LNCT Brief: Mobilizing Resources for Immunization in Decentralized Health Systems

The Learning Network for Countries in Transition (LNCT) is a country-driven network dedicated to supporting countries as they transition away from Gavi support to full domestic financing of their national immunization programs (NIP) through a peer learning approach. As Gavi support decreases and countries take on a higher proportion of the financing of immunization, they must mobilize not only the funding needed for vaccines, but also funding for critical operational costs, including cold chain and logistics, service delivery, health promotion, and more. Mobilizing adequate resources and promoting efficient spending to sustain high immunization coverage is a high priority for many LNCT countries. In countries with decentralized health systems, responsibility for these functions (and the requisite funding) rests not only with authorities at the national level, but also with subnational authorities.

In decentralized health systems, decision-making authority and responsibility for critical immunization program functions may reside at the subnational level or may be shared between national and subnational levels. For example, the national level may be responsible for vaccine delivery to district offices, but then rely on district and facility staff to ensure distribution to service delivery points. Similarly, the national level may develop health worker trainings and train trainers at regional levels, but district budgets are required to deliver that training to frontline health workers.

As LNCT countries transition to fully self-financing their immunization programs, program managers in decentralized health systems may need different strategies than their counterparts in more centralized health systems to ensure adequate resource mobilization and effective program management. The NIP may need to engage additional stakeholders and/or support subnational EPI managers to develop new skills in order to mobilize adequate financing and high-quality services. It is important that national immunization program managers understand funding allocation and disbursement processes, as well as bottlenecks, so they can identify opportunities to improve funding availability at subnational levels.

The challenges found across LNCT countries with decentralized systems stem from several common issues that constrain immunization program performance:

• Coordination between national and subnational levels. In decentralized LNCT countries, the national level typically retains control over long-term planning, regulations, technical and operational policies (e.g., new vaccines, immunization schedule, vaccine storage), donor coordination, vaccine procurement, monitoring and reporting, and subnational capacity development, while subnational governments are responsible for service delivery. Many critical functions such as capacity building, data collection, or logistics require strong coordination to cascade down, or roll up, multiple health system levels. Improved coordination would allow subnational levels to be better prepared to implement new guidelines, update staff trainings, conduct activities to close immunization gaps, or introduce new vaccines, by providing the time needed to ensure sufficient funding, human resources, and political commitment.
• Management and budgeting capacity at subnational levels. Subnational immunization managers may not have a clear idea of what the subnational government’s immunization responsibilities are and what a complete immunization budget should include. Complex budgeting processes and multiple uncoordinated streams of funding may exacerbate this problem. Immunization managers at subnational levels with more knowledge of budgeting and cash disbursement processes, awareness of upcoming activities planned at the national level, as well as more guidance about how to budget for priority activities, would be better able to prepare budget requests with sufficient funding to support immunization activities.
• Awareness of, and funding for, key immunization functions at subnational levels. In most countries, the national level has limited visibility into immunization expenditures at the subnational level, partly because these expenditures may be shared with other programs, but also because there are no systems to collect such information. LNCT countries have reported funding gaps across all aspects of immunization service delivery, but human resources are often underfunded, along with logistics, outreach, and training, which impact vaccine availability, access to services, and service quality. Regular monitoring of immunization expenditures at subnational level would help national level staff to advocate for increased funding using data on spending over time and across geographies, particularly if better performance can be observed in localities with higher expenditures.

Based on a review of decentralized LNCT country experiences, there are promising strategies for NIPs to support increased resource mobilization and effective service delivery:

1. Develop effective systems for training, communications, and coordination, cascading down to all administrative levels. An effective immunization program requires that all levels of the health system perform their required functions. Providing clear guidance, such as Standard Operating Procedures (SOPs), for subnational managers and sufficient notification times to allow for sufficient planning and budgeting will increase the likelihood that subnational governments implement new guidelines and activities and carry out their assigned responsibilities. Strong coordination systems would also alert the NIP to issues at subnational levels.
2. Strengthen capacity for program management at subnational levels, including financial and programmatic planning. The NIP must rely on local governments and local managers to plan, fund, and implement needed activities; however, they can support the planning process by providing clear, practical guidelines, about how to budget for immunization functions and activities, including indicative budget levels. Detailed guidance on the necessary components of a strong immunization program and how to budget for them, along with guidance for successful implementation, can help subnational managers to secure funds and show strong outcomes.
3. Monitor subnational immunization expenditures and support subnational immunization managers to advocate for increased funding. Regular and reliable data on subnational immunization expenditures is the foundation for effective advocacy to increase funding. Data on subnational immunization expenditures have been successfully used by national level managers to increase budgets. The NIP can support a system for regular reporting of key immunization expenditures, or relevant primary health care expenditures, to monitor trends and assess inadequacies. Developing the capacity of subnational managers to advocate for funding within their localities, as well as continued advocacy at the national level for immunization resources is needed over the long term.

National immunization programs, and immunization partners may need to consider new strategies and new funding sources in order to mobilize sufficient funding for immunization following the Gavi transition. To support these strategies, the NIP may also need to build its own capabilities related to budget allocation and financial analysis to engage with decision makers to address barriers and improve funding availability.