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Health Affairs Editor-in-Chief Alan Weil interviews Salin Sriudomporn from the Johns Hopkins Bloomberg School of Public Health on her paper in the January 2023 issue of Health Affairs examining gaps in immunization funding among 94 low and middle income countries.
Each week, Health Affairs Editor-in-Chief Alan Weil brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;01 - 00;00;39;01
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil. Vaccines exist for more than a dozen conditions that are responsible for the loss of millions of lives around the world. While vaccination is routine and fairly widespread in higher income countries, lower and middle income countries face significant barriers to achieving high rates of vaccination. Despite the existence of critical global funding mechanisms, sizable gaps exist between the resources available to provide vaccines and what's needed to achieve the full benefits of vaccination.
00;00;39;29 - 00;01;10;13
Alan Weil
What resources are needed to close the vaccination gap between high and low income countries? That is the topic of today's episode of “A Health Podyssey”. I am here with Salin Sriudomporn, a research associate health economist at the Johns Hopkins Bloomberg School of Public Health. Ms. Sriudomporn and coauthors published a paper in the January 2023 issue of Health Affairs, examining gaps in immunization funding among 94 low and middle income countries.
00;01;10;27 - 00;01;24;12
Alan Weil
They estimate a gap of $38.4 billion in the period 2011 to 2030. We'll discuss these findings and their implications in today's episode. Ms. Sriudomporn, welcome to the program.
00;01;25;07 - 00;01;26;24
Salin Sriudomporn
Hi, Alan. Thank you for having me.
00;01;27;15 - 00;01;49;21
Alan Weil
This is a really important topic and one that maybe many of our listeners haven't paid a lot of attention to. So I'm going to start pretty far back with you, if you don't mind. Let's just, if I could, let's just start with you explaining a little bit about why vaccine coverage is so important in low and middle income countries in particular.
00;01;49;22 - 00;01;53;19
Alan Weil
What problem are vaccines able to solve?
00;01;53;28 - 00;02;26;22
Salin Sriudomporn
Okay. So first of all, vaccine is one of the most effective health care intervention existing as we have seen in the past with, you know, cholera and measles outbreak, for example, and specifically low and middle income countries, because these countries have such high rates of infectious diseases, meaning that the cost of illness among these countries are high. That would include, you know, direct medical costs and other intangible costs, like loss of productivity for parents taking their children to see the hospital and have to take off their work, etc..
00;02;27;03 - 00;02;56;24
Salin Sriudomporn
And these costs are higher than the vaccine implementation cost itself. And so therefore, if we implement, that would be a cost saving in the long run for health system. And another benefit is it would benefit the community as a whole through herd immunity. So if people are vaccinated, then it's harder for disease to spread to those people who cannot be vaccinated if they're ill or have a weakened immune system.
00;02;56;24 - 00;03;03;19
Salin Sriudomporn
So that's like the general idea of why vaccine coverage is important, especially among low and middle income countries.
00;03;04;00 - 00;03;32;05
Alan Weil
So this is a critical health intervention both for people's health and as you note, it has significant economic benefits as well, which makes it a positive investment in these countries. Those two benefits have led to the creation of a number of global enterprises and efforts to increase rates of vaccination. This is a very complex environment, and I'm not going to ask you to explain all of it.
00;03;32;14 - 00;03;43;13
Alan Weil
But since your study focuses on the funding gap, we kind of need to start with the question of what funding is out there and kind of how it works. Can you say a little bit about that?
00;03;43;25 - 00;04;28;13
Salin Sriudomporn
Yes. So among the low and middle income countries, the countries we focus on in the study, majority of the financing are coming from two main sources. One being Gavi, the Vaccine Alliance, which is, you know, public and private global partnership with the goal of increasing access to vaccine among these low and middle income countries. And the second main sources is from the countries government expenditure itself in our study, the entire period of 2011 to 2030, Gavi financing was approximately 45.2% of the total financing, and government financing is 44.6%, which combined is already almost 90% of the total financing.
00;04;28;25 - 00;05;02;20
Salin Sriudomporn
And the other sources are development assistance for health. That's not including Gavi, of course. That's like 4.4%. And then we have out-of-pocket expenditure at 4.1%. And last is the pre-paid private spending, which is like the expenditure paid to voluntary health insurance, for example, and that is 1.6%. And the way Gavi funding work is that not all low and middle income countries are eligible for Gavi support.
