnew vaccines • Action plans as part of the multi-yearplan to achieve:

■ safe injections and safe managementof sharps waste■ a reduction of vaccine wastage andimmunization drop-out rates

MonitoringCountries are expected to submit annualreports to GAVI with a more extensivemid-term review two years from the startof initial disbursement. Overall perform-ance as measured by DTP3 coveragerates at the district level are to be exter-nally verified through a Data QualityAudit (DQA), which was first performedon a pilot basis in 2001. This process willbe the first of its kind to verify achieve-ments in health services performance.

GAVI is providing support tostrengthen the financial managementand institutional capacities within recipi-ent countries, and thereby improve thechances of long-term sustainability. Atthe half-way point in funding, countriesare required to submit a financial sus-tainability plan, specifying how futurefunding requirements will be met. If theprocess of preparing the plan is under-taken as a serious effort to obtain com-mitments from the beneficiary govern-ment, as well as development partners, itcan represent important progress towardsustainability. GAVI also is makingefforts on the vaccine supply side,working with private sector manufac-turers to ensure a reliable supply of bothtraditional and newer products, ataffordable prices.

For more information . . . See the Global Alliance for Vaccines andImmunization website:www.vaccinealliance.org.

See the Vaccine Fund website:www.vaccinefund.org.




What are the majorcharacteristics of using theVaccine Fund for theprocurement of vaccines andsupplies and strengthening ofimmunization services? • Promoting equity (o). Whether use of the Vaccine Fund has equity-enhancing effects depends on program-matic decisions.• Achieving efficiency (+). With respect to efficiency of financial manage-ment, there are no special procedures or costs required to access the VaccineFund resources.

In terms of programmatic efficiency,the use of the Vaccine Fund is linked toUNICEF’s procurement mechanism andfacilitates access to vaccines of assuredquality at the best available price.• Providing adequate, timely and reli-able resources (+). While the process ofsubmitting and obtaining approval forthe application can take several months,support from the Vaccine Fund can bemobilized relatively quickly once a coun-try’s application is approved.• Engendering accountability (+). TheVaccine Fund concentrates on accounta-bility for results, rather than spending.Countries are expected to monitor andshow an increasing number of childrenbeing immunized with DTP3. They arefree to allocate the grant funding as theychoose to support immunization services.• Encouraging self-sufficiency (-/+). Asan external source of funding, there is arisk that use of the Vaccine Fund willundermine efforts to increase nationalfinancial commitments to the immu-nization services, and/or stimulate anexpansion in the program that ultimatelyis unaffordable. However, steps are beingtaken to mediate this risk.

Mixed Domestic and ExternalPublic Finance: Development Loans

Financing immunization with public debt.

What is a development loan?A development loan is money borrowedby a government from a regional devel-opment bank or from the World Bank.The government guarantees the loan andis responsible for repaying it in full, withthe interest rate varying depending onthe country’s economic situation. Loansmay also be referred to as debt financing;in the case of no-interest loans, they arecalled credits.

Loans usually are negotiated withMinistries of Finance, and then used aspart of a funding package for a sectorministry, such as a Ministry of Health.

There are two types of loans:• Loans offered at market or near-market interest rates, such as those fromthe International Bank for Reconstruc-tion and Development (IBRD) of theWorld Bank, the Asian DevelopmentBank and the Inter-American Develop-ment Bank, the African DevelopmentBank, the Asian Development Bank andthe Inter-American Development Bank.Interest-bearing loans are fundamentallytypes of domestic finance.• Highly concessionary loans with onlyan administrative fee, and a below-commercial market (or no) interest ratecharged for use of the funds, and repay-ment periods of up to 40 years. TheInternational Development Association(IDA) of the World Bank, and theregional development banks, providethese interest-free loans, called “soft”loans or credits. Taking into considera-

tion inflation and other factors, thesehighly concessionary loans are estimatedto be approximately 65 percent grant.The remaining 35 percent constitutes the amount which is repaid with domes-tic resources in real (as opposed to nominal) terms.

What are common internationalpolicies and practices in usingdevelopment loans forimmunization service financing?The World Bank and regional develop-ment banks are able to provide loanfinancing in support of immunization.Generally, loans for immunization formpart of a larger health sector loan butthere has been at least one World Bankloan solely for immunization (for polioeradication in India).

The GAVI Board has stated that coun-tries’ willingness to use development bankcredits for immunization may be seen asevidence of countries’ financial and politi-cal commitments to immunization.

IBRD loans typically are taken bymiddle-income countries and have inter-est rates which vary with market condi-tions. IBRD borrowers generally receive a15- to 20-year repayment term with aninitial five-year grace period.

IDA loans are specifically targeted atcountries with per capita incomes lessthan US$885, with exceptions for somesmall island states. Seventy-eight coun-tries currently are eligible for IDA loans.

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What are the maincharacteristics of usingdevelopment loans to financeimmunization services?• Promoting equity (+/-). Whether thereare inherent equity-enhancing character-istics of development loans dependslargely on whether the future tax struc-ture is progressive.• Achieving efficiency (-). With respectto the efficiency of financial manage-ment, accessing funds through loans canimply cumbersome and costly adminis-trative procedures.

In terms of programmatic efficiency—the per child cost of immunization—thesubstitution of loans for grants will leadto a higher cost to the government perfully immunized child, taking into con-sideration the requirement of repaymentplus interest.• Providing adequate, timely and reli-able resources (+). Development loanscan provide accessible resources over arelatively long period (5-8 years), with ahigh degree of certainty regarding thelevel of financing. Development loansalso can provide needed access to foreign exchange.

In some instances, funds from devel-opment loans can be made availablequickly to respond to urgent needs. Thishas happened many times in response tonatural disasters and sudden shortfalls ingovernment outlays for essential services,such as immunization.• Engendering accountability (+).Accounting and oversight proceduresrequired by development banks canincrease the level of accountability inprocurement and funds management.• Encouraging self-sufficiency (+).Loan financing of immunization, in con-trast to grant financing, may be inter-

preted by donors and international agen-cies as evidence of a government’s finan-cial and political commitment to immu-nization as a national priority. Usingdevelopment loans to finance immuniza-tion services represents a national com-mitment to immunization—albeit bycommitting future national financialresources in the form of loan repayment.

In addition, there are ways in whichdevelopment loans stimulate self-sufficiency in the near term. Develop-ment loans typically require some level ofmatching national counterpart; thus,national governments are required todemonstrate their commitment to a pro-gram in a very immediate way. Second,development loans must be repaid, whichimplies a long-term financial commit-ment on the part of the government.

The policy conditions on loan fundscan provide leverage for focusingnational resources on priority programssuch as immunization. Governmentsable to use loans to mobilize additional,sustainable national resources for immu-nization are best situated to use loanfinancing effectively.

What are some keys to success of development loans?Because immunization represents only afraction of health sector costs, a loan forimmunization generally is included as asmall part of a broader loan package. Forthese multipurpose loans, performancecriteria should be structured to preventfunds for immunization being cut off ifoverall health sector performance fails tomeet targets.

