The GAVI financial sustainability planning process
In its first phase of support (2000-2005), the Global Alliance for Vaccines and Immunization (GAVI) sought to address the question of financial sustainability in a systematic way. It has done so, first, by requiring that all countries receiving GAVI Fund grants indicate in their applications, in general terms, how they plan to finance the added recurrent cost burden in the future, and commit to preparing a detailed Financial Sustainability Plan (FSP). Because GAVI Fund support has an initial term of five years, countries needed to plan mid-way through the funding period, how they will manage the transition and finance the costs of immunization services with new vaccines after the end of the initial commitments from the GAVI Fund.
Secondly, GAVI defined financial sustainability in a way that supports the achievement of the immunization programme's long-term programme objectives. In June 2001, the GAVI Board accepted the following definition of financial sustainability: "Although self-sufficiency is the ultimate goal, in the nearer term sustainable financing is the ability of a country to mobilize and efficiently use domestic and supplementary external resources on a reliable basis to achieve current and future target levels of immunization performance in terms of access, utilization, quality, safety and equity". Through this definition, GAVI moved away from earlier conceptualization that equated financial sustainability with self-sufficiency in vaccine procurement and towards the idea that financial sustainability: (a) is a shared concern and a shared responsibility of both governments and their development partners; (b) requires matching financing to evolving programme objectives; (c) includes the concepts of adequate and reliable financial resources, focusing not only on the quantity of funds but on how well they reach the levels where they are needed; and (d) is related to both mobilization and efficient use of resources.
Thirdly, GAVI developed and supported the use of financial sustainability planning guidelines and tools to help national decision makers understand the current cost and financing patterns of their immunization programmes, project forward both future costs and prospects for financing, and defining and initiating implementation of a strategy for mobilizing resources, reducing unnecessary costs, and making the flow of future funding more reliable.
The Financial Sustainability Plan (FSP) is a document that assesses the key financing challenges facing the national immunization programme, and describes the government’s approach to mobilizing and effectively using financial resources to support medium and long-term programme objectives. It is prepared by the national government (including managers of the national immunization programme, and officials of the Ministries of Health and Finance), in collaboration with other members of the Inter-Agency Coordinating Committee (ICC) and/or other relevant donor groups. The financial sustainability plan is expected to be a key instrument for governments to use in planning for the financial health of the immunization programme – and in advocating among the Ministry of Health, Ministry of Finance and development partners to support planned and agreed programme expansion and improvement.
Financial sustainability of the immunization programme is part and parcel of setting priorities, mobilizing resources, and using resources effectively throughout the health sector. While the FSP was a requirement of GAVI during its first phase of support and was submitted as a stand-alone document, it was expected that the plan would be part of the broader strategic planning processes in the health sector and immunization, and would take as a starting point the public sector commitment to the health sector, and priority-setting within the sector. The FSP would therefore build on - and contribute to - on-going discussion about national and health sector priorities and mechanisms for reliable and sufficient financing of those priorities (ex: the immunization financing database).
For GAVI, the financial sustainability plan was designed to ensure that every country receiving GAVI Fund support had a reasonable and feasible plan for financial sustainability. In addition, information from all countries FSP will improve global understanding of the size of the financing challenges, and the strategies countries and their development partners are employing to meet those challenges.
Evaluation of the financial sustainability planning process revealed that for both for countries and for the larger community of international donors and technical agencies, the experience has been a positive one. Although the data-intensive process of preparing an FSP required a major commitment of time and effort, in virtually all countries immunization programme managers and other national officials reported that the effort was more than equalled by the benefits. Most indicated that they had not previously had an understanding of their own programme costing and financing structures, or fully comprehended the financial challenges of introducing new vaccines supported by the GAVI Fund, and the financial implications that will emerge over the medium term to sustain the needs of the immunization programmes. Many expressed the desire and need to have such a document and information for other health interventions. Moreover, the FSP process had contributed to building capacity in an important area and built bridges between the Ministries of Health and Finance, resulting in improved communication.
One of the limitations of the FSP was that it was often detached from national multi-year plans (MYP) for immunization and these processes were rarely synchronized with broader strategic planning and budgeting processes in the health sector. As a consequence, sustainable vaccine financing was often not integrated in national plans and budgets. Recognizing this weakness, in late 2005, WHO and UNICEF, together with GAVI Alliance partners, developed Guidelines for developing a comprehensive Multi-Year Plan (cMYP) for immunization. This new approach was guided by the need to simplify and harmonize what had become a proliferation of various immunization planning activities at national level which lead to duplication of efforts, high transaction costs to national and partners with variable degrees of national ownership, and a lack of alignment with national systems. Through the Global Immunization Vision and Strategy (GIVS) initiative and framework, the cMYP process marks current efforts to streamline immunization planning process at national level into a single comprehensive and costed plan. It is within this context that these new guidelines build on existing multi-year planning experience, while adding the critical elements of costing and financing by drawing heavily upon the methods developed for the immunization Financial Sustainability Plans. Likewise, the costing and financing exercise builds on the FSP costing tools and methodologies.
In December 2006, the GAVI Alliance Board endorsed the principles that future applications for GAVI Fund support will be assessed as part of comprehensive multi-year plans for immunization and, where appropriate, broader health sector planning processes.