Is health expenditure on immunisation associated with immunisation coverage in Sub-Saharan African countries?

In a bid to address the high burden of vaccine-preventable disease and low immunisation coverage in Africa, Ministers of health and finance from several African countries conveyed at the maiden Ministerial Conference on Immunisation at Addis Ababa, Ethiopia on the 25th of February 2016 to pledge political commitments to reduce the prevalence and deaths from vaccine-preventable diseases to the barest minimum. The fulfilment of this pledge across Africa would require the design of contextually tailored sustainable plans to finance the procurement of vaccines and the running of apt immunisation programs. A robust understanding of the trend of immunisation financing in Africa will support the development of suitable national immunization financing plans, guide policy makers to develop immunisation financing strategies focused on domestic resources but factor in donor support; and provide insights for the rejuvenation and expansion of immunisation programs. Our study’s objective is to estimate the minimum fraction of a country’s health budget that should be invested in the national immunisation programme to achieve a national immunisation coverage of 80% or greater depending on the context with and without donors’ support. The study results did not find any evidence to indicate that health expenditure on immunisation (as a proportion of total health expenditure) could be a strong predictor of immunisation coverage. However, we observed an association between total health expenditure (as a % of the GDP) and immunisation coverage, for BCG (p=0.047) and DPT3 (p=0.013) vaccines. Therefore, health expenditure as a percentage of GDP can be considered as an important predictor of immunisation coverage. We demonstrate in selected countries that to achieve the GAVI target of 80% in the countries with low DPT3 coverage, health expenditure as a percentage of GDP would need to be increased by more than 45%. We are optimistic that our study results and recommendations will facilitate the development of strategies that support African countries to increase domestic financing for national immunization programmes towards achieving 2030 targets for immunization coverage. Evidence before this study We conducted a desk review to identify official government records and reports on immunisation financing in African countries in Google scholar, WHO Library, GAVI and World bank databases using keywords such as “immunisation financing”, “health budget”, “health financing policies”, “immunisation financing policies” and “health expenditure”. We identified data for all countries in Africa but were only able to retrieve complete data from 24 countries. We considered the retrieved data for each country to be complete for our study if we found data on immunisation expenditure, health expenditure as a percentage of Gross Domestic Product, Gross Domestic Product, BCG coverage, DPT3 coverage, PCV1 coverage, MCV1 coverage, fertility rates, under-five mortality rates, under-five population and the total population. Added value of this study We sought for any association between immunisation expenditure and health expenditure (as a % of the GDP) and immunisation coverage over a five-year period (2013 to 2017) in twenty-four African countries. To our knowledge, this is the first study that has shown a correlation between immunisation financing, health expenditure and immunisation coverage and how this association varies across countries. Prediction modelling of vaccine coverage time series for countries with less than desired level of coverage (below 80%) enabled us to construct a predictive index that visualised the effect of increasing health expenditure (as a % of the GDP) would have on immunisation coverage with all other variables unchanged. Implications of the available evidence We posit that immunisation expenditure is not a statistically significant predictor for immunisation coverage for DPT3 and BCG vaccines; rather, with strong statistical evidence, health expenditure (as a % of the GDP) can be used to predict immunization coverage. Our prediction model estimated the percentage increase in health expenditure (as a % of the GDP) that would be required for countries with low immunization coverage to attain the target for immunization coverage recommended by the IA2030 Framework for Action. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.