Weak States, Wealthier States, and Incentives for Polio Eradication

Bill Gates’ effort to close the $2.6 billion funding gap for polio eradication has been accompanied by high-profile coverage at Davos, in The New York Times and even The Daily Show. New grants from the UK have been announced and USAID is partnering with Russia to move the agenda forward. In the big scheme of things, this is not a lot of money (in the NYT, Gates notes that it is “like 5 percent of the US dog food market”).  But there are two strategies that might make the funds go further by differentiating the approach to polio eradication in weak versus wealthier states:First, polio and other vaccine-preventable disease outbreaks occur mainly in weak and fragile states and districts –in Pakistan, Afghanistan and DRC– where intermittent progress is made, but is frequently interrupted by armed conflict, security concerns and natural disasters. Eradication depends critically on continuity in vaccination and surveillance and we know that fragile states are vulnerable to outbreaks.Yet current financing is always in emergency mode. For example, in December 2010, WHO, UNICEF and Rotary International launched an emergency appeal for polio vaccination campaigns in DRC.  The Global Polio Eradication Initiative (GPEI) has a modest emergency response fund, but apparently it is insufficient. It is also a pity that it is limited to a single vaccine-preventable disease.There have been earlier, more ambitious efforts in this direction. In 2002, WHO set up a Global Emergency Outbreak Response Fund (focused on response to all disease outbreaks, not just vaccine-preventable disease), but its size is modest and its resources almost expended. There is the UN Central Emergency Response Fund, but there is a lengthy application process and it is broadly targeted to humanitarian responses. Of course, the new International Health Regulations establish a legal framework for surveillance and response, but there are limited funds available for implementation (see here).What about this in the meantime: a fragile states vaccine-preventable disease outbreak response fund be established  as part of the GAVI Alliance or GPEI that would allow UNICEF, WHO and their partners to deploy quickly and without expensive, ad hoc fundraising. This would not solve the security issues, but it would allow for rapid modification of vaccination strategies –for example, from government to civil society groups in the flood-affected areas of Pakistan or from NGOs to NATO medics in southern Afghanistan. By starting with polio and other vaccine-preventable disease, and building on the funding structures that have worked efficiently (GPEI and GAVI), we may generate proof of concept for a better approach system-wide.Second, more than half of GPEI funding goes to India and Nigeria (see here). These countries are relatively affluent and reasons for irregular and low vaccination have much to do with “non-technical” factors such as insufficient state-level budgets and weak governance. To leverage the continuous and reliable public funding that is needed to eradicate polio and maintain surveillance, financing and advocacy efforts need to be very different, creating incentives –financial and reputational- for sustained public effort and funding.On financial incentives, I’d like to know what happened to the polio debt buy-downs. In 2003, the World Bank partnered with the Bill & Melinda Gates Foundation, Rotary International and the UN Foundation to buy down World Bank IDA loans in Nigeria and Pakistan based on improvements in polio vaccination coverage. Results up to 2009 were encouraging in Nigeria, but I can’t find other references online.Conceptually, the scheme is appealing. Donors agree to pay off the debt upon successful achievement of a pre-determined level of vaccination coverage. An independent evaluation determines whether the set level is achieved. If achieved, funds for the buy-down are released and the debt is paid off. If not, the country is responsible for paying back the IDA credit. Using IDA as an ex ante source of financing assures that routine immunization program and epidemiological surveillance expenditures are on-budget and a central part of the Ministry of Finance-Ministry of Health dialogue on annual budgets and expenditures; thereby reducing the need to spend scarce GPEI funds in relatively wealthy countries.Another option is to have GPEI or GAVI directly buy-down any kind of government debt based on the achievement of threshold vaccination rates. By placing the onus on Ministries of Finance to find resources to fund the program ex ante, an incentive is created to program national resources or leverage in-country donor funding for this very cost-effective priority. The year to year reviews of performance help to keep the focus on results rather than inputs.A final alternative could be ex-post performance-based grants – modeled on COD Aid– at the sub-national level; this might be a good strategy in the Indian states of Bihar and Uttar Pradesh where public budgets are highly earmarked to salary and pension expenditures such that the more flexible grant funding becomes a genuine incentive for change.On reputational incentives, civil society budget and coverage watchdogging –with international back up and visibility to protect local institutions- will be important in the relatively affluent states that are less likely to respond to modest financial incentives. The political process will also a fruitful channel.  In Nigeria, a presidential election is coming up on April 9. I’d like to see all three candidates commit upfront to polio elimination in Nigeria, with a specific policy and financing plan.Thanks to Todd Moss for his input to this blog.