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. LNCT developed two resource products to illustrate how countries can mobilize adequate resources and promote efficient spending to sustain high immunization coverage in decentralized health systems. This resource document extensively outlines different types of decentralization contexts, roles and responsibilities, and funding allocation and disbursement bottlenecks in decentralized health systems with rich examples from LNCT countries.
View the document as a PDF in English, Français, Português, or русский or below by topic by clicking on each tab header. You can also view the two-page LNCT brief, which outlines some of the key challenges found across LNCT countries with decentralized systems along with several promising strategies for NIPs to support increased resource mobilization and effective service delivery.
The Learning Network for Countries in Transition (LNCT) is a country-driven network dedicated to peer learning to support countries as they transition away from Gavi support to full domestic financing of their national immunization programs (NIP). 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. In countries with decentralized health systems, responsibility for these functions (and the requisite funding) rests not with central authorities, but also with subnational authorities. Mobilizing adequate resources, and promoting efficient spending, to sustain high immunization coverage is a high priority for many LNCT countries.
Countries undertake decentralization in different forms (as defined below) and for various reasons, including to increase responsiveness to local conditions and needs, to allow greater political representation for diverse groups, and to alleviate bottlenecks in decision-making. Decentralization is seldom initiated in the health sector, and rarely is it undertaken in the health sector alone. Often the form of decentralization does not consider the impact on the health system, let alone the impact on one health program.
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 central 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 central level may develop health worker training and train trainers at regional level, but district budgets are required to deliver that training to health workers. Historically, external support for resource mobilization have focused on national budgets. It is important that NIP managers understand funding allocation and disbursement processes and bottlenecks, so they can identify opportunities to improve funding availability. The purpose of this brief is to:
- Highlight common resource mobilization challenges in LNCT countries with decentralized health systems;
- Present examples of approaches LNCT countries and other LMICs have employed to address these challenges; and,
- Identify strategies that immunization program staff at the national and subnational levels can use to advocate for, and increase, the availability of resources for immunization.
Country Case Studies
Building Subnational Immunization Program Management Capacity through Peer Learning Exchanges in Nigeria
Authors: Raihana Ibrahim and Uchenna Igbokwe
The Constitution of Nigeria establishes a highly decentralized federation comprising 37 states, which themselves comprise 774 Local Government Areas (LGAs). Within this system, the federal government is responsible for policy development, vaccine procurement, technical support, and tertiary care, while the states and LGAs are responsible for lower levels of care and routine immunization infrastructure and logistics. States exercise broad budgetary authority, with the majority of their budgets coming from unconditional transfers from the federal government.
A major concern for Nigeria’s immunization program is the large disparity in immunization coverage and spending between states, with states in the south tending to fare better than those in the north. DTP3 coverage ranges from 76% in the southern state of Anambra to 7% in the northern state of Sokoto. Subnational health expenditure accounts for an average of 2.2% of total health expenditure, but this proportion varies from 7.1% in the southern state of Imo to 0.7% in the northern state of Zamfara. On average, 26% of a state’s revenue is generated by the state, but this number varies greatly from nearly 500% in Lagos to practically negligible amounts elsewhere. A landscape analysis conducted by IVAC identified a broad range of challenges impacting immunization coverage in low-performing states. Among these were many issues related to lack of program management capacity in areas such as leadership and governance, financing and resource management, and logistics and planning.
Since 2017, Solina Center for International Development and Research (SCIDaR) has partnered with six underperforming states to improve immunization program performance through a series of Peer Learning Exchanges. The Exchanges build on an existing platform of Memoranda of Understanding between these states, the Bill & Melinda Gates Foundation, and the Aliko Dangote Foundation that aim to strengthen immunization systems and increase state financing of immunization through a phased pooled funding agreement under which states contribute increased funding over time into a dedicated RI “basket account”. Through the Peer Learning Exchanges, the key immunization officers and managers from the states meet twice a year on a challenge of mutual interest, with the best-performing state designated to lead the meeting with agenda-setting support from SCIDaR. The participants for each meeting are selected based on the chosen theme of each of the learning exchange meetings.
