This study presents trends in the resource envelope for immunization and expenditure analysis at sub-national level. In Uganda, the resource envelope for immunization increased fourfold since 2012 to 85.6 million in 2016 with the biggest increment in 2015 and 2016. The Ugandan Government was the greatest contributor (55%) to the immunization resources from 2012 to 2014. However, in 2015 and 2016, the government contribution decreased to 24% while Gavi contributed the majority of the resources (59%) to immunization. Estimates from a similar study conducted in 2010 showed a 50% contribution from the Government of Uganda (14). In comparison with our findings, there has been a 26% reduction in the Government’s contribution to the resource envelope for immunization. Analyses from country multiyear plans (cMYPs) also estimate the government contribution to account for about 54% of the total routine program financing and non-vaccine financing respectively (20). It is apparent that there is still a substantial contribution of development partners in supporting the immunization program especially for operational EPI activities.
The increase in the resource envelope for immunization can be explained two factors. Firstly, Gavi lifted the ban on its funding to Uganda in 2012. Uganda was approved for Immunization Services Support (ISS) of US$ 9,230,520 in 2000 however, in 2006, Gavi suspended cash transfers to the Government of Uganda following misuse of funds (21,22). This ban was later lifted following the institutionalization of fiduciary risk management approaches such as strengthening government oversight mechanisms, internal and external audits, establishment of a fiduciary agent within the government system to manage Gavi risks, and channeling of funds through country partners (23,24). Secondly, the increase in the resource envelope can be attributed to new vaccine introduction. Since 2013, Uganda has introduced several new vaccines in quick succession; including Pneumococcal Conjugate Vaccine (PCV) in 2013, Human Papilloma virus vaccine (HPV) in 2015, Meningitis A in 2016 and Injectable Polio Vaccine (IPV) in 2016 (25). Gavi disbursed US $97 million to support the introduction of PCV, HPV and IPV (26). In addition to the new vaccine introductions, the EPI conducted Meningitis A vaccine campaigns, shifted from the trivalent (tOPV) to the bivalent (bOPV) polio vaccine while implementing the Health Systems Strengthening (HSSI) grant from Gavi during the study period (26).
The expansion of immunization schedules through introduction of new vaccines increases program and system costs of national immunization programs (20,27,28). Evidence shows that resource requirements for routine immunization continue to increase due to higher prices of new vaccines and in some countries program budgets have doubled and tripled (31). Experiences from countries graduating from Gavi support have shown that a substantial increase in government expenditure is required to maintain and sustain the immunization program and is difficult to achieve especially due to high costs of vaccines (30). As such, the magnitude of domestic funding required by EPI programs to sustain gains is heavily driven by the number of new vaccines introduced into the program (30). The increase in costs and resource requirements during and after new vaccine introduction should be commensurate with increases in government expenditure on immunization, however this is not always the case as government budgets may not easily absorb the portfolio of vital vaccines financed by Gavi (31,32). During the study period, the Government of Uganda’s contribution decreased tremendously despite the introduction of additional vaccines. In light of the decrease in support from development partners in Uganda, challenges in fulfilling previous co-financing obligations (9,25), and the magnitude of support from Gavi and other development partners, this raises sustainability concerns of a critical national program. Our findings are similar to experiences from other poor countries that also show a significant contribution by Gavi to meeting the increasing needs of EPI programs to introduce and scale up vaccines (29). However, these countries showed limited signs of the ability to transition to other sources of financing outside Gavi support with evident financing gaps to sustain the current immunization gains (29). In Uganda, the sustainability concerns are exacerbated by a 90% (US$ 487.5 million) financial gap in the immunization resources required for Uganda over a five-year period (2016-2020) when Gavi’s contribution is excluded (33).
The achievement of sustainable immunization however, needs to be considered in the context of the broader health system financing landscape. Financing for health in Uganda is largely inadequate with the a decreased budget for health expenditure from 8.9% in 2010/11 to 6.9% in 2015/16 (9,34). The immunization financing in Uganda, is not sustainable to maintain high coverage rates and is exacerbated by expensive new vaccines that have been and are planned to be introduced. Inadequate financing for immunization coupled with the heavy reliance on development partner support not only raises sustainability concerns but also highlights other challenges of external funding. Majority of the funding from development partners is ‘off-budget’ making it difficult for the Ministry of Health to plan for, coordinate and track expenditures and efforts of development partners coupled with a lack of alignment to key country priorities (35). The predictability of funding from development partners is challenging due to the difficulty in making multi-year commitments (27). Evidence also shows that support from development partners is often unevenly targeted in terms of its developmental impact given that it is mainly focused on financing recurrent costs (vaccines and supplies) rather than long term improvements (infrastructure) (36). Development partner support is expected to increase allocation of developing country resources towards health programs/immunization or even result into the same degree of benefit however, this cannot be guaranteed due to several complexities of the ability and willingness of governments to pay for health care (29,37–39). Despite the challenges of relying on development partner support, low income countries have been able to introduce new vaccines at a faster rate than middle income countries due to support from development partners (40).
Since its inception in 2000, Gavi has facilitated the vaccination of 760 million children from 17 infectious diseases through routine immunization programs (41). Support from Gavi has not only increased access to lifesaving and underutilized vaccines, but also improved immunization coverage especially for new vaccines like pentavalent, pneumococcal, measles and rotavirus vaccines in over 120 countries Uganda inclusive (42). In order to qualify for Gavi’s support, a country’s three year average Gross National Income (GNI) per capita has to be equal to or below the eligibility threshold (43). Gavi’s support is phased out in a gradual transition process that starts after countries exceed the World Bank’s threshold for status as a low-income country(44). Uganda is considered a low-income country, currently in the initial self-financing phase and is projected to stay in this phase for the next 5 years before the preparatory transition phase (13). The Government of Uganda finances the traditional EPI vaccines and co-finances 20% of the new vaccines including Penta, PCV, HPV and Rota virus vaccines (35).
