Bhutan's immunization costing and financing situation
Macroeconomic and health system context
Bhutan’s economy has been growing at an annual rates close to 7% and is projected to continue to grow at similar levels in the next few years.
The health sector has been implementing health reforms with the decentralization of its administrative functions down to the peripheral levels. In addition, the Royal government created the Bhutan Health Trust Fund (BHTF) in 1998 to stabilize the flow of funding to the health sector. Specifically, the Trust Fund is used to insure:
- the provision of, and uninterrupted supply of primary health care supplies of vaccines, essential drugs, needles, syringes, cold chain equipment and other related drugs and equipment;
- to finance training, and strengthen programme management and human resource development; and
- to develop and implement management plans for drugs and vaccines, and strengthen monitoring capacity on pharmaceuticals.
In 2001, per capita national expenditures on health were $11.
Immunization programme objectives
According to the WHO and UNICEF estimates, the DTP3 coverage in 2001 was 91%. The national immunization programme objectives are to:
- sustain high national immunization coverage level at, or above, 90% for children under one year of age;
- achieve poliomyelitis certification by 2005;
- eliminate maternal and neonatal tetanus by 2005;
- achieve 90% reduction of measles cases;
- increase injection safety for all vaccines by the end of 2004;
- develop sustainability in the national immunization programme through national capacity building;
- strengthen surveillance for EPI diseases; and
- introduce sustainable inclusion of newer vaccines in the immunization schedule, justified through burden of disease studies.
Immunization costs and financing
In 2001, the pre-GAVI Fund year, Bhutan spent $0.4 million on programme-specific expenditures for routine immunization services and about the same amount on supplementary immunization services. The programme-specific spending on routine immunization service equated to about $7.0 per DTP3 vaccinated child or $0.18 per capita. Programme-specific spending on routine immunization increased by 16% in 2003, the first year of GAVI Fund support, due to an increase in expenditures on vaccines.
Although the absolute amount of total expenditures paid by the government for the programme increased during the two years, the percent of total expenditures decreased to 45%, due to an increase in donor contributions for new vaccines and other recurrent expenditures. The government pays mainly for salaries and maintenance and overheads, while donors pay for vaccines, injection supplies, training, social mobilization, transport, supplementary immunization, and capital costs. The main funding partners are the GAVI Fund, UNICEF, WHO and JICA.
Routine immunization financing by source - 2003
Future resource requirements, financing and gaps
Resource requirements of the programme are projected to increase as expenditures on vaccines are projected to rise. The average annual resource requirements during 2004-2007 for the NIP are estimated to be $0.6 million per year. Over 70% of the funding is classified in the FSP as secure during these years. If funding classified as probable is included as well, 90% of needs are covered.
Only a small annual gap in funding for the NIP exists ($0.07 million) if both secure and probable funding is included ($0.2 million if probable funding not included) during the remaining GAVI Fund years (2004-2007). During the post-GAVI Fund years (2008-2013), the gap remains low at an average of $0.07 million per year if both secure and probable funding are taken into account. The reason that the post GAVI Fund gap is so small is that the government and Trust Fund are projected to begin financing tetravalent vaccine at that time.
Average annual funding gaps (millions of US$)
Financial sustainability strategies
Several strategies have been developed to improve financial sustainability of the NIP. These strategies include:
- improve coverage through increased micro-planning;
- reduce vaccine wastage through the use of the multi-dose vial policy and possible reductions in vial size;
- improve coverage of hard-to-reach populations;
- improve planning, procedures and supervision of cold chain management; and
- improve reliability of cash flow and disbursement procedures for immunization.