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LNCT’s virtual workshop on the topic of financing and managing resources in decentralized contexts took place over three days in late April 2021. The purpose of this workshop was to help countries understand the implications of decentralization for immunization coverage and equity for both routine immunization and COVID-19/emergency response and to offer action-oriented problem-solving support for specific decentralization-challenges identified by country participants. Specifically, the workshop aimed to answer the questions:
- How does decentralization affect the financing and implementation of immunization programs and what is the impact on the program’s coverage and equity goals?
- What is the impact of decentralization on emergency response, such as in the case of COVID vaccine roll out?
- What are common financial and programmatic challenges and opportunities for immunization programs in decentralized LNCT countries?
- What strategies have countries successfully used to overcome or mitigate common decentralization-related challenges?
The countries invited to participate in this workshop, including Cote d’Ivoire, India, Nigeria, Pakistan, Republic of Congo, and Vietnam, have consistently identified this topic as a priority for their LNCT engagements and have indicated that it is particularly significant in the context of their COVID-19 responses.
Throughout the workshop, technical framing presentations were complemented by country experiences and discussions among participants. Here are a few key learnings that emerged from the workshop:
- Decentralization can have a wide-ranging impact on immunization programs, shifting program management and financing responsibilities, introducing new stakeholders, and changing how funds and other resources are mobilized. Although decentralization is a reform in many ways beyond EPI control, immunization program managers can help shape it and leverage it to enhance the program’s outreach, resilience, and impact.
- Decentralization can offer opportunities to increase coverage and equity by allowing subnational governments to adapt to their local contexts and increasing local ownership and accountability, but it can also magnify weaknesses, inefficiencies, and inequity in a system. Coordination between key stakeholders, clear assignments of roles and responsibilities, alignment of funding and program responsibilities, support for subnational capacity development, strong accountability mechanisms, and a commitment to immunization at all levels are key to building a strong immunization program in decentralized contexts.
- COVID vaccine introduction has demonstrated a need for emergency response planning, learning about the roll out, and a more sustainable model for routine immunization. During the pandemic, immunization is high on the agenda of decision-makers. Countries should leverage opportunities to mobilize domestic and external resources, strengthen critical country capacities, and “build (back) better”.
- Decentralization can pose some coordination and mobilization challenges for emergency response, but it can also help countries rapidly adapt their response to local contexts and needs. On the whole, most participants felt that their country’s decentralized structure aided their response to the pandemic.
And here are just a few of the many country experiences shared during the workshop:
- Nigeria’s Peer Learning Exchanges, which build off of a Memorandum of Understanding (MOU) mechanism between partners and states with low immunization coverage, allow states to come together on challenges of mutual importance, share good practices, set goals to hold themselves accountable, and share their learnings with each other, the national government, and other states in the country. Critical to the success of the platform is a willingness to work collaboratively with the state teams, the involvement of high-level decision-makers, the availability of adequate resources including financing and technical capacity building, a plan for disseminating learnings, and the existence of a platform for cross-state and stakeholder collaboration.
- Pakistan established a mechanism that pools provincial funds for vaccine procurement so that it can be carried out efficiently at the national level in its highly decentralized system. The country reflected on the importance of strong public financial management practices, including accountability mechanisms like external audits, and the centralization of certain functions like vaccine procurement for ensuring efficiency in a decentralized context.
- In Republic of Congo, immunization coverage dropped by 16% between December 2019 and June 2020 due, in part, to disruptions in the supply chain and drops in vaccine demand. The country was able to successfully conduct catch up campaigns by sharing tools, communication plans and other knowledge with local and regional departments and involving them in major decisions. The combined efforts of all levels of government together with close monitoring at the national level led to a 10% gain in immunization coverage between June and December 2020.
- Vietnam’s provinces have been taking on a greater responsibility for immunization financing over time and are responsible for financing the operational costs of COVID vaccine roll out. Although this shift has created some challenges for ensuring that adequate funds are raised for immunization service delivery, it has also helped Vietnam respond to the pandemic by providing provinces with authority and flexibility to quickly shift funds to high priority activities.
We are very grateful for the active engagement from our country participants, presenters, and facilitators. Virtual formats for engaging in in-depth discussion are challenging under any circumstances, but particularly in the context of a global pandemic that is rightfully occupying most our members’ time and attention. We appreciate the commitment of our participants to continuing to learn from and support each other in difficult times.
For those of you who did not attend the meeting, the presentations and session recordings can be found here on our website. You may also be interested in our resource document summarizing LNCT country experiences managing immunization programs in decentralized contexts. We would like to encourage you to continue engaging on this topic with your fellow network members, experts, and partners on the LNCT website’s discussion forum, and if you are interested in learning more about a specific theme or country experience discussed during this workshop, please let us know!