This resource guide collects 26 brief documents on topics related to the cost and financing of national immunization programs in low- and middle-income countries. Some of the briefs explore possible financing sources. Others examine the components and drivers of immunization costs, planning and decision-making processes related to immunization programs and budgets, and the relationship between immunization and broader health system financing. The resource guide concludes with a set of country case studies that illustrate particular approaches or important challenges.

This volume is intended for immunization advocates, program managers, decision-makers, and planners in ministries of health and finance. The information is relevant to countries that are eligible for support from Gavi, the Vaccine Alliance, as well as to countries that are transitioning out of Gavi support and middle-income countries that have never received Gavi support. The briefs can be read in sequential order or individually. Each begins with a summary of key points. Some of the briefs are more technical than others, due to their subject matter, but they are all meant to convey practical information to readers who do not have specific technical expertise. Many of the briefs recommend other resources that offer more in-depth information. The following table outlines the contents of the resource guide and the main questions addressed by each brief. It is followed by a list of key terms used in this document.

part i: Immunization Fundamentals
Brief 1 Why Immunization and Immunization Financing Matter What is the value of immunization? Why is it important for governments to finance it? What new financing needs should countries plan for?
Brief 2 Universal Health Coverage and Immunization Financing How does immunization fit into the movement toward universal health coverage? What challenges do changes in health financing pose for immunization?
Brief 3 Components of Immunization Costs What are the key components of immunization costs, and how do they vary across delivery platforms? Which costs are typically shared with other health services, and which are specific to immunization?
Brief 4 Vaccine Decision-Making What should countries consider in deciding whether to introduce a new vaccine? What kinds of institutions and processes can strengthen vaccine decision-making?
part ii: Sources of Financing
Brief 5 Domestic Public Funding Sources What are the main sources of domestic public financing? Why is domestic public revenue likely to remain the primary source of immunization financing, especially as countries transition away from development assistance?
Brief 6 Earmarking to Finance Immunization What is earmarked funding? What are the pros and cons of earmarking for immunization?
Brief 7 Domestic Trust Funds What are trust funds for immunization? How have they worked in practice?
Brief 8 Household Out-of-Pocket Payments Why are out-of-pocket payments so strongly discouraged for immunization services? What kinds of informal fees persist in some countries today?
Brief 9 Gavi Financing for Immunization Which countries are eligible for funding from Gavi? What kinds of support does Gavi provide? What is the process of transitioning from Gavi support?
Brief 10 Development Assistance for Immunization How can development assistance for immunization be put to best use, bearing in mind the need for alignment with government priorities, efficiency, predictability, and sustainability?
part iii: Strategic Purchasing and Procurement
Brief 11 Vaccine Procurement Overview What vaccine procurement options do countries have, and what are the pros and cons of each? What are the main factors that determine the prices that countries pay for vaccines?
Brief 12 Pooled Procurement What is pooled procurement? What options do countries have for participating in pooled procurement arrangements?
Brief 13 UNICEF’s Vaccine Independence Initiative Why did UNICEF establish a vaccine financing credit line? What countries might benefit from it? What are the requirements for participating?
Brief 14 How Provider Payment Approaches Affect Immunization Services What are the pros and cons of the various approaches to paying providers for immunization services? What kinds of incentives do they create?
part iv: Strategies for Policy Change
Brief 15 Building Parliamentary Support for Immunization Financing How can immunization advocates engage with national parliaments, including through parliamentary leaders, standing and ad hoc committees, and secretariat staff?
Brief 16 Immunization Financing Legislation and Regulation How can immunization legislation create a legal commitment to immunization and support sustainable immunization financing? What are the common elements of immunization legislation and regulation?
Brief 17 Immunization Planning and the Budget Cycle What are the main elements of the budget cycle, and what are the implications for immunization financing? When are the best times for advocates to engage in the budget process?
Brief 18 Key Questions for Immunization Advocates What questions on immunization financing might immunization advocates raise with policymakers?
part v: Country Case Studies
Brief 19 Armenia: Strong Government Support for Immunization What lessons can be drawn from Armenia’s high-performing immunization program, which has benefited from close collaboration between the Ministry of Health, Ministry of Finance, and the Standing Committee on Health Care, Maternity, and Childhood in Parliament?
Brief 20 Azerbaijan: Dramatic Savings from a Change in Procurement What has been the impact of Azerbaijan’s switch from direct procurement to using UNICEF Supply Division? How did the country evaluate the pros and cons? What implementation challenges did it face?
Brief 21 Bhutan: A National Trust Fund for Immunization What factors have contributed to the success of the Bhutan Health Trust Fund, one of the longest-running funds dedicated to essential medicines, including vaccines?
Brief 22 Costa Rica: Lottery Contributions for Immunization in a Mixed Financing System Lotteries are among the innovative mechanisms that countries may consider for immunization financing. What role has the national lottery played in financing vaccines in Costa Rica?
Brief 23 Ghana: Mixed Financing for Immunization and Shifting Responsibility What can other countries learn about immunization financing from Ghana’s experience with its National Health Insurance Scheme, which includes complex health financing and service delivery systems?
Brief 24 Indonesia: The Challenge of Protecting Immunization in the Transition to Universal Health Coverage How have health financing reforms, decentralization, and the expansion of social health insurance affected the immunization program in Indonesia?
Brief 25 Kenya: Decentralization and Immunization Financing Decentralization can pose challenges to immunization if roles and responsibilities for key functions are not clear. How have Kenya’s recent decentralization efforts affected immunization financing?
Brief 26 Sri Lanka: Sound Decision- Making Processes for Immunization Sri Lanka’s national immunization technical advisory group (NITAG) is seen as a model of immunization decision-making. How does it work? 