All loans have to be repaid. Loansmake sense when a government is notheavily indebted, when there is littledanger of a substantial currency devalua-

tion, when the economy is expected togrow, and when the country can obtain acompetitive interest rate. Most impor-tantly, loans make sense when the valueof the immediate and long-term benefitsto be generated by project activities isgreater than the sum of the loan, feesand interest over time, if any.

Where additional financing is needed,the decision to take a loan should bebased on the benefits associated with theincrease in coverage and/or antigens thatcould be financed; availability of lowercost financing options; strength of thepolicy environment; and capacity of thenational economy to support the debtload when repayment comes due.

For more information . . . The World Bank: In developing coun-tries, contact through your World Bankresident representative or liaison officer,or at the World Bank web site:www.worldbank.org.

Information about the African Devel-opment Bank can be found atwww.afdb.org.

Information about the Asian Develop-ment Bank can be found atwww.adb.org.

Information about the Inter-AmericanDevelopment Bank can be found atwww.iadb.org.

“The Role of Loans in Financing Immu-nization in Developing Countries” byMatthew Hodge, which is posted on theGlobal Alliance for Vaccines and Immu-nization web site:www.vaccinealliance.org.

Assessing Aid, David Dollar ed., (1999)The World Bank, Washington DC.

Domestic Private Finance:User Fees

Recovering costs for immunization.

What are user fees in health?User fees are any official charges to theconsumer applied by the governmenthealth service. Typically, user fees areapplied at the point-of-service, and areintended to generate revenues toimprove public health services. Theymay also be applied to encourage con-sumers to use one type of health serviceinstead of another. For example, user feesmay be charged for primary careobtained in hospitals but not at healthposts, in an effort to direct patientstoward the lower-level facilities whenseeking basic care.

What are common internationalpolicies and practices infinancing immunization services with user fees?Based on research findings showing thatuser fees deter utilisation of preventivehealth services in most settings, the WorldBank, the United Nations and many otheragencies discourage the application ofuser fees for childhood immunization.Major recent statements include:

Global Alliance for Vaccines andImmunization (June 2001), “The GAVIBoard recognizes that countries are explor-ing a variety of mechanisms to fund essen-tial and routine immunization services.User fees have been shown to be a disin-centive to the utilization of preventivehealth services including immunization, inparticular. The GAVI Board therefore

recommends that in the absence of com-pelling country or regional data unequivo-cally documenting their value, user feesshould not be levied in publicly financednational immunization services.”

United Nations Economic Commis-sion for Africa, Addis Ababa Consensuson Principles of Cost sharing in Educa-tion and Health in June 1997 (in collab-oration with UNICEF and the WorldBank) states that “cost sharing in healthshould exempt preventive care, in whichbenefits extend beyond users (e.g. immu-nization) as well as selected primaryhealth services”.

Convention on the Rights of theChild (Article 24) specifies that “StatesParties recognize the right of the child tothe enjoyment of the highest attainablestandard of health and to facilities for thetreatment of illness and rehabilitation ofhealth. States Parties shall strive to ensurethat no child is deprived of his or her rightof access to such health care services.”

A PAHO/Caricom/UNDP projectpolicy round table (May 1999) con-cluded that “user fees have no potential tomake a positive contribution as part of ahealth care financing strategy.” Therelated policy document noted that, inCaribbean countries, user fees haveadded administrative burden while fail-ing to contribute discernibly to revenue.User fees were shown to be a barrier tohealth services for the poor.

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What are the maincharacteristics of fundingimmunization services with user fees?• Promoting equity (-). As a source offinancing for immunization services, theapplication of user fees is inequitable.There is solid evidence to indicate that indeveloping countries user fees discouragethe poor from seeking vaccination forthemselves and their children.• Achieving efficiency (-). Typically,additional administrative costs areincurred to manage a user fee system.Income-based exemption mechanismsare costly.• Providing adequate, timely and reli-able resources (+). User fees can mobi-lize incremental resources for healthservices, and thus can contribute to over-all financial balance. However, user feesgenerally are able to generate only asmall portion of total costs of a healthservice. Thus, the potential benefits ofuser fees for sustainability of the immu-nization services would not offset thenegative effects on equity.• Engendering accountability (-). Thelevel of accountability depends entirelyon the transparency of the collection,aggregation, safeguarding and distribu-

tion of funds. The availability and move-ment of cash often represents a tempta-tion to illicit behavior, so in settingswhere there is inadequate policing a userfee scheme can engender substantialleakage of funds.• Encouraging self-sufficiency (+). Inconcept, user fees can be an importantsource of funding for vaccines that arenot yet on the list of essential immu-nization services that the governmenthas deemed appropriate and necessaryfor all children.

For more information . . .England, S., Kaddar, M. Nigam, A., andPinto, M. (2001). Fact Sheet—User feesfor immunization in developing countries,(WHO/V&B/01.06)

England, S., Kaddar, M. Nigam, A., andPinto, M. (2001). Practice and policies onuser fees for immunization in developingcountries (WHO/V&B/01.07) Depart-ment of Vaccines and Biologicals, WorldHealth Organization, Geneva. This paperis posted on the Global Alliance for Vac-cines and Immunization web site:www.vaccinealliance.org. It is also avail-able on the WHO web site: www.who.int/vaccines. It has been translated intoFrench and Russian.




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Using “extra” revenues from other health servicesto finance immunization.

Domestic Private Finance:Cross-subsidies

What are the maincharacteristics of financingimmunization services through cross-subsidies?• Promoting equity (+/-). The extent towhich cross-subsidies can promote equitydepends entirely on how they are struc-tured, and the consumption patterns ofdifferent income and social groups. If thesource of the subsidy is relatively well-offhouseholds, a cross-subsidy strategy cancontribute to income redistribution—albeit in a very modest way. It is worthremembering, however, that if the extracharge is essentially a tax on the sick—often the poor—cross-subsidies will havea regressive effect.• Achieving efficiency (-). Collecting,safeguarding and distributing revenuescan require considerable administrativeresources, particularly if a means-testedor other exemption mechanism isrequired to ensure that the poor areexcluded from paying fees.• Providing adequate, timely and reli-able resources (+). Cross-subsidizationcan augment limited public resources bymobilizing private funds—without jeop-ardizing utilization of immunizationservices. However, it is important to notethat the potential amounts that can bemobilized through cross-subsidizationare very small. There are only a limited

What are cross-subsidies?A cross-subsidy is a charge for one groupof goods or services above cost, with thesurplus then used to finance revenueshortfalls when other goods or services aresold at prices below-cost or provided free.

For example, charges for some aspectsof curative care, such as sales of somedrugs, might be set high enough to gen-erate revenues to cover some of the costsof providing free immunization. Thisextra charge may be referred to as a sur-charge or tax. The financing source is theprivate individuals who use the higher-priced services.