00;05;03;26 - 00;05;38;08
Salin Sriudomporn
Only those countries that have the country's gross national income or the GNI per capita below a specific threshold. So, for example, in this year 2023, the eligible threshold is the GNI per capita below 1,730 US dollars. So for Gavi, support can change over time as the GNI per capita increases. So the government of Gavi’s eligible countries are actually expected to provide a fraction of the financing as well.
00;05;38;09 - 00;05;59;23
Salin Sriudomporn
So we would call that co-financing. As the GNI per capita increases, then the government co-financing level would also increase as well until they gradually become fully self-financing and no longer receive the support from Gavi. By then the government financing itself would come into play/increase.
00;06;00;07 - 00;06;31;14
Alan Weil
So the idea here is you have global assistance for the countries with the greatest need, and it tapers off as the country's ability to pay increases. But ability to pay doesn't necessarily mean willingness to pay. So the Gavi formula is based on per capita income, but then you have to convince the country as it moves, if you will, off the Gavi highest levels of support to come in and say, okay, you know, we have more income as a country,
00;06;31;14 - 00;06;58;20
Alan Weil
We need to put more into these efforts. I want to go into sort of how the gap all works and what it will take to close it. But I do want to move ahead to the question of, so what did you find? So you've explained to me what the sources are for funding today. But you look over this period, 2011 to 2030, what is that gap so that we can start talking about what it would take to fill it.
00;06;59;05 - 00;07;32;00
Salin Sriudomporn
Overall, you know, with our studied 94 countries among 16 common routine vaccines over this period, 2011 to 2030, our results highlight the large funding gap and the majority of the funding gap is actually associated with the immunization delivery, which is almost 80% of the total funding gap. And people often think about vaccine pricing itself, but not the cost of how to deliver the vaccine to the population, especially those in the heart to each area.
00;07;32;08 - 00;07;58;13
Salin Sriudomporn
And this portion requires the significant resources like personnel, storage and transportation, for example. So we can't just procure the vaccine and then give them to the country and just call it a day. We should also invest it in the health system as well. And if we invest in their health system, I know it's a significant portion of the money like community health worker, for example,
00;07;58;13 - 00;08;05;04
Salin Sriudomporn
But then the system can be operate for other things to share the burden across disease cycles.
00;08;05;27 - 00;08;32;04
Alan Weil
So what you're telling us is not only is there a significant funding gap, but it's not primarily associated with procuring the vaccines. It's associated with delivering them, getting them from vials into people's arms and where they can actually do some good. We're going to talk a little bit more about what that gap means and what it might take to close it.
00;08;32;05 - 00;09;21;02
Alan Weil
We'll do that after we take a short break. And we're back. I'm speaking with Salin Sriudomporn about the funding gap for 16 vaccines across 94 low and middle income countries. Before the break, we got this sort of blockbuster finding about the tens of billions of dollars it's going to take to make this happen. The gap is the difference between what it's going to cost to deliver the vaccines and how much is currently available.
00;09;21;25 - 00;09;39;02
Alan Weil
So I think in order to understand what 38+ billion dollars means, it would be helpful to get a sense, how much does it cost? How much does your study project it would cost to deliver these vaccines over this period? And about how much do you estimate is currently available to cover those costs?
00;09;39;22 - 00;10;11;18
Salin Sriudomporn
So for the period of 2018 to 2030, we estimated that the total immunization program would cost approximately 77.7 billion US dollars and 36.9 billion of that total cost is allocated toward vaccine pricing, while 40.8 billion US dollars is allocated toward vaccine delivery costs. At the same time period, the total financing was estimated to be approximately 47.6 billion US dollars.
00;10;11;29 - 00;10;28;06
Salin Sriudomporn
This resulted in the total of 30 billion US dollars funding gap, specifically 7.8 billion toward vaccine costs and 22.3 billion toward a vaccine delivery funding gap.
00;10;28;15 - 00;10;52;08
Alan Weil
Okay, so I know that's a lot of numbers, but I want to try to make sure that I understand them and have some sense about what they imply. So out of, in the 2018 to 2030 period, your study goes back to 2011, but in the 2018 to 2030 period, we have funding secured, if you will, for a little more than, for significantly more than half.
