Madagascar's immunization costing and financing situation
Macroeconomic and health system context
Madagascar had positive economic growth from 1997 and in 2000 its per capita GDP was $243. As a result of the political crisis in 2002, the GDP per capita income declined and the share of the population living under the poverty line increased from 69% in 2001 to 80% in 2002 - Madagascar is a HIPC country. The government is introducing some reforms in the health sector through the introduction of a minimum package of services, and the decentralization of the budget to the district level. In 2000, the per capita expenditures on health were $5.8.
Immunization programme objectives
Madagascar’s immunization coverage remained at the same level for the past few years with recent increases. According to the WHO and UNICEF best estimates, the DTP3 coverage in 2000 was 55%. The national immunization programme’s objectives are to improve the coverage for each vaccine; eradicate polio by 2005; eliminate maternal and neonatal tetanus; control measles in the country; and introduce new vaccines (Hepatitis B and Hib). Specific objectives of the programme include the following: increasing immunization coverage to 80% by 2005 for all antigens and for under 1 year old infants; reduce the dropout rate to less than 15% for DTP-Hepatitis B, polio, measles and tetanus toxoid; assure 100% injection security and management of wastage by 2013; improve the coverage of the cold chain to 90% of the country by 2005 and upgrading of equipment by 90% by 2013; introduce Hib vaccine in 2006; undertake supplementary immunization activities against measles in 2004 and maternal and neonatal tetanus in 2005; and improve disease surveillance of maternal and neonatal tetanus and measles.
Immunization costs and financing
In 2000, the year before Vaccine Fund support began, Madagascar spent $2.4 million to deliver routine immunization services. The programme-specific spending on routine immunization service equated to about $7.1 per DTP3 vaccinated child or $0.15 per capita. Spending on routine immunization rose in 2003 to $5.4 million, an increase of 225%, due to the introduction of Hepatitis B into the programme.
In absolute terms, the government’s expenditures on the immunization programme increased by 41% between 2000 to 2003. However, in relative terms, the share of funding from the government decreased from 46% to 29% of overall immunization financing, because of GAVI/Vaccine Fund supported new vaccine introduction. The government pays mainly for vaccines, injection supplies salaries, transport costs, and some capital costs (cold chain equipment and vehicles) while donors pay for other vaccines, injection supplies, some operational costs, and cold chain equipment. The main funding partners in the Vaccine Fund year are UNICEF, WHO, GAVI/Vaccine Fund and USAID. Donors that provided funding in 2000 include JICA, Rotary International, CIDA and UNFPA.
Routine immunization financing by source - 2003
Future resource requirements, financing and gaps
Resource requirements of the programme are projected to increase with increasing expenditures on capital costs and supplemental immunization activities. It is also projected to increase with planned introduction of new vaccines (Hepatitis B and Hib). The average annual resource requirements during 2003-2006 for the NIP are estimated to be $10.4 million. Approximately three-quarters of the funding is considered secured. If funding classified as probable is included as well, over 80% of the resource requirements to meet programme objectives are covered during the remaining years with Vaccine Fund support.
During 2003-2006, the gap in funding for the NIP is on average $2.7 million each year if probable funding is not included and $2.0 million if probable funding is included. The average annual gap in the post-Vaccine Fund period (2007-2012) with secure and probable funding rises to $3.9 million, an increase of 200%.
Average annual funding gaps (millions of US$)
Financial sustainability strategies
Several strategies have been developed to increase financial sustainability and lower the gap in funding. These include: (1) to increase government resources for immunization; (2) to increase resource mobilization from external partners; (3) to improve mobilization of adequate resources through improved planning; (4) to improve the reliability of funding from both government and partners; and (5) to improve the management of the national immunization programme to increase efficient use of resources.