What are common internationalpolicies and practices infinancing immunization servicesthrough cross-subsidies?The UNICEF-WHO Bamako Initiativeendorses the cross-subsidization ofimmunization services, which are free.The subsidies are derived from user feesfor other health services, particularlydrug charges. This cross-subsidizationcovers only a portion of the cost of run-ning the immunization services. TheBamako Initiative aims to improve serv-ice quality in low-income countriesthrough user fees for curative, but notfor preventive health services.

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number of goods and services producedin the government health system that cangenerate a profit.• Engendering accountability (-). Thelevel of accountability depends entirelyon the transparency of the collection,aggregation, safeguarding and distribu-tion of funds. The availability and move-ment of cash often represents a tempta-tion to illicit behavior, so in settingswhere there is inadequate policing across-subsidization scheme can engendersubstantial leakage of funds.• Encouraging self-sufficiency (+).Cross-subsidization can contribute tonational efforts to finance immunizationservices, although the contribution is amodest one.

What are some keys to successof cross-subsidization schemes?If the government has a desire to redis-tribute income from the rich to the poor,

then goods and services consumed pri-marily by the better-off should be sub-ject to a higher surcharge than others.For example, luxury goods such as a pri-vate hospital room could be subject to asurcharge (see table below).

Surcharges on goods and serviceswhose consumption is more responsiveto price changes should be lower thantaxes on other goods and services.

When banking services are limited,problems with safe-keeping of fees can argue against facility-based revenue collection.

Example of a cross-subsidy:GhanaAs of early 2001, the Ghanaian publichealth service charged user fees. Exemp-tions to user fees are officially providedfor the elderly and the very poor, forprenatal care and for services to childrenunder five years of age. Immunization

services are provided free of charge. Alluser fees remain in the facility wherethey are collected and are fullyaccounted for as “internally generatedfunds”. They are used at the discretion ofthe facility. In some cases, the funds areused to pay for the travel costs of staffinvolved in immunization outreach, orfor fuel and maintenance of vehiclesused to transport vaccines.

For more information . . .Jack, William. (1999). Principles of HealthEconomics for Developing Countries.World Bank Institute, The World Bank,Washington, DC.

Possible sources of cross subsidies for immunization within a health facility

Source Performance

Other drugs and Charging extra for some drugs could induce more rational use, but prescription rates could actually other medical supplies increase if the provider seeks to increase revenues. Administrative costs of collection and safe-keeping

could be high.

Hotel services in These sources probably are well-targeted to the better-off and would require an exemption scheme hospitals (e.g.: meals) for the poor, which could be difficult to administer. This from of cross- subsidization has the same

problems of administration as other fees.

Priority treatment Charging higher prices to individuals who see doctors earlier or who see better doctors may leave thepoor without urgently needed care, and could discourage use of curative care as well as immuniza-tions. However, charging for non-emergency access to tertiary care without referral from a primaryhealth care provider is an option.

Non-medical goods Some hospitals and health centers have financial interests in other commercial activities. This tends todivert scarce administrative resources away from the delivery of care, and reduces the transparency offinancial operations.

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Domestic Private Finance: Health Insurance

Health insurance coverage for immunization services.

What is health insurance?A working definition of health insuranceis: “A group of persons contributingfunds to a common pool, usually held bya third party. These funds are then usedto pay for part or all of the costs of adefined set of health services for the mem-bers of the pool. This third party caneither be a governmental social security,a public insurance fund pool, or a pri-vate insurance fund pool” (adopted fromChawla and Berman, 1996).

What are international policiesand practices related to healthinsurance financing ofimmunization services?Insurance is not an obvious choice forfinancing immunization services becauseof the nature of vaccination itself:required at a predictable time, by all chil-dren, and available at low cost. Insuranceis most useful for financing health serv-ices that are rarely required within apopulation, and are so costly that theyexceed a household’s ability to pay out-of-pocket. Small periodic payments byall the members of an insured groupprovide the financing for specific indi-viduals when they require costly services.

Insurance also is not an obviouschoice for the populations of greatestinterest to those wishing to extend

immunization coverage. An insuranceprogram generally requires relativelysophisticated administrative andaccounting systems, as well as the abilityto collect premiums, such as throughformal sector wages. This reduces theirutility in many of the lowest incomecountries, and for populations outside ofthe formal labor market.

There is little evidence that commercialhealth insurance provides significantlevels of financing for immunization serv-ices, particularly in low-income develop-ing countries where the insurance markettends to be very small and the package ofbenefits is limited.

On the other hand, experiences fromthe middle-income countries of Romania,Bulgaria, Turkey and the Philippines sug-gest that social health insurance—a gov-ernment-run mechanism to pool contri-butions from the whole population tomeet the costs of defined health serv-ices—can be used to finance immuniza-tion services, as part of a larger package ofbenefits. For example, in Bulgaria (as wellas some other countries), vaccines areprocured directly by the Ministry ofHealth, but the general practitioners pro-viding vaccination services are compen-sated through contracts with the NationalHealth Insurance Fund.

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What are the maincharacteristics of using health insurance to financeimmunization services?• Promoting Equity (-). If there is uni-versal coverage of a social insuranceprogram, all segments of the populationmay benefit from essential immunizationservices. However, if there is partialcoverage concentrated in the formalsector—a more common scenario—informal sector, rural poor may beexcluded from coverage.• Achieving Efficiency (-). The costs ofraising funds through health insurancecan vary with the method chosen to gen-erate the income. Mandated social healthinsurance can have relatively low admin-istrative costs, compared to privateinsurance arrangements. However, in all

cases insurance implies administrativecosts that are additional to those associ-ated with tax-based financing.• Providing Adequate, Timely andReliable Resources (+). Potentially, awell-run insurance program can providea steady flow of funds to compensateservice providers.• Engendering Accountability (o). Iffinancing of immunization services isdispersed over multiple insurers, keepingtrack of expenditures and financingsources can be challenging.• Encouraging Self-sufficiency (-). Tothe extent that private funds are mobi-lized for an insurance program thatincludes immunization in the benefitpackage, the goal of self-sufficiency canbe advanced. However, for the reasonsstated above and others, it is unlikely

that insurance coverage can play a majorrole in immunization service financing.

For more information . . . “The Role of Health Insurance andCommunity Financing in FundingImmunization in Developing Countries,”by Afsar Akal and Roy Harvey, June2001. This background paper was pre-pared for the GAVI Financing Task Forceand is available on the Global Alliancefor Vaccines and Immunization website:www.vaccinealliance.org.

Community Financing as a Special Type of Insurance

Community financing is a special form of social health insurance in which adefined community group cooperates to raise funds with which to financedefined health services for some or all members of the community. Commu-nity financing can sometimes involve the provision of in-kind services bymembers of the community to the provision of services. Community financ-ing schemes usually focus on primary care, particularly drugs, but may alsoinclude referral services and often have a broad community development ori-entation. Commonly, community financing is based on some type of tradi-tional self-help arrangements, and is part of a broad development initiative,often fostered by a non-governmental organization. Examples of communityfinancing schemes can be found in Guinea-Bissau, Indonesia, Taiwan, VietNam and Thailand, among other places.