00;10;52;08 - 00;11;25;17
Alan Weil
But the $30 billion remaining, it's a big share. It's not just a large amount of money, it's a big share of the costs. And it also sounds like we come pretty close to covering the cost of acquiring the vaccines. But the biggest part of the shortfall has to do with delivering the vaccines. So if those two, if I got both of those right, I guess the question for me is what does it look like in a country that's trying to close this gap?
00;11;26;14 - 00;11;37;13
Alan Weil
What are the opportunities? What are the prospects for obtaining or securing domestic government funding to meet the need that currently looks like its unmet?
00;11;38;09 - 00;12;09;23
Salin Sriudomporn
So for the government, the government should utilize economic evaluation like cost effectiveness of intervention or a budget impact analysis along with other disease burden data existed to prioritize, and what so-called essential package of services that is prioritized for funding. And this package can be expand over time as there are more resources available. This is similar to what Thailand has done with their comprehensive benefit package.
00;12;10;15 - 00;12;47;02
Salin Sriudomporn
This along with increased government spending on health. Thailand has evidently shown that the prevalence in catastrophic health spending decrease, as well as the low level of unmet health needs, along with the higher level of universal health coverage index. So another prospect is potentially have a pooled procurement for vaccine, which is a strategic initiatives that, you know, aggregate orders, volumes on behalf of participating countries.
00;12;47;12 - 00;12;56;09
Salin Sriudomporn
And this can significantly reduce negotiated cost as well as adjust for timing for delivery and averted the stockpile.
00;12;57;05 - 00;13;26;15
Alan Weil
Those are really interesting ideas, and it makes me wonder with the gap being dominated by the delivery side, whether countries have as clear a return on investment, understanding of the delivery relative to procurement and whether they even know necessarily what investments to make to build the delivery infrastructure for vaccines. Procurement, I don't want to say it's easy, but it's buying something.
00;13;26;15 - 00;13;35;19
Alan Weil
Delivery is much more complex and I wonder if the countries feel like they're not sure where to make the best investment in that.
00;13;36;10 - 00;14;07;28
Salin Sriudomporn
For a vaccine delivery. There are two types of vaccine delivery, actually. One being the routine vaccine delivery, which is usually done every fiscal year at health care facility at fixed sites, outreach area or on like a mobile team. But then there's also another delivery, which is so-called campaign delivery, like a catch up campaign to those who wouldn't receive initial routine delivery vaccines or the outbreak response campaign for epidemic management.
00;14;08;23 - 00;14;44;08
Salin Sriudomporn
And both delivery actually account for various variables like personnel, which is cause for a salary per diem, or any travel allowances related to labor, cost of cold chain equipment. This is pretty essential as you have to maintain the vaccine, a specific temperature. There is also a vehicle for transporting the vaccines itself, fuel cost. Anything related to transportation mainly. And there's also capital and other recurrent costs associated with delivery.
00;14;44;15 - 00;15;00;08
Salin Sriudomporn
So you can see there are so many component toward vaccine delivery, which is why it required such a big portion of the financing. And these costs are actually even higher in the hard to reach household like urban slums or remote rural area.
00;15;00;19 - 00;15;23;10
Alan Weil
And this work predates the COVID-19 pandemic in terms of estimating costs. I know this is a really big question, but is there anything about the COVID-19 pandemic that either changes your sense of what the results of your study are or that give you insights into what's needed to close this financing gap?
00;15;24;09 - 00;15;42;26
Salin Sriudomporn
We expected that COVID has disrupted on the vaccine delivery system. We're waiting to see the updated number on coverage and see how coverage rebounds on trajectory for target. But we definitely expect that this would require additional funding with COVID.
00;15;43;04 - 00;16;07;28
Alan Weil
Well, Ms. Sriudomporn, thank you so much for the work that you've done, for bringing it to life, and showing us that we have a big challenge ahead. But there really is a such a positive yield if we can figure out how to come up with these resources. And as you noted, a big part of coming up with the resources is building the economic case, and that's exactly what your paper has done.
00;16;07;28 - 00;16;13;10
Alan Weil
So I appreciate your work in this area and I thank you for being my guest today on “A Health Podyssey”.
00;16;13;26 - 00;16;17;26
Salin Sriudomporn
Thank you so much, Alan. Thank you for having me.