At the end of each meeting, the states reach a resolution and agree to specific measures of progress towards achieving an objective. Some examples of resolutions that have come out of these meetings include:
- Direct vaccine delivery: SCIDaR convened the State Immunization Officers/Managers, State Logistics Officers, and State cold chain officers, and relevant partners to address the challenges with vaccine logistics in the states. To reduce the frequency of stock-outs, states resolved to transition from an unfunded “pull” system of vaccine delivery that varied across states to direct vaccine delivery from state cold stores to the service delivery points across all six states. As a result, average stock-out rates fell from as high as 30-50% to 1-5%. The impact was significant enough that the states fed this learning up to the federal government, with the federal government considering adoption of this direct vaccine delivery system for scale-up in other non-MoU funded states.
- Financial management: To ensure that all funds deposited into the basket account were adequately accounted for, SCIDaR worked with the State PHC Board Leadership, Immunization Program Managers and their finance teams (Directors of Finance, Chief Accountants, Cashiers and Internal Auditors) to develop a financial management system for RI funds that included direct electronic disbursements, retirements and validation, and routine internal and external audits. These systems were co-created during a series of learning exchange meetings conducted with the finance teams (comprising Directors, Cashiers and Auditors) from the state primary health care boards; and were followed by direct on-the-job mentoring sessions to transfer capacity to the officers such that they can independently perform their job functions. Following the success of the RI financial management system, SCIDaR convened the states to develop roadmaps to expand this RI legacy to broader PHC, and also co-developed and published a financial management start-up guide which has been shared widely with other state, national and international stakeholders.
- Community engagement: The learning exchanges on this topic sought to devise a sustainable community engagement strategy to improve demand for routine immunization across these 6 northern states. During the learning exchange, the name-based community engagement strategy (which involved identification and tracking of newborns, drop-outs and left-outs by traditional leaders) was co-created and fine-tuned. The strategy was adopted by the National Primary Health Care Development Agency (NPHCDA) and is being implemented in 4 other states, with plan to scale nationwide and expand its scope to broader primary health care.
Additionally, SCIDaR also facilitated various learning tours between selected states to directly observe and engage with stakeholders in the field and to better understand the implementation. For example, the Bauchi state team conducted learning visits to Kano state to understand the transition processes necessary for moving from outsourced vendor-led deliveries to state-led deliveries. Through this tour, Bauchi state was also able to effectively transition its vaccine delivery model to an insourced model at a lower cost and with greater efficiency.
Nigeria’s Peer Learning Exchanges used the MOU platform as a starting point to foster state and partner collaboration. Some of the key challenges have included the slow pace of implementation of the resolutions from the exchanges due to programmatic constraints, system bureaucracies and inertia at the state level. Competing priorities in the state also affect the scheduling and the sessions, which require convening all key officers for relevant themes in the discussions. However, the Peer Learning Exchanges have overall been a success, and some of these implementation lessons have gone on to be used in other countries, including Chad, Niger and Guinea, where similar MoU approaches have been established. However, the existence of such an initial platform may not be necessary for other countries interested in emulating Nigeria’s example. The several key factors that were critical to the Peer Learning Exchanges’ success included:
- The Peer Learning Agenda provided a platform for high-level decision makers to come together to make strategic decisions and high-level agreements.
- Partners were engaged to support state success by providing technical assistance to build state-level capacity. For example, Solina embedded a staff member in the finance departments of the state health agencies to provide day-to-day on-the-job coaching to agency staff, until the staff were confident enough to train others
- Resolutions were achievable with the existing financial resources and other system enablers already available to the states through the MoU
- The Peer Learning Agenda’s strategy of showcasing state success stories created a sense of healthy rivalry between states that provided an incentive for them to meet their resolutions.
- National level stakeholders (specifically, the NPHCDA) were engaged to participate in the meetings/workshops, address issues arising from national policy and disseminate learning to other non-MoU states.
- The topics discussed during the sessions were jointly selected with stakeholders to address relevant, common challenges. Solutions were also developed to be fit-to-purpose with contextualization to state-specific realities. For example, with the COVID-19 pandemic, the SCIDaR team plans to convene the states to discuss critical and SMART solutions for building back better integrated PHC systems – a topic that is timely, relevant and addresses the needs of all 6 states.