In light of its support to countries, Gavi has prioritized financial sustainability especially at country level despite the challenges and limitations in its approaches (29). This has been through its policies on eligibility, transition and financing to enable countries fully finance immunization programs beyond the time limited contribution from Gavi (27,29,44,45). Also, National Immunization Technical Advisory Groups have been established as independent technical bodies to guide immunization programs and ensure evidenced based decision making especially on new vaccine introduction (13,46). The co-financing policy has proven to be an affordable and innovative mechanism that has fostered country ownership of vaccine financing and sustainable financing of vaccines (47). Conversely, Gavi’s transition policy has its limitations as it is unable to identify system wide constraints to sustainability and sector wide approaches to overcome them due to its focus on immunization (30).
Alongside Gavi’s initiatives to ensure sustainability at country level, EPI programs need to prioritize financial sustainability planning for immunization as it has been shown to have a positive impact on mobilization of resources despite its limitations (48). In order to be able to domestically fund their immunization programs, countries need to fully comprehend the cost of immunization, identify financial gaps and develop detailed projections of vaccine funding requirements to guide projections on government spending and assess the feasibility of meeting the additional costs (29,30). Additionally, countries need to pay attention to their public funding for health as a proportion of their Gross Domestic Product (49). Closing funding gaps for immunization and achieving financial sustainability does require a significant increase in the public sector budget, increase in government commitments for immunization, greater commitments from development partners and a reduction in vaccine prices in the context of Gavi funding so as to allow countries to transition (29,49).
Findings on immunization spending on program activities, showed that there was a spike in expenditure (274%) for facility based routine immunization from US$ 18 million in 2014 to US$ 70 million accounting for 80% of the immunization expenditure by activity. The increase in expenditure was mainly driven by expenditure on human resources which includes salaries for health workers. These findings are similar to earlier costing estimates that showed that facility based routine costs took up majority (45%) of the immunization expenditure driven by expenditure on human resources (43%) (29,50). Personnel expenditure is a key driver especially for program resources after the expenditure on vaccines and supplies (27). Our findings also highlighted a change in management of funds at national level. The amount of funds managed by National Medical Stores increased by 78% since 2010 (50). This change can be explained by organizational changes and the increase in funds from Gavi in 2015 and 2016. In 2013, the responsibility for supplies vaccine logistics management and vaccine quality and safety was shifted from UNEPI to NMS in April 2012 (52). As such this meant less financial flow of funds to UNEPI. However, due to the Health System Strengthening grant and several new vaccine introductions, UNEPI is also managing more funds (17%) despite the organizational changes when compared to the 8% it was managing in 2010 (50).
At district level, the district health office receives immunization funding from two sources including public funds (PHC grant) and funding from development partners including Gavi, UNICEF and WHO. From the seven districts visited, findings show that WHO provided the largest proportion (57%) of the funds followed by UNICEF that provided about a quarter of the resources. Gavi provided an average of 15% of funds at district level. Under the PHC grant, more than half of the districts allocated less than 15% of the total annual resources to immunization activities which translates to US$ 1,452 annually per district. Considering that the PHC grant is sent on a quarterly basis and is meant to support all the activities conducted by the health office, including immunization activities as well as support routine supervisions to the health facilities, deliver vaccines to the health facilities, maintain the cold chain systems at the health facilities and facilitate immunization meetings (16), these funds are inadequate. Due to the decentralized system in Uganda, the allocation of the PHC grant to immunization varies by district and is highly dependent on the degree of prioritization of immunization activities and availability of additional resources from development partners. For instance, in Lamwo district, public funds were completely re-directed to fund other activities as such, there was a 0% allocation of PHC funding to immunization. The 0% allocation to immunization was attributed to the availability of funds from development partner to support immunization activities. These findings highlight the challenges of inadequate funding at district level to support immunization activities and emphasize the significant contribution of resources from development partners at district level.
At health facility level, the overall annual average expenditure on immunization (PHC grant) across all levels of care was 5.5% over the two-year period. This allocation is lower than the Ministry of Health recommendation that stipulates at least 10% allocation of the PHC grant should be allocated to immunization activities. Majority of the facilities spent their PHC grant on outreaches (88%) specifically on per-diems/outreach allowances (73%) for staff to conduct the outreaches. These findings show an increase in resources allocated to outreaches when compared to an earlier costing analysis in 2011 that showed that health facilities (all levels) were allocating only 28% of their resources to outreaches (50). In terms of service provision, majority of services are being provided by government health facilities of which the bulk of the funding supports facility based routine immunization activities (80%). This is consistent with similar study that also showed that the largest proportion of funding in 2011 was devoted to routine facility based immunization with an average of 40% across all levels of care (14). Therefore, majority of the funds are still spent at the level of service delivery. Despite the fact that health facilities and district health offices provide the largest proportion of immunization activities, it is important to note that they do not manage an equally large proportion of funds as illustrated by the existing financing agents. This implies that the financing agents make decisions on how the funds should be utilized while service providers implement what has been decided upon.
This study had limitations but, they are unlikely to affect the findings and conclusions. The district level expenditure analyses only purposively sampled seven districts due to budget constraints and therefore findings cannot be generalized to all districts. Despite this, the study ensured that the district selection accounted for performance in line with RED strategy, geographically representation and vaccine coverage performance. Also, the study triangulated findings at national, district and health facility levels. Further, the Government of Uganda resources at sub-national level could have been underestimated given that we did not include the cost of salaried labor, purchase, storage, and distribution of vaccines. Despite this, this contribution was accounted for at national level using previous costing estimates (50).