Community financing arrangements are so setting-specific that it is impossi-ble to arrive at generic advice regarding their use. As a general rule, however,they operate at a relatively small scale, and often do best if they develop out ofexisting grassroots community efforts, rather than being fostered through publicsector and/or donor action. Experiences in attempting to transfer communityfinancing models from one cultural setting to another have rarely succeeded.




Financing Instrument: National Trust Funds

Placing funds for immunization in trust funds.

What are national trust funds?National trust funds are funds set aside togenerate income for a particular purpose,with specific rules about how the pro-ceeds can be used. They are flexible finan-cial tools in which a relatively large sum isprovided, under a specific legal arrange-ment, and the capital and/or interest isused over time. Depending on the capitalbase, a trust fund can provide a reliableincome stream, grants, short-term credit,loan guarantees and/or foreign exchange.The original capital can come fromdomestic and/or external sources.

Trust funds can be organized as foun-dations, funds-in-trust, charities, cooper-atives, social enterprise funds, creditunions or non-profit organizations.

A trust fund must be legally incorpo-rated and have a capital base, statutesand articles of constitution that stipulatepurpose and beneficiaries as well as gov-erning, operating and controlling organs.It must have procedures for planningand outside supervision.

What are common internationalpolicies and practices in usingnational trust funds forimmunization service financing?Trust funds are emerging as promisingfinancial instruments for funding immu-nization services because they have thepotential to “protect” resources over a longperiod, but experience to date is limited.

When trust funds are held by theWorld Bank or a UN agency as trustee,

they are not subject to taxation. In manycountries, contributions to charitabletrust funds benefit from tax relief. Invest-ment proceeds are generally tax exempt.

What are the maincharacteristics of using nationaltrust funds to financeimmunization services?• Promoting equity (o). Whether nationaltrust funds have equity-enhancing effectsdepends on programmatic decisions.• Achieving efficiency (-). Nationaltrust funds require administrativeresources. However, countries with ini-tially low levels of management andoperational capacities are suitable candi-dates for trust funds that pool multipledonor contributions and thus reduce theneed for countries to conform to eachseparate donor’s rules and procedures. Inthis sense, trust funds are consistent withsector-wide approaches to health finance(SWAps), and with the reduction inadministrative costs.• Providing adequate, timely and reli-able resources (+). If capitalized at arelatively high level, trust funds canmake an important contribution to thefinancing of an immunization programover the long-term. A trust fund canensure significant resources will be avail-able on a steady basis. In addition, trustfunds can be structured to have somedegree of flexibility to respond to urgentresource requirements.

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• Engendering accountability (+). Asautonomous bodies, trust funds canoperate in a businesslike fashion withinthe national legal and regulatory system.• Encouraging self-sufficiency (+). Thelegal status and financial autonomy oftrust funds can shield program fundingfrom economic and political volatility,which is not the case with some forms oftraditional project finance. Trust fundscan expand and leverage additionalfunds as the capacity to absorb fundsgrows. In addition, trust funds can act tohold funds while absorption capacity isdeveloped or to gather funds togetherfrom a variety of sources for a commongoal. For example, they can be used tochannel debt relief funds. Finally, off-shore investment of the capital can lessenforeign exchange constraints.

The value of an extended cash flowmust be weighed against the opportunitycost of not spending the funds immedi-ately to satisfy urgent needs. Tying upcapital makes the most sense when capi-tal is available suddenly (due to debtrelief or a gift) and absorption capacity islow. Investing capital to provide an in-come stream is appropriate only if somedifficult conditions are met, including:

■ The resource requirements can bereasonably well estimated over themedium term: the demographicdemand for the services can be clearlyforecast, and the services contemplatedcan be accurately costed.■ The needed revenue stream can beachieved through investment of capitalwithin an acceptable range of risk.■ There is enough leeway to build upreserves to protect the fund’s operationalpurchasing power against the effects ofinflation and currency fluctuations.

■ Additional domestic sources offinance can be tapped to cover admin-istrative costs.

What are some keys to successof national trust funds?The mission of the trust fund, the avail-able capital and donor preferences willdetermine investment and cost recoverystrategies. A key document to be pro-duced to create common ground amongthe potential partners to the trust fund isthe Memorandum of Understanding(MoU). It spells out the responsibilities,rights and obligations of the foundingpartners and contributors, the goals to beattained, organs to be created, operationsenvisaged, reporting required, and whenand how result are to be reviewed basedon performance and achievement criteria.

Establishing the governing board andselecting its members are decisive stepsfor the trust fund’s future. The direc-tors/trustees are charged with theresponsibility of bringing the Statute orCharter and the MoU to life. Their roleis to establish the fund’s strategy, adoptits business plan, select the managementfor operations, and as the case may be,the asset/investment managers.

Three tiers of competence are neededin the trust fund architecture:• Technical operations are in the handsof those who are competent in that area.• Policy and financial management isprovided by the board of directors/trustees, including planning and evaluat-ing activities, reporting, control, supervi-sion and guidance.• Asset management and investment areusually handled by professional invest-ment managers, whose job it is to pro-tect, place and increase the capital, withmaximum return at desired levels of risk.

For additional information . . . Becher, Ernst. (2001). National TrustFunds to Finance Immunization in Devel-oping Countries. This paper is posted onthe Global Alliance for Vaccines andImmunization website:www.vaccinealliance.org.

“Experience with Conservation TrustFunds,” Evaluation Report #1-99, GlobalEnvironment Facility, Washington DC.




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Using revolving funds for procurement of key inputs.

Financing Instrument: Revolving Funds

try-specific lines of credit for vaccinepurchase through UNICEF that formpart of the Vaccine IndependenceInitiative (VII).

What are the maincharacteristics of usingrevolving funds for procurementof vaccines and supplies?• Promoting equity (o). There are noclear equity-related effects of usingrevolving funds.• Achieving efficiency (+). The use ofrevolving funds can be linked to UnitedNations bulk procurement mechanismsto facilitate access to vaccines of assuredquality at the best available price • Providing adequate, timely and reli-able Resources (+). The short-termcredit for vaccine purchase providedunder revolving funds can bridge thegaps among the vaccine procurementschedule, government budget disburse-ments and the release of donor funds.• Engendering accountability (+). Thestandard procedures for procurementand disbursement used by many interna-tional revolving funds promote trans-parency in the use of funds for procure-ment of vaccines.• Encouraging self-sufficiency (+). Ifrevolving funds permit repayment of thefunds’ foreign exchange outlays in localcurrency, they can alleviate the difficultythat many governments have securing

What is a revolving fund?A revolving fund is a pool of capital—from domestic and/or external sources—that is used to provide short-termcredit—and is then replenished in full bythe countries or agencies that have usedthe funds. Such funds can be linked witha currency exchange mechanism, a pro-curement mechanism, technical assis-tance, and/or financial support tonational budgets. Revolving funds alsocan provide loan guarantees, which canreduce the cost of borrowing. Revolvingfunds can charge interest or an adminis-trative fee, or they can provide free credit.

