Uganda’s increasing dependence on development partner’s support for immunization – a five year resource tracking study (2012 – 2016)

Immunization is a cost-effective intervention that has played a vital role in controlling and eliminating vaccine-preventable diseases. Globally, immunization is estimated to avert approximately 2–3 million deaths each year as access to immunization services has improved especially among the hard-to-reach and vulnerable populations [1]. Uganda is a low-income country with a population of 34.9 million people [2]. In line with the Sustainable Development Goal 3.2 that seeks to end preventable deaths of newborns and children under 5 years of age [3], the Uganda National Expanded Program on Immunization (UNEPI) has increased access to immunization services nationally through the introduction of new vaccines and improvement in vaccine coverage with support of its partners [4‐6]. Coverage estimates show high performance for third dose of Diphtheria, Tetanus and Pertussis -DPT3 (93%), BCG (88%), Measles (87%), Polio 3 (92%) and Pneumococcal Conjugate (92%) vaccines [4].

The Global Vaccine Action Plan highlights the need to increase the total amount of funding for immunization from countries and development partners even though financing for immunization is primarily the responsibility of governments [7]. In order to ensure predictable and sustainable funding for immunisation, resource tracking efforts are needed to guide governments and partners [7]. Resource tracking in Uganda has been possible through the institutionalization of the National Health Accounts (NHA) that has provided evidence to monitor health financing since 1997 [8]. Findings from the NHA show that the Government of Uganda’s (GOU) expenditure on health for 2016/17 & 2017/18 fiscal years was US$1.8 billion representing 1.1% of the Gross Domestic Product [9]. However, Uganda’s budget allocated to health (8.7%) is below the Abuja declaration target of 15% [9, 10]. Additionally, the health expenditure per capita (US$56) is also lower than US$84 per capita recommended by the World Health Organization (WHO) [9]. The current health expenditure estimates also highlight an increase in public and private funds but a decrease in funding from development partner funds [9]. In addition to the NHA, WHO/UNICEF jointly capture various domains on performance, planning, financing and quality indicators from member states through the Joint Reporting Form (JRF) so as to track implementation of the Global Vaccine Action Plan (GVAP) [11]. From the JRF, the GOU’s spending on routine immunization per surviving infant has increased from $3 (2006) to $11 (2014) [12]. More recent estimates in 2017 show that the GOU contributes approximately 35% of the total expenditure on immunization [13]. Nevertheless, Uganda has not consistently reported on JRF indicators and therefore exacerbating the need for resource mapping exercises.

A mapping of financial flows for immunization in 2009 showed an increase in financing for routine immunization in Uganda from $24.2 million to $32.9 million in 2009/10 and 2010/11 respectively with the GOU contributing approximately half of all the resources [14]. There is a dearth of evidence in the financial flows specific to immunization especially in light of the newly introduced vaccines. Additionally, persistent weaknesses have been noted in obtaining accurate reliable and complete data on local and external investments in immunization and yet these are critical to estimate costs, resource needs and resource gaps. It is vital to have accurate data on funding flows and expenditure to aid country level planning, financing and also resource mobilization.

Gavi, the Vaccine Alliance (Gavi) commissioned a prospective evaluation in four countries including Uganda with an aim of generating evidence regarding the relevance, effectiveness, impact and efficiency of their support. A key evaluation question was centered on identifying how Gavi resources are utilized and their relationship with domestic and development partners resources. This paper presents findings from the resource tracking sub-study that traced the flow of immunization resources from national to sub-national levels. The objectives were: 1) to measure and describe the financial envelope for immunization activities at national level in Uganda from 2012 to 2016, and 2) to conduct an expenditure analysis of the resources received and utilized in 2015 and 2016 at sub-national level.

In Uganda, the resource envelope for immunization increased fourfold to US$ 85.6 million in 2016. The contribution from the Ugandan Government increased by US$ 5.7 million over the study period accounting for 55% of the resource envelope in 2012 to 2014. Despite the increase in its contribution for immunization, the Ugandan Government’s contribution to the resource envelope reduced to 24% in 2015 and 2016 as Gavi contributed more resources for immunization accounting for 59% of the resource envelope. Other development partners contributed 18% to the resource envelope. There is a substantial contribution (76%) of development partners in supporting the immunization program in Uganda. Similar resource tracking efforts estimate the government’s contribution to be 50% [14] indicating a reduction in its 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 [21]. The increase in the resource envelope for immunization can partly be explained by the lift in the ban on Gavi funding to Uganda in 2012 following the misuse of funds [22, 23]. This ban was lifted following the institutionalization of fiduciary risk management approaches [24, 25]. Additionally, the introduction of new vaccines and implementation of other Gavi support can also explain the increase in the resource envelope for immunisation. Uganda 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 [26]. In addition, the EPI conducted Meningitis A vaccine campaigns, shifted from the trivalent to the bivalent polio vaccine while implementing the first Health Systems Strengthening (HSSI) grant from Gavi during the study period [27].

