No time to lose: we must increase budgets now for COVID-19 rollout

This blog provides information for colleagues concerned with COVID-19 immunization about the need for Ministries of Health and Ministries of Finance officials to work together to budget for COVID-19 vaccine rollout.

Authors: Peter Cowley, Nathalie Vande Maele – all World Health Organization

Acknowledgement: We appreciate contributions shared by and comments to the blog received from Helene Barroy (WHO/HQ), Amos Petu, Juliet Nabyonga, Alexis Satoulou (AFRO), Juan-Pablo Pagano (PAHO), Valeria De Oliveira Cruz, Tsolmongerel Tsilaajav (WHO/SEARO), Tessa Edejer Tan Torres, Tania Cernuschi (WHO/HQ). We would like to thank Alison Dunn for editing the blog.

Two key messages:

  1. Governments need to formulate robust health budgets that include COVID-19 vaccines; if insufficient funds are allocated to immunization, there is a risk of last minute reprogramming.
  2. Immunization and health colleagues therefore need to engage in participatory budget planning right now - May 2021 onwards - to influence the plans and allocation for the financial year 2022.

With SARS-Cov2 ravaging communities across the globe, governments are looking for practical ways to rollout the COVID-19 vaccine to their populations. The arguments for COVID-19 vaccination investment are simple:

  1. COVID-19 vaccination saves lives and reduces morbidity.
  2. The economy cannot open or restart safely and sustainably unless the epidemic is controlled. This requires COVID-19 vaccination in combination with non- pharmaceutical interventions.
  3. The immunization programme and the broader health system are enablers to a successful delivery of the COVID-19 vaccination.
  4. International trade is dependent on global vaccination against COVID-19.

Decisions about next year’s budget are being made in the coming months. It is therefore vital that immunization specialists, who understand the technical aspects of vaccine rollout within a health system, and colleagues in the Ministry of Health who submit proposals for health budget allocation, establish dialogue with the Ministry of Finance about the realities of financing this extraordinary national and international endeavour.

The budget cycle includes four steps: budget development, legislature approval, budget execution and expenditure tracking and auditing. In this blog, we focus on budget development. The COVID-19 Vaccine Introduction and deployment Costing tool (CVIC) supports credible COVID-19 vaccination costing to help facilitate a dialogue with stakeholders. This, or another planning and costing tool, can help you identify all necessary additional cost items needed for rolling out the COVID-19 vaccine, which will be the basis for budget preparation (and negotiations).

Why is it important to properly budget for the COVID-19 vaccine?

When COVID-19 struck in early 2020, it was an unforeseen event. In 2020, at the time of preparation of the 2021 health budget, most countries had not included costs to cover the procurement and programmatic rollout of the COVID-19 vaccine. Indeed, the vaccine did not even exist at that time.

When the vaccine became available in 2021 governments reprogrammed budgets (including away from the health sector and other health interventions), accessed grants or loans from development banks, raised new taxes or social health insurance premiums, or simply charged households at the point of service [1]. 

Inevitably, reprogramming funding away from essential health services, raising taxes and charging for services risks leading to increased poverty and ill health, particularly for those who are most vulnerable in a society. Replacing one cause of death with another is not the solution.

It is vital therefore for governments to be strategic about the use of shrinking government resources (declined revenues and/or increased expenditures) to encourage effectiveness, efficiency and equity and formulate robust funding plans for the COVID-19 vaccine rollout to proactively reprioritize immunization and health systems objectives in the context of COVID-19.

[1] https://reliefweb.int/report/egypt/egypt-provide-equitable-covid-19-vaccine-access-enar

https://timesofindia.indiatimes.com/india/covid-vax-price-to-be-capped-at-r250/dose-at-private-hospitals/articleshow/81250696.cms

Where and when can immunization-concerned colleagues take action?

Many economies have been hit by a recession in 2020 and vaccinating against COVID-19 may require more resources than are available, especially health workers who deliver the vaccines. Gross Domestic Product (GDP) and government revenues have declined in the majority of countries, meaning greater competition for resources and the need for the government to prioritize.