What are common internationalpolicies and practices in using revolving funds for the procurement of vaccinesand supplies?Many international agencies, govern-ments and non-governmental organiza-tions have launched revolving funds forhealth supplies. These include the WorldHealth Organization and its regionaloffices, UNICEF, Médecins Sans Fron-tières, the International Federation of theRed Cross, and the European Union.

Current revolving funds for immuni-zation finance include the InternationalCoordinating Group for EpidemicMeningitis Control Revolving Fund, thePan American Health Organization(PAHO) Revolving Fund, and the coun-

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sufficient amounts of convertible cur-rency for imported vaccines, syringesand waste disposal boxes.

What are some keys to successof revolving funds?A revolving fund should respond to aclearly defined need, which will deter-mine the fund mission, structure andfunctions. Revolving funds can be simplelines of credit with few conditions, pro-viding a purely financial service. How-ever, they can also be elements of a morecomplex inter-connected system of tech-nical assistance for procurement, immu-nization service improvement andexpansion, and tiered pricing.

The mission of the fund will deter-mine what the trade-off should bebetween simplicity on the one hand, andcomplexity on the other. A funddesigned to provide incentives forimproved immunization service per-formance at the lowest feasible cost willinvolve considerably more complexitythan a fund intended simply to provideshort-term credit for vaccine purchase.

Example of revolving funds:PAHO and VII

The PAHO Revolving Fund is part ofa system for immunization expansionand improvement in the Americas.When countries can justify the integra-tion of new vaccines into their programson epidemiological and technicalgrounds, they become candidates to usethe PAHO revolving fund for the pur-chase of these vaccines.

To be eligible for the PAHO RevolvingFund, countries must have:• a national budget line for the purchaseof vaccines and syringes

• a five-year plan for the immunizationsystem that conforms to the general poli-cies of Expanded Programme of Immu-nization in the Americas,• a national program manager withsufficient authority to implement the program.

The Fund obtains low prices for vac-cines through bulk purchasing andmarket intelligence. Payment for the vac-cines by governments can be made inlocal currencies within 60 days of theinvoice. PAHO charges a 3 percentadministrative fee that covers fundexpansion, losses due to fluctuations incurrency exchanges, and overhead.Except in the case of a national disaster, amissed payment results in the suspensionof purchasing privileges. PAHO alsoworks with donors to find financial sup-port for countries which cannot cover thewhole cost of a new vaccine introduction.

The results have been the growth ofthe fund from US$1 million in 1979 toUS$145 million in 1999, and substan-tially improved access to new and under-used vaccines at lower prices. Thenational plans have provided a means offorecasting vaccine demand. The fundalso functions to re-route vaccine deliv-eries in the case of emergency outbreaks.

Success factors include a learningorganization and institutional memorythat has allowed the evolution of policiesand implementation over a 20-yearperiod; intense market surveillance andintelligence; ease of communicationamong partners, most of whom speakSpanish and Portuguese; an excellenttechnical advisory committee that istrusted and respected by the client coun-tries and donors; transparency in deter-mining country eligibility through a

process that encourages good planningand management at country level; andlong staffing continuity at PAHO.

The Vaccine Independence Initiative(VII), launched by WHO and UNICEF in1991 with financing from several bilateralagencies, provides countries with a lim-ited line of credit for vaccine purchaseusing local or hard currency through theUNICEF procurement system. It is a spe-cial type of revolving fund, and since1999 has been a guarantee fund.

Participating countries must establisha national budget line for vaccines andhave a national immunization plan sothat vaccine needs can be projected.They must commit to raising the pro-portion of vaccine purchase costs thatare paid through the national budget.

VII’s purpose is to increase the self-reliance of countries in financing theirimmunization services and to ensure asustainable supply of vaccines in thosecountries. The intent is to transfer theresponsibility for vaccine finance fromexternal donors to government budgets inthe context of decreasing donor support.

WHO and UNICEF promote self-suf-ficiency in financing of vaccine pur-chases. The VII provides participatinglow- or middle-income countries with aceiling line of credit for the purchase ofvaccines and related materials throughthe UNICEF procurement system. Coun-tries can pay for vaccines using hard orlocal currency. Lines of credit arefinanced by donors and are capitalized atover US$9.1 million. There are plans toincrease the capitalization by anotherUS$10 million. UNICEF charges a 6 per-cent administration fee for vaccines pro-cured through its system and an 8 per-cent administration fee for

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vaccine-related supplies. Low-incomecountries have been assisted in meetingVII criteria by the support of financialcontributions to their national budgetsby donors.

Local currency is exchanged usingconvertible currency derived from theUNICEF program budget. UNICEFcountry programs typically spend in-country in local currency, but they arefinanced in convertible currency, so theyare a source of foreign exchange. Coun-tries that do not have a UNICEF pro-gram must pay in convertible currency.In some cases, the UNDP or other UNcountry program budgets can be usedfor currency exchange.

Countries have 45 to 60 days to payfor vaccines (including freight) they havereceived. Lines of credit and spendinglimits are specific to each participatingcountry, and dependent to some extenton the local country office’s capacity toabsorb local currency. There are increas-ing possibilities to purchase new andadditional vaccines through the VII.

To qualify for the VII, countries mustestablish a national budget line for vac-cines and related consumables, and musthave a national immunization plan toproject vaccine needs. They must committo raising the proportion of vaccine pur-chase costs that are paid through thenational budget.

Since 1996, more than 30 countrieshave used the VII, although not all haveceilings in operation. Twelve of thesecountries pay for 100 percent of vaccinepurchase through their national budget.

The European Union program ofbudget support for Sahelian countriesparticipating in the VII—known asAppui au Renforcement de l’IndépendenceVaccinale en Afrique Sahélienne(ARIVAS)—involved eight countries ini-tially. All of these have set up budgetlines for vaccines. Six have increased thevaccine budget over the first two years ofthe initiative.

For more information . . .England, S. (1999). Options for a GlobalFund for New Vaccines. Department ofVaccines and Other Biologicals, WorldHealth Organization, Geneva.WHO/V&B/99.13

For information on the PAHO Revolv-ing Fund, please contact PAHO Divisionof Vaccines and Immunization throughtheir web site, www.paho.org, or throughWHO representative offices in develop-ing countries.

For information on the Vaccine Inde-pendence Initiative, please contactUNICEF through your country office orat UNICEF Headquarters in New Yorkthrough their web site: www.unicef.org.




Key Concepts: Essential Immunization Services

Defining basic immunication.

What are essentialimmunization services?Essential immunization services can bedefined as the safe and timely delivery ofeffective vaccines of public health impor-tance and assured quality to those whoneed them. Essential vaccines have beenidentified by the World Health Organiza-tion, but vary across regions and coun-tries depending on disease burden.

What are international policiesand practices related todefining essential vaccines?While national governments determinethe list of vaccines deemed essential fortheir immunization services, WHO pro-vides a Model List of Essential Drugs as aguideline for policy-makers at thenational level. This list is based on dis-ease prevalence, product efficacy, prod-uct safety and availability.

