Immunization Financing in MENA Middle-Income Countries

May 2018

health worker vaccinates a boy using a syringe


Most MENA countries have high immunization coverage rates. But immunization coverage has dropped considerably in some (including Iraq, the Syrian Arab Republic and Yemen), due to the conflicts, instability and the prevailing geopolitical situation in the region. Approximately 1.3 million surviving infants in MENA missed their third dose of DTP vaccine in 2016. In many of the region’s countries, problems of equity persist, particularly concerning displaced populations, nomads, ethnic groups and marginalized urban populations.

The Ministry of Health budget remains the mainstay of immunization financing in most of the countries. External financing is important mainly in the three countries eligible for Gavi support (Djibouti, the Sudan and Yemen) and, to some extent, in the Syrian Arab Republic. Some external assistance for refugee populations exists in Jordan and Lebanon. While social insurance is growing as a financing scheme in many MENA countries, it is currently not a source of immunization financing. The private sector provides some immunization services and has a growing role in many MENA countries. In the future, voluntary health insurance schemes covering immunization or some vaccines as a component of the benefit package may arise. Social health insurance may also be involved in the future, depending on how countries move towards UHC.

New vaccine introductions pose challenges for the region. As the region’s only countries eligible for Gavi support, Djibouti, the Sudan and Yemen have benefited from such support in introducing new and underused vaccines at UNICEF SD prices for Gavi countries. The three countries have all introduced rotavirus and pneumococcal conjugate vaccines, for example. Of the countries not eligible for Gavi support, only Libya, Morocco and State of Palestine have introduced both rotavirus and pneumococcal conjugate vaccines; Egypt, the Islamic Republic of Iran, the Syrian Arab Republic and Tunisia have introduced neither of these. Algeria and Lebanon have not introduced rotavirus vaccine, and Iraq and Jordan have not introduced pneumococcal conjugate vaccine. In many cases, NITAGs have recommended the introductions, but budgetary room has not been created. The problem is exacerbated by high and uncertain prices for these vaccines.

The Sudan will be the first of the Gavi countries in MENA to move into the ‘accelerated transition process’. Expected to occur in 2020, this phase comes after countries cross the eligibility threshold. At that time, the Sudan will have its final years of Gavi support, during which country co-financing scales up more rapidly as the support winds down. The Sudan is expected to fully self-finance its Gavi-supported vaccines in 2025. Nevertheless, the country will likely face challenges in scaling up the financing of vaccines and related activities given its indebtedness, relatively low growth prospects and low tax base. While the Sudan’s tax base is only 12 per cent of GDP, it devotes about 18 per cent of government spending to health (according to WHO’s global health expenditure database), a very high share compared to other countries globally. Scope may exist to finance co-financing requirements by reallocating funds from lower-priority activities within health towards immunization.

Local and external factors have made procuring and purchasing vaccines and related products a considerable challenge for most MENA countries. The global vaccine market is experiencing many changes, such as the emergence of new manufacturers with pre-qualified products, a decrease in the number of producers from industrialized countries, and the importance of the PAHO Revolving Fund, UNICEF SD, Gavi and the Bill & Melinda Gates Foundation as global players. Countries are often not well informed about these developments and their consequences, nor about the vaccine pipeline and quality or reliability of manufacturers and suppliers.

Globally, UNICEF SD and regional and country offices play a vital role in supplying quality and affordable vaccines to low- and middle-income countries, particularly to those eligible for Gavi support. However, some of the requirements are not always compatible with country public procurement rules. Moreover, country laws and regulations for public procurement are not always well adapted to the context and market of vaccines, or to the smooth use of UNICEF procurement services. Requirements for local agents, prior registration, bundling of services and payment in local currency, among others, are neither adapted to nor compatible with efficient vaccine regulation and procurement.

Most countries have established NITAG and NRA bodies, some of which are quite active. However, both bodies are making slow progress on various matters – NRAs on the update of vaccine regulation and procurement rules and procedures, and NITAGs on issues of data quality, cost-effectiveness, budget impact analysis and disease modelling. In addition, service delivery strategies for marginalized urban populations, nomads and other groups need to be addressed. Other areas with potential for improvement are related to waste management and the environmental impact of immunization activity programmes, controlled temperature chain, vaccine presentation and delivery technologies.

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