This current period in May 2021 is roughly when many governments – with budgetary calendar starting in January – will start to prepare for the 2022 health budget. All governments are fully aware of the need to vaccinate their populations, and this year’s budgeting process needs to accommodate discussions and allocations to the COVID-19 vaccine rollout, alongside meeting broader health sector goals.

Firstly, immunization colleagues should find out exactly when budget preparation is due to take place. Typically, this starts four to five months before the start of the fiscal year. Do you know what your country budgetary calendar dates are? 

What key activities will support effective budget planning for COVID-19 vaccine rollout?

1. Identify and understand COVID-19 vaccination budget provisions (use of supplementary budgets to "cover" programmatic costs), and who the budget holders are (for example, understand who holds the budget for costs of facilities, the health workforce, medical goods etc).

Financing the vaccination intervention may be complex as it could be a mix between using existing resources funded through Ministry of Health and adding new resources (most likely) funded through another budget (e.g., Ministry of Finance).

2. Find out exactly when budget preparation is due to take place. Typically, this starts four to five months before the start of the fiscal year. Do you know what your country budgetary calendar dates are?

Find out timings of budget preparatory meetings and participate in or contribute to activities between the Ministry of Finance and the Ministry of Health as much as possible. This is easier said than done. The evidence produced on scenario-based costs for the COVID-19 vaccination rollout should be leveraged in order to enter into discussions with the MOH. This can support integrated (and more efficient) costing for preparing the MOH budget proposal to be presented for negotiations with the MOF.

3. Prepare supporting narrative of your evidence-based budget plan (good cost estimates; proposed more efficient use of resources) to argue for support to enhance health systems to enable COVID-19 vaccination rollout without a negative impact on essential health services, and in turn request more than the usual routine immunization budget.

Immunization colleagues need to develop a sound financial plan backed up by planning tools, such as the National Deployment and Vaccination Plan (NDVP) and medium-term costs of COVID-19 vaccination (e.g., using the CVIC tool [2]). The plan and cost should show efforts to use resources efficiently (e.g., integrating remote COVID-19 vaccination delivery with other outreach essential health services). The costed plan should then be used by the health sector planning department to cost overall health budget needs and strategically allocate resources (i.e., identify what activities to reprogram for the future).

The Ministry of Health and Ministry of Finance need to be aware of the trade-off between the need to flow funds smoothly - and therefore sit funds with or near the Ministry of Finance - and the need to integrate COVID-19 vaccination with the health system to maintain current vaccination programmes and other essential health services - and therefore sit funds with the Ministry of Health.

4. Be loud, strong and persistent in your demands, and technically well prepared. This is a competitive space for scarce resources, despite the obvious health, social and economic benefits of a successful COVID-19 vaccine rollout.

[2] https://www.who.int/publications/i/item/who-2019-ncov-vaccine_deployment_tool-2021.1

If public resources are insufficient, how should the gap be funded?

Firstly, it is important to avoid privately financed vaccinations through out of pocket payments. This is not only from an equity and universal health coverage perspective. Domestic financing should be the primary route.

In 2021, external support through financing instruments is available and may complement government budgets. The COVAX Advance Market Commitment can support countries to access vaccines for 20% of a country’s population, as part of the COVAX facility. In addition, international financial institutions can provide grants and loans. The World Bank, ADB, IADB, IsDB alone approved over 17 billion US$ to support the COVID-19 health response.

Conclusion

The economic, social and health imperative to act has never been so urgent, yet many countries face real financial and health systems constraints. It is a huge challenge for nations to vaccinate their population, while maintaining essential health services and protecting the health system from being overwhelmed by the pandemic.

This is an urgent call to action to colleagues working in immunization, health planning and health finance to collaborate to influence the budget for COVID-19 vaccine delivery. With effective planning, all countries can develop a properly costed health sector strategy, which incorporates the maintenance of essential health services combined with an effective COVID-19 vaccination plan.

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