The WHO Model List of EssentialDrugs, 11th edition (November, 1999)lists the following vaccines for universal

immunization: BCG, diphtheria, hepa-titis B, measles, pertussis, oral polio-myelitis and tetanus.

For specific groups of individuals,such as inhabitants of areas with highdisease burden, the following additionalvaccines are deemed essential on themodel list: Influenza, meningitis,poliomyelitis injection, rabies, rubella,typhoid and yellow fever.1

Although it is not yet on the modellist, WHO encourages the introductionof Haemophilus influenzae type b vac-cine where there is high disease burden.2

Technical assistance is available for coun-tries that wish to determine the burdenof disease of Haemophilus influenzaetype b in their population.

For more information . . . For information on which vaccinesWHO recommends as essential for aspecific country, please contact theDepartment of Vaccines and Biologicalsat WHO, Geneva.

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1 Countries which should incorporate vaccination against yellow fever into the national immuniza-tion programme are identified in the WHO publication by J. Vainio and F. Cutts, Yellow Fever, WHOGeneva, 1998. WHO/EPI/GEN/98.11 distributed by the Department of Vaccines and Biologicals,World Health Organization, Geneva. 34 African countries are at high risk and should consideryellow fever vaccine as essential. Medium risk countries may also consider the vaccine essential.

2 The WHO position paper on Haemophilus influenzae type b (Hib) conjugate vaccines. WeeklyEpidemiological Record, Vol. 73, No. 10, pp. 64-68. 6 March 1998. World Health Organization,

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Key Concepts: Costing ofNational Immunization Programs

Measuring the costs of providing immunization.

What is costing?Costs are defined as the value of theresources used to produce or provide agood or service. “Cost” is different from“price” in that price is the amountcharged to consumers, usually set by theproducer of a good, and it may vary fromthe actual cost of production of the good.

Costing is the process of identifyingand measuring the costs of provision ofimmunization services. Costing is differ-ent than expenditure analysis, whichcompiles information on how much wasspent on a given set of activities over aspecific time period—for example,immunization program-specific publicexpenditures during the past year. Acosting analysis differs from an expendi-ture analysis in that it estimates theactual value of resources used. The quan-tity of resources used for the good orservice is estimated and its value is calcu-lated. For example, for vaccines, theamount of vials opened to vaccinate agiven population of children is esti-mated, taking into account actual cover-age and wastage levels. This amount ismore precise in estimating the value ofresources used than is the amount spenton vaccines in that year.

Why is costing important forimmunization programs?

Costing analyses provide useful infor-mation about actual resource needs orinputs required to provide a service. Fur-thermore, costing analyses can providein-depth information on the efficiencyand effectiveness of the use of theseresources, as well as estimate the value ofadditional efforts needed, often in termsof staff labor and inputs.

Costing analyses are useful tools whenassessing financing options for nationalimmunization programs. They providecomprehensive information for assessingresource requirements for immunizationactivities, estimating the share of eachcomponent, and identifying potentialcost-saving measures. They also allowprogram managers to evaluate differentoptions for program improvements byestimating the resource requirements foreach. The additional costs of improve-ments, such as the introduction of newvaccines, are an important considerationin deciding whether or not to proceedwith their use.

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What types of costing analysesare useful, and for what?Total costing involves examining allcosts, no matter who bears the cost.These costs include all kinds of costs—fixed and variable, direct and indirect,and investment and recurrent. Theseinclude not only the costs of operatingthe program on a daily basis, but also thecosts of setting up the program orinvestment costs. A total costing analysisprovides a picture of the magnitude ofthe total cost of a program and howmuch is being spent on each component.This information is useful for planningand, together with information onsources of financing, can be used to eval-uate the roles of the government, donorsand the private sector in financing theprogram. Gaps in funding for the pro-gram can be estimated with this infor-mation as well. It can also be used todetermine what percent of the programis being spent on routine immunizationversus other types of service delivery.

Typically, total costs are used as thebasis for cost-effectiveness analysis, inwhich a ratio is created to relate the netcosts of delivering a particular service(such as immunization) to the effects(such as the years of life gained as a resultof the intervention). When such ratiosare available for a variety of interventionsthat compete for resources, the informa-tion can help health planners and policy-makers determine how to allocateresources to achieve the greatest positiveimpact.

Incremental costing is the assessmentof the cost of adding an activity to a pro-

gram. This analysis provides informationon the extra costs of changing programactivities or adding additional activitiesto existing ones. Program managers maydo incremental costing to make decisionsabout the benefits and costs of undertak-ing additional activities, such as intro-ducing auto-destruct syringes or intro-ducing Hepatitis B vaccine to the existingprogram. This cost information can beused to make informed decisions aboutfuture costs to the program as a whole.

Calculation of average incrementalcosts also is useful when comparing pro-gram options. That is, a program man-ager may want to compare the incremen-tal cost of introducing auto-destructsyringes or a new vaccine at differentlevels of coverage. In making these esti-mates, a program manager can anticipatesome of the additional costs that could beincurred in coverage changes. It also ispossible that the average incremental costwill decrease if such factors as vaccinewastage decline as coverage increases.

Marginal costing examines the addi-tional cost incurred for the production ofone additional unit of output. For exam-ple, the cost of increasing immunizationcoverage by one percentage point can beestimated. This information informs pro-gram managers or policymakers of howmuch it will cost to reach a goal ofincreasing coverage or reaching morechildren in harder-to-reach areas. In addi-tion, it will provide information onwhether costs will increase, stay the same,or decrease as coverage increases. Thisrelationship can change over time becausemarginal costs may decline as more

immunization services are provided, andthen increase as more immunizations areprovided in hard-to-reach areas.

Why are different definitionsused for total costs?Total costs include the proportion ofdepreciated capital costs—health facilities,vehicles, equipment, etc.—that are esti-mated to be used for immunization serv-ices, as well as the estimated cost of healthpersonnel time used to provide immu-nization services. In a complete costingstudy, other types of costs are included aswell, such as in-kind contributions.

Total costs are useful to calculate forevaluating the full costs of a programand to estimate the cost per dose and thecost per fully immunized child. Theinformation can be helpful when makingcomparisons of costs of different servicesand trends in program costs over time.

Program-specific costs of the immu-nization program include only the coststhat are incurred specifically for the deliv-ery of immunization services, over andabove the costs shared with other healthactivities, and regardless of who pays forthem. These include: all recurrent variablecosts required to provide immunizationservices, such as vaccines, syringes, needlesand other vaccine costs; and IEC/socialmobilization costs that are related to theimmunization program; contributionsfrom non-health sectors for the NationalImmunization Days; as well as the cost ofimmunization-related equipment (i.e.,cold chain and sterilization equipment).The calculation of this type of total costs isuseful for two reasons: (1) it includes costs

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specific to the program and leaves outcosts that would probably be paid for inany case because they are shared, e.g., per-sonnel time; and (2) it does not necessitatethe calculation of shared costs, which aremore difficult to calculate and dependgreatly on the country-specific personnelarrangements (making international com-parisons more complicated). This type ofcosting is a measure that can be calculatedwithout too much difficulty and could beconducted on an annual basis.