The expansion of immunization schedules through introduction of new vaccines increases program and system costs of national immunization programs driven by high prices of new vaccines and program budgets have been shown to double or triple in countries graduating from Gavi support [21, 28, 29]. The increase in costs and resource requirements during and after new vaccine introduction is expected to be commensurate with increases in government expenditure on immunization, however government budgets may not easily absorb the portfolio of vital vaccines financed by Gavi [30, 31]. The Ugandan Government’s contribution to the resource envelope for immunization increased over the study period however, the magnitude of support from development partners raises sustainability concerns of a critical national program. Several low income countries also rely on the significant support from Gavi to meet the increasing needs of EPI programs to introduce and scale up vaccines however, there have been 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 [32]. 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 and has decreased overtime to 6.9% in 2015/16 [9, 34]. As such, the available financing is not sustainable to maintain high coverage rates and is exacerbated by new vaccine introduction. Inadequate financing for immunization coupled with the heavy reliance on development partner support also highlights challenges of relying on external funding as the support is often ‘off-budget’ making it difficult to plan and track expenditures, unpredictable due to the difficulty of making multiyear commitments and is often unevenly targeted in terms of its developmental impact mainly focused on financing recurrent costs (vaccines and supplies) rather than long term improvements [15, 28, 35].

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 [32, 36‐38]. Gavi has not only increased access to lifesaving/underutilized vaccines and improved immunization coverage for new vaccines but, has also prioritized financial sustainability at country level despite the challenges and limitations in its approaches [32, 39‐42]. Financial sustainability has been prioritized through its policies on eligibility, transition and financing to enable countries fully finance immunization programs beyond the time limited contribution from Gavi [28, 32, 43, 44]. 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 [45]. Closing funding gaps for immunization and achieving financial sustainability requires 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 [32, 45, 46]. In Uganda, an immunization bill was passed and enacted into law in 2016 and has the provision for the establishment of an immunization fund to facilitate mobilization of domestic resources for immunization however, it is not yet operational [26]. These funds are meant to support purchasing of vaccines and related supplies, cold chain as well as other immunization activities.

Findings on the expenditure by immunization activity showed that the majority of the funds are spent on facility based routine immunization. Over the study period, there was a 285% increase in the expenditure on facility based routine immunization mainly driven by spending on human resources which includes salaries for health workers. Facility based routine costs have been shown to take up the majority of the immunization expenditure driven by expenditure on human resources as it is a key driver of program resources after the expenditure on vaccines and supplies [32, 47]. Our findings also highlighted a change in management of funds at national level with National Medical Stores managing more funds in 2016. This change can be attributed to the organizational changes in which the responsibility for supplies vaccine logistics management, vaccine quality and safety were shifted from UNEPI to National Medical Stores in April 2012 [48]. 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 [47].

At district level, the district health office received immunization funding from the government (PHC grant) and development partners. WHO provided the largest proportion (57%) of the funds in the districts visited. More than half of the districts allocated less than 15% of the total annual resources (PHC grant) to immunization activities which translates to US$ 1452 annually per district. The PHC grant received on a quarterly basis to support all health programs as well as facilitate facility supervisions, vaccine delivery, cold chain maintenance and meetings is inadequate [18]. 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.

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. Majority of the facilities spent their PHC grant on outreaches (88%) specifically on per-diems/ allowances for staff. These findings show an increase in resources allocated to outreaches when compared to an earlier costing analysis that showed that health facilities were allocating only 28% of their resources to outreaches [47]. Majority of services are being provided by government health facilities of which the bulk of the funding supports facility based routine immunization activities. These findings are consistent with a similar study that also showed that the largest proportion of funding 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.

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/district 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 [47].

The resource envelope for immunization has increased fourfold since 2012 to a total of US$ 85.6 million in 2016 and is mainly attributed to new vaccine introduction and the lift of the ban of Gavi funding to Uganda in 2012. The Ugandan Government was the greatest contributor of immunization resources but Gavi, the Vaccine Alliance is now the greatest contributor of the immunization envelope in Uganda. Districts allocated 15% of their total annual resources to immunization to support supervision of lower health centers and distribute vaccines. Health facilities spent about 5.5% of their total annual resources to support outreaches. Although the support from development partners has facilitated the improvement of immunization coverage and new vaccine introduction in Uganda, with Gavi and other development partners contributing the bulk of funding for immunization, it raises sustainability concerns of a critical national program. Additionally, development partners support is often off-budget and unpredictable. The immunization financing in Uganda is not sustainable to maintain high coverage rates and this is exacerbated by high costs of newly introduced vaccines. To ensure financial sustainability of the immunization program, findings from this study emphasize the need to operationalize the immunization fund in the immunization act, advocate and mobilize additional resources for immunization from the ministry of health and private sector, increase the reliability of resources for immunization as well as leverage on health financing reforms like the National Health Insurance. Additionally, on budget funding from development partners would guide national programs plan adequately. At district and health facility level, there is need to ring-fence resources for immunization. This study calls for continuous tracking of resources for immunization.