Comoros: immunization costing and financing situation
Macroeconomic and health system context
In recent years, Comoros been politically unstable after one of the 3 islands attempted to secede. Since a reconciliation agreement was signed in 2003, the country’s government and economy has become more stable and has been growing, although the growth has been moderate and declined to 2.3% in 2003.
The economy is dependent on a few agricultural products - cloves, vanilla, perfume essence, and considerable remittances from the Comorian Diaspora – and the level of investment in its economy is relatively low. The debt to GDP ratio is extremely high (80%) and the country’s efforts to join the HIPC Initiative (Highly Indebted Poor Country) have thus far been unsuccessful.
The country introduced decentralization into its health system in 1994. In 2001, per capita government expenditures on health were $8.
Immunization programme objectives
According to the WHO and UNICEF estimates, the DTP3 coverage in 2001 was 78%. The national immunization programme objectives are to:
- eradicate poliomyelitis;
- eliminate maternal and neonatal tetanus;
- eliminate measles;
- attain a coverage rate of 95% for the EPI antigens;
- eliminate vitamin A deficiency;
- introduce hepatitis B vaccine in 2003 and haemophilus influenzae type b vaccine in 2006; and
- introduce a surveillance system to monitor vaccine-preventable diseases.
Immunization costs and financing
In 2001, the pre-GAVI Fund year, Comoros spent $0.2 million on programme-specific expenditures for routine immunization services. The programme-specific spending on routine immunization service equated to about $10 per DTP3 vaccinated child, or $0.29 per capita. Programme-specific spending on routine immunization increased by 26% in 2003, the first year of GAVI Fund support, due to an increase in expenditures on personnel and training.
The share of programme expenditures paid by the national and regional governments declined to 29% in 2003, due to an increase in donor contributions for new vaccines. The government pays mainly for salaries, transport, and maintenance and overheads, while donors pay for vaccines, injection materials, training, capital costs, and supplementary immunization activities. The main funding partners are the GAVI Fund, WHO, and UNICEF.
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 projected to be $0.4 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, 80% of needs are covered.
An annual gap of $0.08 million will exist during 2004-2007 if both secure and probable funding are included ($0.12 million if probable funding is not included) during the remaining GAVI Fund years. During the post- GAVI Fund years (2008-2011), the gap will average $0.19 million per year if both secure and probable funding are taken into account. In other words, 42% of needs are unmet.
Average annual funding gaps (millions of US$)
Financial sustainability strategies
Several strategies have been developed to improve financial sustainability of the NIP. These strategies include:
- increase funding for immunization from the national health budget;
- introduce a budget line for the purchase of vaccines;
- advocate that the government pays for the cold chain and other equipment needs;
- advocate that immunization is prioritized in the Poverty Reduction Strategy Paper (PRSP);
- advocate for continued donor financing of the programme;
- use GAVI support to introduce Hib vaccine in 2007;
- begin funding injection materials after GAVI funding ends;
- advocate for contributions from non-governmental organizations, private societies, community associations, and internal and external Comorian Diaspora;
- increase training of health workers on vaccine wastage reduction;
- reinforce social mobilization activities to reduce drop-out;
- reinforce the outreach strategy; and
- reinforce supervision and monitoring of trained workers.