Recurrent, variable, non-personnelcosts are the costs that the Ministry ofHealth (MOH) must mobilize each yearfor the national immunization pro-gram—either from its own budget orfrom donors. These costs include: vac-cines, syringes and other supplies, andother recurrent costs, such as mainte-nance, transportation costs incurred bythe MOH, IEC, and short-term training.This set of costs is useful if calculatingthe base costs when making cost projec-tions for the program.

For more information . . . “Costing of National Immunization Pro-grams: The Whys and Whens,” by AnnLevin and Janet Edmond, August 2001.Posted on the Global Alliance for Vac-cines and Immunization web site:www.vaccinalliance.org.




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Key Concepts: Economics of Vaccine Production

Understanding vaccine prices.

Why are there so few vaccinemanufacturers?Vaccine production involves high invest-ment costs for research and development,and for production facilities. It alsorequires significant know-how. Know-how is difficult to acquire and so technol-ogy transfer requires a strong cooperativerelationship between the partners. All ofthese factors create barriers of entry intovaccine production. As a result of thesehigh barriers to entry, there are relativelyfew vaccine producers, compared withproducers of other classes of pharmaceu-ticals. In addition, the world’s vaccinemarket is very small—less than 2 percentof the pharmaceutical market—attractingfew suppliers.

Why have prices for traditionalvaccines gone down over time?Vaccine production costs have a signifi-cant fixed cost component, reaching upto 90 percent of total costs. These costsinclude research and development(R&D), quality control and qualityassurance, selling and distribution over-head, and the construction and mainte-nance of production facilities.

Vaccine production costs per unit canbe reduced significantly through gains inproductivity (the “learning curve”) andthrough economies of scale. Because ofthe high fixed cost element, the cost of

production per dose decreases withincreasing batch size.

The traditional six vaccines of theExpanded Programme on Immunization(EPI), measles, diphtheria, pertussis,tetanus, oral polio and BCG, are matureproducts. Because the fixed costs of pro-duction of these vaccines have been cov-ered long ago, and because their produc-tion costs have been lowered due to thelearning curve and economies of scale,their prices are relatively low.

How did developing countriesbenefit in the past?In the past, high- and middle-incomecountries have paid the initially higherprice of vaccines while the fixed costswere paid off. Low income countrieshave adopted the vaccines once the pricecame down following this paying off offixed costs such as R&D, the entrance ofcompetitors into the market, the reduc-tion in cost of production that resultsfrom learning, and economies of scalefollowing widespread adoption of thevaccine into national programs.

Historically, there has been excess pro-duction capacity of these vaccines as newproducers have entered the market, thussales to developing countries at lowprices covered the variable costs of pro-ducing extra doses of vaccine, and didnot require additional capacity.

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What will the future bring fortraditional vaccines?Excess capacity is disappearing as manu-facturers reallocate their production capac-ity to vaccines with higher added value.Therefore, we can expect the price of vac-cines from traditional manufacturers to goup. However, manufacturers from develop-ing and emerging economies are enteringthe vaccine market, offering significantquantities at low prices. Therefore, the netincrease in prices is difficult to predict.

What about new vaccines?High fixed costs and steep learning curvemake new vaccines relatively moreexpensive, as the investments in R&Dand production facilities need to be paidoff and optimum production techniquesneed to be perfected to bring down vari-able production costs.

New vaccines that involve recombinantDNA technology or conjugation of apolysaccharide with a protein may not be

as amenable to large-scale production asvaccines produced by more traditionaltechniques. Therefore, the prices for thesevaccines may never reach the same lowlevel as the traditional six EPI vaccines.

Consumers used to purchasing the tra-ditional six EPI vaccines at low prices maybe unwilling to pay the high pricedemanded for innovative new products,especially where financial constraints aretight. The market for new products hasbeen limited to middle- and high-incomecountries until very recently. There hasbeen little financial incentive for manufac-turers to develop and produce new prod-ucts for the developing country market.

As new vaccines come into the marketto address diseases of huge public healthimportance such as tuberculosis, malariaand HIV/AIDS, there will be tremendouspressure to make these vaccines availableimmediately to all those who need them.This might be facilitated through tieredpricing with the richer countries paying

the full cost and the lower income coun-tries paying the marginal cost of produc-tion (mainly variable costs).

An acceptable strategy for a supplierand the most appropriate strategy toincrease access is to maximize produc-tion volume to meet demand from allpotential markets, in combination withtiered pricing. This is a way to ensureequitable access to vaccines for the poor, and a profit incentive for vaccineproducers through sales in higher-income countries.

For additional information . . .Batson, Amie. Win-win interactionsbetween the public and private sectors.Nature Medicine Vaccine Supplement.1998, 4(5): 487-491.

Mercer Management Consulting.(1997). Economic Framework for GlobalVaccines: Optimal Methods to MeetGlobal Demand. Commissioned by theChildren’s Vaccine Initiative.

Managing the product lifecycle (adapted from Mercer Management Consulting, 1997)

Global supply of new vaccines can be optimized if new strategies are developed to manage the product lifecycle

New Product Factor Launch Market Penetration Product Maturity Optimal Situation

Number of One or few Several producers in high income Several producers in both high producers countries income and developing countries

Pricing High, uniform Tiered within and across markets. Tiered within and across markets Tiered within and across High average price mainly for (global): low average price markets (global): low rich countries and the private average pricemarket in ower income countries

Cost High Medium Low Low

Profitability Uncertain High Low Uncertain

Capacity Low High Surplus High

Vaccine Poor Good in high income countries Good world-wide Good world-wideavailability

Market demand Low High demand in high income High world-wide High world-wide countries and the private sector of lower income countries

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Key Concepts: Tiered Pricing

Understanding a new approach to vaccine pricing.

What is differential pricing?Differential pricing, also known as tieredpricing, means that different classes ofbuyers are charged different prices for thesame product. In the context of vaccines,low-income countries are charged areduced price compared to the open mar-ket rate through bulk procurement sys-tems established by UNICEF and PAHO.

The idea behind differential pricing isto reduce financial barriers to vaccineaccess for low-income countries whileproviding manufacturers with a prof-itable market in richer markets so thatthey will have an incentive to invest insufficient production capacity and newproduct research and development.

What are international policiesand practices on differentialpricing of vaccines?WHO’s Director-General has publiclycalled for movement toward “equitypricing” meaning a significantly lowermanufacturers’ selling price for a selectednumber of essential health goods forlow-income countries.

The prices of the basic six vaccines ofthe Expanded Programme on Immu-nization (EPI) as procured by UNICEFand PAHO for the developing countrymarket are frequently less than 10 per-cent of the price of those vaccines in thericher countries.

Differential prices also exist in the spe-cial low prices for hepatitis B andHaemophilus influenzae type b vaccineand combinations containing themobtained by UNICEF for vaccines pro-cured GAVI/VF for countries with GNPper capita lower than US$1000.

