Published on Investing in Health

How to finance “The Big Catch-Up,” allowing more children and communities to be protected from vaccine-preventable diseases

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 nurse (hands in far left) prepares to vaccinate children at Redemption Hospital in Monrovia Millions of children missed out on receiving routine immunizations during the pandemic. Copyright: Dominic Chavez/World Bank

‘The Big Catch-Up’ is the theme of this year’s World Immunization Week, emphasizing the need to catch-up on the millions of children who missed out on receiving routine immunizations during the pandemic. Data recently published by WHO and UNICEF show that globally, the percentage of children who received three doses of diphtheria, tetanus and pertussis-containing vaccine (DTP3)—a marker for immunization coverage within and across countries—fell 5 percentage points between 2019 and 2021 to 81 per cent. A new report released by UNICEF earlier this month, finds that 67 million children across the world missed out on either some or all routine vaccinations between 2019 and 2021, and 48 million children didn't receive a single dose during this time period.

This sharp two-year decline follows almost a decade of stalled progress, underscoring the need for investment in primary health care (PHC) services, with explicit support to strengthen and sustain essential immunization services. For the past three years, resources and personnel have been diverted from providing essential health services, including immunization, to COVID-19 vaccination efforts. As a result, the demand for routine vaccines has slowed down and the risk of vaccine-preventable disease (VPD) outbreaks—including measles, diphtheria, polio, and yellow fever—is increasing across all regions.

The pandemic response has justifiably required dedicating attention and resources to support rapid scale-up and delivery of COVID-19 vaccines, at times via coordination, financing, delivery and other approaches outside of or on top of already overburdened health systems. But the time is now to rebuild stronger primary health care services for essential immunization in the future.

Preparing for tough times ahead: securing financing for immunization programs through coordinated, data-based decision making and advocacy

The coming months and years will bring increasing financing challenges to immunization programs in many low- and lower-middle income countries due in part to constrained or shrinking health budgets.  As the COVID-19 emergency phase ends, projections show many countries with falling government budgets, due to declines in revenue and borrowing. World Bank projections suggest that some 40 countries (29 of which are low- or middle-income) will not return to pre-pandemic levels of income per capita, even by 2026. Contracting overall government spending could have large repercussions on domestic government expenditure on health and PHC, including on immunization, unless action is taken.

Governments will need to find ways to protect financing for PHC interventions, including immunization, given the health and economic benefits they confer. Strategies for these difficult times include protecting government allocations for immunization and ensuring that money is spent so as to maximize allocative and technical efficiency.

The Lancet Global Health Commission on financing primary health care suggests that policy makers can use three categories of policy tools to protect resources for PHC, including immunization. Tools related to budget allocation include program budgeting, which provides visibility and transparency of government support for immunization. Tools related to budget execution include how health services are purchased and paid for. For example, a recent trial in Nigeria found that both performance-based financing (PBF) and direct facility financing (DFF) were more effective than input-based financing in terms of increasing DTP3 coverage. Service delivery levers might include: clarity and transparency around the vaccines that are to be provided, and service delivery norms, including the number of immunization staff per unit population.

Governments should ensure that processes are in place for prioritizing immunization program investments and that these are linked to broader health sector prioritization processes.  One way to prioritize such investments and link them to broader processes is through the National Immunization Strategy (NIS) strategic framework approach. The success of these NISs will depend on: (i) making allocation decisions within immunization programs using best available evidence to inform new vaccine introductions, product choices and delivery strategies; and (ii) recognizing that important allocation decisions are taken at higher levels of government, ensuring that NIS processes are embedded in broader sectoral planning (and prioritizing) and budgeting processes.

Governments may also address technical inefficiencies in spending, so as to get better value-for-money. Studies find wide variations in efficiency in immunization sites, both across countries and within countries. Some reforms focused on enhancing spending efficiency might be immediate, such as bulk tenders for vaccines. Many inefficiencies, such as leakage due to corruption or fraud, are structural; tackling them requires addressing historical precedents and social norms in addition to administrative processes. Program managers should draw on available guidance and experience and should go for quick wins but at the same time start to lay the foundation for longer term efficiency improvements.

World Bank support for immunization financing

The World Bank supports sustainable immunization financing, through analytics, capacity building and operations. For example, across many countries, the Bank provides technical assistance aimed at improving public financial management, implementing or strengthening strategic purchasing of health services, or otherwise identifying addressing inefficiencies in service delivery. The World Bank has a long history of financing operations that include immunization. Recently, this has included 115 COVID-19 vaccine projects, across 78 countries, many of which have supported broader immunization and health systems’ strengthening.

We would like to thank the IA2030 Sustainable Financing Working Group for sharing their valuable insights.


Phillis Kim

Senior Health Specialist and Behavioral Scientist

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