 NDHS 2017
Locating Procurement Responsibilities at Appropriate Level of Government
Authors: Yasodhara Kapuge, Anuji Gamage, Nihal Abeysinghe, Soofia Yunus
Background: Devolution in Pakistan
In 2010, Pakistan’s parliament passed the 18th Amendment, which restructured the country as a decentralized federation with substantial devolution to provinces of legislative and policy-making power in key areas such as health, education, and social welfare. Within provinces, there is additional decentralization of government activities to the lower-level: the districts.
Under these changes, the Ministry of National Health Services Regulations and Coordination plays a key role in national policy-making, strategy, vision, and planning , but it is the provincial and local governments that take the lead in operationalizing these policies. The decentralized system was intended to provide districts with the freedom and autonomy to utilize their allocated budgets according to their needs and to exercise managerial authority over human resources to improve the efficiency of the services and encourage community participation. As a result, 60% of government health expenditure is managed at the district level.
After devolution, responsibility for the Expanded Programme in Immunization (EPI) shifted to the provincial governments. The national EPI holds limited responsibility for vaccine procurement, managing immunization supply chain, coordination, and technical guidance. Although the federal government has been endorsed by the provinces to manage the vaccine procurement process, the provinces are responsible for paying for vaccines as per their annual forecast as well as service delivery, which they fund through provincial government revenue.
Key Challenges for Vaccine Procurement
Pakistan is the only country in Gavi’s portfolio that pays for vaccine procurement at the provincial level. Delayed release of funds from the provincial level is a challenge for all the provinces in Pakistan, particularly Sindh, Khyber Pakhtunkhwa (KP) and Baluchistan, due to slow bureaucratic processes. Annual budgetary allocations for health are approved by the legislature, handed over to provincial health departments, and ultimately to the District Health Officers (DHOs). DHOs release funds for the EPI from the same fund, which can result in competing priorities and a slowing down of the process.
Prior to devolution, the federal EPI’s low technical capacity for vaccine procurement resulted in sub-optimal management of the procurement processes for vaccines, supplies, and equipment, as well as equipment maintenance. Immediately following devolution, these challenges resulted in stock-outs, the procurement of low-quality vaccines, and overall negative effects on coverage outcomes. World Bank analysis indicated that Pakistan incurred an average annual loss of $38 million due to such inefficiencies in vaccine procurement and program management, in addition to declines in the quality and equity of immunization services.
National Immunization Support Project (NISP)
In April 2016, the World Bank approved $50 million to increase the availability of vaccines for infectious diseases for children under two years of age in Pakistan through the National Immunization Support Project (NISP). The development objective of the NISP for Pakistan was to increase equitable coverage of services for immunization against vaccine preventable diseases in Pakistan.
The NISP also received additional support totaling $84 million by Gavi the Vaccine Alliance, into the World Bank administered Multi-Donor Trust Fund (MDTF), and the United States Agency for International Development support that was not routed through the trust fund. The MDTF for the NISP was established to help address the long-standing issues of inefficiency and unsustainability caused by the fragmented financing structure of Pakistan’s EPI program. The MDTF permits funds to flow directly to provinces through disbursement-linked indicators (DLIs). Funds are disbursed through two mechanisms:
- Through the DLI mechanism, the funds are disbursed to the provinces on achievement of desirable results after verification by federal EPI through a third party.
- Under the Technical Assistance (TA) mechanism, funds are provided to the EPI in designated accounts for provinces and the national level. The funds may be used for cold chain, goods and consultations depending upon the needs of these areas.
To ensure timely co-financing payments for Gavi vaccines and sustainable fund availability for traditional vaccines, a mechanism for pooled vaccine procurement was established as a part of NISP. The mechanism allows the provinces to pool their funds for vaccine procurement as per their need of vaccine forecast, which is then managed at the national level. Pooled procurement often offers a way for a purchasing entity to join a larger pool of purchasers, generating a larger market and driving down prices than self-procurement , but it must be properly managed to be efficient. Accountability for pooled vaccine procurement was improved through frequent review meetings and stock-takes across the provinces. The pooled procurement mechanism has successfully implemented in the country under the NISP that procured vaccines for whole of the country, resulting in an uninterrupted supply of vaccines for the past four years. Additionally, when the COVID-19 outbreak began earlier last year, NISP’s pooled procurement mechanism provided a fast, reliable and structured way to procure essential supplies such as masks and other personal protective equipment for frontline health care staff.