Does differential pricing make sense?Two factors influence vaccine costs andprices. The first is the volume of pro-duction. As most of the costs of vaccineproduction are fixed, larger batches costless per dose to produce than smallerbatches. The second factor is the stage ofthe product lifecycle. When a product isnew, the price tends to be high to pay offinvestments in research and develop-ment and production facilities and togenerate profit while there is a monop-oly position. Later in the product cyclethere may be competitors, leading tosurplus production capacity, and invest-ments may have been paid off, so pricescome down. Traditionally, it was at alater stage of production that developingcountries began to adopt a vaccine, as itbecame affordable.

Vaccine price tiering could workbecause there is very little danger of there-export of vaccines procured byUNICEF or PAHO from a developingcountry for re-sale in a rich country. In

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addition, the bulk procurement systemsmake this market inexpensive to servicein terms of transaction costs, since asingle UNICEF or PAHO tender com-prises such a large volume of vaccine.

For the basic six vaccines of the EPI,differential pricing makes economic sensefor the manufacturers because there is aricher country market for these vaccines,so they can recover the fixed costs of pro-duction through sales to the rich coun-tries at higher prices. Because there hashistorically been excess production capac-ity of these vaccines as new producershave entered the market, sales to develop-ing countries at low prices covered thevariable costs of producing extra doses ofvaccine, and did not require capitalinvestment for additional capacity. Thissituation is beginning to change as excesscapacity is disappearing, manufacturersare reallocating their production capacityto vaccines with higher added value.Therefore we can expect prices for thesevaccines to go up, although there arecompensatory influences with the emer-gence of manufacturers in developing andemerging economies.

Differential pricing has worked well tobring down the prices of traditional vac-cines, but this low price in developingcountries means to manufacturers thatthe developing country market is notprofitable. Therefore, vaccines aimed onlyat the developing world, such as malariavaccines, have suffered from inadequate

research and development investment.One solution to this problem could befurther tiering of the developing coun-try market into higher and lowerincome groups, so that the higher enddeveloping country market is seen asprofitable. Another solution could beto accept to pay a reasonable price forsuch vaccines, whereby the price to thepoorest countries would be subsidizedby donors, for example through a pur-chase fund.

Until recently, new vaccines havenot been taken up by developingcountries until they reached a stage intheir product lifecycles at which theirprices went down. However, there isinternational momentum to reduce oreliminate the lengthy delay in theintroduction of new vaccines of publichealth importance into developingcountries. Differential pricing, coupledwith assured uptake of the new vac-cines, may be a means of speeding upthe process of introduction of vaccinesinto low-income countries at afford-able prices. However, this wouldrequire early investment by manufac-turers in high production capacity.This would only be feasible if theinternational community could assuremanufacturers of a viable market.

The ultimate test of a differentialpricing strategy is the long termimpact on burden of disease throughthe use of present and future vaccines.

For more information . . . “More Equitable Pricing for EssentialDrugs: What do We Mean and What Arethe Issues.” Background paper preparedby the WHO secretariat for the WHO-WTO secretariat workshop on differen-tial pricing and financing of essentialdrugs, Høsbjør, Norway, 8-11 April 2001.

Whitehead, Piers. (2000). Public SectorVaccine Procurement Approaches. Paperprepared for the Global Alliance for Vac-cines and Immunization. Mercer Man-agement Consulting, London. Availableon the Global Alliance for Vaccines andImmunization website: www.vaccineal-liance.org.




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Key Concepts: Information Sources

Selected sources for more information.

Global Alliance on Vaccines andImmunization (GAVI):GAVI can provide information on part-ner agencies, on the Vaccine Fund whichfinances new and underused vaccineintroduction and service delivery infra-structure in lowest income countries,and on the Financing Task Force whichhas commissioned this resource kit.Comments and feedback on the Immu-nization Finance Resource Kit can bedirected to GAVI. GAVI and the VaccineFund can be contacted through UNICEFor WHO offices in developing countriesor directly at:

GAVI Secretariatc/o UNICEFPalais des Nations1211 Geneva 10Switzerland Tel: 41.22.909.50.19Fax: 41.22.909.59.31Email: [email protected]

Le Fonds Mondial pour Les Vaccins(Lyon, France)36 Quai Fulchiron69005 LyonFranceTel: 33.4.7842.6389Fax: 33.4.7842.3424Email: [email protected]

Vaccine Fund (Washington, D.C., USA)The Vaccine Fund601 13th St, NWSuite 820 NWashington, DC 20005USATel: 202.628.4910Fax: 202.628.4909Email: [email protected]

PAHO: For information on the PAHO revolv-ing fund, PAHO can be contactedthrough WHO representative offices indeveloping countries or directly at thefollowing address:

Pan American Health OrganizationPan American Sanitary BureauRegional Office of the World Health OrganizationDivision of Vaccines and Immunization525 Twenty-third Street, N.W.Washington, D.C. 20037-2895USA Tel: 202.974.3000Fax: 202.974.3663www.paho.org

UNICEFUNICEF can be contacted through theiroffices in developing countries, throughtheir regional office, or through theirheadquarters in New York or throughtheir supply division in Copenhagen.

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UNICEF NYHQHealth Section/Programme Division3 UN PlazaNew York, NY 10017USATel: 212. 824.6340Fax: 212. 824.6460www.unicef.org

UNICEF Supply DivisionUNICEF Plads, Freeport2100 Copenhagen ØDenmarkTel: 45.35.27.35.27Fax: 45.35.26.94.21 Email: [email protected] [email protected]

UNICEF New York Supply CenterUNICEF House3 UN Plaza, H-6LNew York, N.Y. 10017USATel: 212.326.7490Fax: 212.326.7477

The World Bank, AfricanDevelopment Bank, AsianDevelopment Bank and Inter-American Development BankThe World Bank and regional develop-ment banks can be contacted through itsrepresentative offices in developingcountries, through regional liaison offi-cers, or their headquarters:

The World BankHealth, Nutrition and Population1818 H Street NWWashington, DC 20433USA Tel: 202.477.1234Fax: 202.477.6391www.worldbank.org

The African Development BankRue Joseph Anoma01 BP 1387 Abidjan 01 Côte d’IvoireTel: 225.20.20.44.44Fax: 225.20.20.49.59www.afdb.org

The Asian Development BankP.O. Box 7890980 ManilaPhilippinesTel: 632.632.4444Fax: 632.636.2444www.adb.org

The Inter-American DevelopmentBank1300 New York Ave, NWWashington, DC 20577USATel: 202 623 1000www.iadb.org

World Health Organization:The World Health Organization can becontacted through its representatives indeveloping countries, through regionaloffices, or through its headquarters inGeneva:

World Health OrganizationDepartment of Vaccines and Biologicals20, avenue AppiaCH-1211 Geneva 27SwitzerlandTel: 41.22.791.2111Fax: 41.22.791.4384www.who.int/vaccines







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