Money for vaccination project major concern

Prime Minister Narendra Modi launches the first indigenously developed and manufactured vaccine against rotavirus in New Delhi. (Photo: PTI)

World Immun-isation Week was commemorated in the final week of April. The moment was particularly important for India because a little over a year ago the Narendra Modi government inaugurated Mission Indradhanush, aiming to “immunise every child” against seven vaccine-preventable diseases by 2020 and achieve above 90 per cent coverage. This is ambitious because India’s current coverage is just above 65 per cent.

The mission is doubly ambitious because shortly after coming to office in 2014, the government exp-anded India’s Universal Immunisation Program-me (UIP) by bringing in four new vaccines — the injectable polio vaccine (IPV), and those against rotavirus (which causes diarrhoea), rubella and Japanese encephalitis. Given India’s population, the roll out of these vaccines, especially of the IPV, will be the largest in any country in immunisation history.

Each year half a million children in India die of vaccine-preventable diseases.

Success for Mission Indradhanush is vital. Do consider that while India’s UIP vaccinates children against seven killer diseases, the World Health Organisation estimates there are some 25 diseases that can be prevented by vaccines. Some of these diseases don’t occur in India in significant numbers. Yet, others do implicate India and the vaccines are used in the private sector, protecting children from well-off families.

Inevitably the UIP will be expanded further in years to come. Where will the money come from The question is of concern to not just immunisation and public health (India spends 1.3 per cent of GDP on health, less than half of what China does, a third of Brazil’s outlay). The question arises in the larger context of development financing.

In 2015, the 17 Sustainable Development Goals (SDGs) were announced by the United Nations. The onus of their attainment is on India, just as the onus of their predecessors, the Millennium Development Goals, was on China. The problem of finding adequate finance for the SDGs, especially given the lacklustre global economy, was the subject of the financing for development conference in Addis Ababa (Ethiopia) in July 2015. Minister of state for finance Jayant Sinha led the Indian delegation.

As is apparent, there is no immediate solution. The search for money, including for alternative and innovative mechanisms of financing, continues. This is not an issue limited to health or immunisation; financing for climate change adaptation technologies and for clean energy is even more pressing. Even so immunisation, with its front-loaded costs, especially for a population as large as India’s, poses a trenchant challenge.

For India, tackling immunisation finance emerges as an arresting case study. For the roll out of the expanded UIP, the government has got half a billion dollars in support from Gavi, the international vaccine alliance. Yet, this is a bridging tool, not a long-term solution. As India’s GDP grows, the country will move out of eligibility for Gavi support by 2021. What next

Then there are fiscal constraints. The pressure on social sector spending in the Union Budget — in the final year of the UPA government and the first two years of the NDA government — has kept absolute outlay for health more or less static: '33,000 crore in 2012-13 and '37,000 crore in 2016-17. With more revenue and social and health sector policy design autonomy going to the states, there are serious questions about the sustainability of an expanded (and likely to further expand) UIP.

A recent report published by the IKP Trust and Global Health Strategies — “Exploring Healthcare Financing Mechanisms for India” — studied the possible cost and funding options for universal health insurance and, in a specific example, for an expanded immunisation programme. It assessed many possibilities, from sin taxes and a health cess to corporate social responsibility funds. It must be said experience with such instruments has been uneven.

Also brought up was the idea of a “National Trust Fund for Health and Immunisation”. “Trust funds”, the report said, “are emerging as promising financial instruments for funding immunisation services because they have the potential to ‘protect’ resources over a long period, but experience to date is limited.” Bhutan famously set up a national trust fund in the late 1990s when it found cost of vaccines and drugs made up close to 50 per cent of public health spending. The trust fund protected the country from volatility in prices and donor support.

Freedom from such volatility is critical for India, and that is why it has prioritised self-financing its major health initiatives. Figures bear this out. Pakistan is dependent on external sources for 89 per cent of its spending on vaccines, and Bangladesh for 70 per cent. In contrast, China self-finances 100 per cent. In India, the government spending on vaccines makes up an appreciable 77 per cent.

Maintaining that figure is a national commitment. As such, for health as for other SDGs, India needs to generate its own resources.

For immunisation specifically, the writers of the report, in consultation with officials at the Union health ministry and economists at the National Institute of Public Finance and Policy, came up with two suggestions. First: “All expenditure on maternal and child health and on preventive healthcare, including but not limited to immunisation, should be classified as capital expenditure by the government rather than revenue expenditure, as it stands currently.”

Second, it was calculated India needed Rs 3,000 crore a year (given current prices) to meet its immunisation targets and give requisite shots to all its children. Could that sum be allocated additionally and separately from the health ministry budget and carved out as a recurring outlay, year after year, indexed for inflation

Practicable ideas for the finance ministry to consider.

The author is distinguished fellow, Observer Research Foundation. He can be reached at malikashok@gmail.com