Through the NISP, national and provincial programs have made adequate and sustainable financing available in the national and provincial recurrent budgets for vaccine procurement and immunization service delivery. The project is scheduled to end in 2021 , however case for its extension is in process.
 Afteb, Mishaal. 2019. “Decentralization and the Provision of Public Services: A Case Study of Khyber Pakhtunkhwa, Pakistan.” PhD in Political Science, University of Connecticut.
 Kumar, Santosh. 2017.
 Haque, Minhaj ul , Muhammad Waheed, Tayyeb Masud, Wasim Shahid Malick, Hammad Yunus, Rahul Rekhi, Robert Oelrichs, and Oleg Kucheryavendo. 2016. “The Pakistan Expanded Program on Immunization and the National Immunization Support Project : an economic analysis.” Nutrition and Population (HNP) Discussion Paper Series: The World Bank.
 UNICEF. 2018. Pakistan Implementation Research for Immunization – A compilation of project objectives, results and recommendations. Pakistan: Implementation Research and Delivery Science (IRDS) Unit, Health Section, UNICEF.
 Haque et al. 2016.
 Coe, Martha, Jessica Gergen, Michaela Mallow, Flavia Moi, and Phily Caroline. 2017. “Landscaping Analysis”. Sustainable Immunization Financing in Asia Pacific. Washington, DC: ThinkWell.
 WHO. 2017.
 Oelrichs, Robert, Aliya Kashif, Jahanzaib Sohail, and Shaza Khan. 2020. “Pakistan’s National Immunization Support Project: An anchor for collaboration during COVID-19 (coronavirus).” World Bank.
 Oelrichsaliya, Robert, Kashifj Ahanzaib, and Sohailshaza Khan. 2020. “Pakistan’s National Immunization Support Project: An anchor for collaboration during COVID-19 (coronavirus).”
 The World Bank. 2020. “National Immunization Support Project.” https://projects.worldbank.org/en/projects-operations/project-detail/P132308.
Using Subnational Expenditure Data to Advocate for Immunization Resources in Vietnam
Authors: Ravi Ranan-eliya, Anuji Gamage, Yasodhara Kapuge
Vietnam’s healthcare delivery system operates at four administrative levels: central, provincial, district and commune. At the national level, the Ministry of Health (MOH) has responsibility for overall health policy, establishing the framework for financing, and overseeing the provision of health services. The MOH’s Expanded Program on Immunization (EPI), situated in the National Institute for Hygiene and Epidemiology (NIHE), is directly funded by the national government budget. It sets the overall strategy and supervises the national immunization program. The EPI decides which vaccines are included in the national program, leads public media and communications efforts, procures, and distributes vaccines to lower levels, monitors national efforts, and provides training and overall technical support. The MOH also makes budgetary transfers from its own budget to lower levels for health care delivery, which supplements additional resources mobilized by lower levels of government, including payments to health care facilities from the national health insurance scheme.
The EPI is implemented at the provincial level by the Preventive Medicine Centers (PMCs), under the guidance of the regional and national EPI offices. These supervise district medical centers (DMCs) and commune health centers (CHCs). CHCs are responsible for conducting monthly immunization services through fixed immunization sites and deploying mobile teams to reach remote areas to administer routine vaccines.
In 2012, Vietnam’s EPI manager requested the support of the Sustainable Immunization Financing (SIF) Project, implemented by the Sabin Vaccine Institute, to resolve a lack of immunization expenditure reporting from all provinces, a critical benchmark for the Global Vaccine Action Plan. The national EPI team also strongly believed that having data on local government spending would help to improve resource mobilization and allocation at the national and local levels. In 2013, only 25 of 63 provinces (40%) reported annual provincial government spending on immunization activities.
Provinces indicated a reluctance to share expenditure data due to fears of subsequent cuts in funding. EPI managers were concerned low budget execution rates may make it appear as though subnational programs were over-funded, when in reality budgeted funds were often not fully released, as problems like cash hoarding and budget misclassification prevented money approved by Parliament from ever reaching provincial and district bank accounts.
SIF’s Budget Flow Analysis Tool and Advocacy
The SIF program’s first step was to hold a briefing with MOH EPI managers from the four regions of Vietnam, and their representatives from the Ministry of Finance (MOF) and the National Assembly. The aim of this briefing was to discuss and analyze resource availability, resource allocation, programmatic performance and annually increasing EPI budget requests, in order to increase immunization funding through intentional, data-driven conversations to better inform policymakers. Other objectives of the briefing were to engage the provinces as active stakeholders in the EPI program, credit local officials for their support and management of the implementation of the EPI program in their region, and secure political commitment from provincial governments to allocate more resources to immunization programmes in domestic budgets across the country. Securing support for EPI from international agencies and foreign governments such as WHO, UNICEF, GAVI, LUXEMBOUTGH, JICA and other local financial resources were also discussed.
Next, an analysis of subnational budget flows helped the national EPI team understand how the provincial levels were spending money to prevent overlaps or gaps in spending. Regional EPI managers supported by the SIF Program were provided with a standard budget flow analysis tool which was adapted from the Public Financial Management Performance Measurement Framework used by the World Bank. EPI managers found significant upstream problems such as “cash hoarding“ by the Treasury Department and misclassification of funds that had been allocated for immunization programming but actually used elsewhere. Taking these diversions in account, the SIF program calculated that Vietnam’s 2014 EPI budget was to be cut by 29%.
Building on relationships established during the initial briefing, the Director of the Department of Social Affairs at the National Assembly supported the EPI team to organize another briefing for the members of the National Assembly by the EPI team in October 2013, and again in November 2013. During these briefings, the EPI team presented the results of this analysis, the current situation of the EPI, its financing issues, and the rationale for considering immunization to be a priority program. As a result of these briefings, Members of the National Assembly placed greater priority on the EPI program and restored the EPI’s allocations in the 2014 budget to 120% of its original amount. The national budget increased an additional 35% by 2015.
The success of these analysis, advocacy and relationship-building efforts also encouraged provinces to improve their expenditure reporting. Eighty percent of the 63 provinces reported expenditures by the end of 2013. This was expected to reach 100% reporting by the end of the following year. Additionally, provincial government spending on immunization increased 55% between 2012-2014. In 2015-2016, Parliament worked with the EPI to organize annual provincial stakeholder workshops to discuss immunization financing and share expenditure data.
Vietnam provides an excellent example of how improving the reliability and quality financial data, when used in combination with improved coordination and communication between levels of government, can lead to increase transparency, improved understanding of immunization expenditures and funding flows, and increased funding for immunization programs.
 Nguyen, Trung Dac, Anh Duc Dang, Pierre Van Damme, Cuong Van Nguyen, Hong Thi Duong, Herman Goossens, Heidi Theeten, and Elke Leuridan. 2015. “Coverage of the expanded program on immunization in Vietnam: Results from 2 cluster surveys and routine reports.” Human vaccines & immunotherapeutics 11 (6):1526-1533. doi: 10.1080/21645515.2015.1032487.
 Nguyen et al. 2015.
 SABIN Vaccine Institute. 2012. SUSTAINABLE IMMUNIZATION FINANCING: Summary Digest.
 SABIN Vaccine Institute. 2013. Immunization Financing News. In Quaterly News from the SIF Program: SABIN Vaccine Institute.
 McQuestion, Michael, Andrew Carlson, Khongorzul Dari, Devendra Gnawali, Clifford Kamara, Helene Mambu-Ma-Disu, Jonas Mbwanque, Diana Kizza, Dana Silver, and Eka Paatashvili. 2016. “Routes Countries Can Take To Achieve Full Ownership Of Immunization Programs.” Health Affairs 35 (2):266-271. doi: 10.1377/hlthaff.2015.1067.
 McQuestion et al. 2016.
 Burrous, Haley , Andrew Carlson, Hélène Mambu-ma-Disu, Mike McQuestion, Eka Paatashvili, and Dana Silver. 2019. A Decade of Sustainable Immunization Financing. SABIN Vaccine Institute.
 Burrous et al. 2019.
 McQuestion, Mike 2016. Sabin SIF country fact sheets.
 McQuestion 2016.