This resource guide was prepared by a team at Results for Development (R4D) led by Helen Saxenian and including Daniel Arias, Danielle Bloom, Cheryl Cashin, and Paul Wilson. It is based on research funded in part by the Bill & Melinda Gates Foundation. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation.

The authors are grateful to the many individuals and organizations who reviewed this volume and provided helpful input. At the Bill & Melinda Gates Foundation, Brad Tytel initiated the project; it was later overseen by Chelsea Minkler with considerable technical input throughout the process from Logan Brenzel.

We appreciate feedback from Sinead Andersen, Santiago Cornejo, Judith Kallenberg, and Deepali Patel (Gavi); Gian Gandhi and Jonathan Weiss (UNICEF); and Sarah Alkenbrack, Jane Chuma, Rama Lakshminarayanan, Robert Oelrichs, Alexander Gallatin Paxton, Gandham Ramana, Owen Smith, Ali Subandoro, and Ajay Tandon (World Bank). The case study on Indonesia draws on a World Bank report authored by Ajay Tandon. We are grateful for contributions and/or comments from Vusala Jalal Allahverdiyeva, Niyazi Cakmak, Irtaza Chaudhri, Amos Petu, Susan Sparkes, and Xiao Xian Huang (World Health Organization) as well as Gabriella Felix, John Fitzsimmons, Cara Janusz, and Daniel Rodriguez (Pan American Health Organization). Taiwo Abimbola and Sarah Pallasof the Centers for Disease Control and Prevention provided comments in their individual capacities.

We also appreciate feedback from several unnamed staff at John Snow, Inc., in a review coordinated by Robert Steinglass, as well as inputs from Amos Chewya, Isaac Mugoya, and Lora Shimp. We also received valuable input from Heather Teixeira (ACTION), Manjiri Bhawalker and Stephen Resch (Harvard University), Joseph Dielman (Institute for Health Metrics and Evaluation), Sachi Ozawa and Lois Privor-Dumm (International Vaccine Access Center), and Andrew Carlson, Mike McQuestion, and Dana Silver (Sabin Vaccine Institute). Rachel Feilden, Miloud Kaddar, and Ann Levin also made valuable contributions.

Senior government health officials took time out of their busy schedules to be interviewed for the case studies. They include Gayane Sahakyan (Armenia); Victor Gasymov, Oleg Salimov, and Rashida Abdullaeva (Azerbaijan); Sangay Phuntsho and Dawa Gyeltshen (Bhutan); Roberto Arroba and Vicenta Machado (Costa Rica); Anthony Ofosu and Daniel Osei (Ghana); Ephantus Maree (Kenya); and Paba Palihawadana (Sri Lanka). Olga Zues (Abt Associates) generously took the time to communicate on our behalf with government officials in Azerbaijan to collect information for the Azerbaijan case study.

Many thanks go to Polly Ghazi, editor; Rebecca Richards-Diop, creative director; and Ina Chang, overall editor, for their contributions. Many thanks as well to Robert Hecht, who helped launch this project while at Results for Development.

This report is based on research funded in part by the Bill & Melinda Gates Foundation. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation. Furthermore, the many other individuals who contributed to this document may not endorse all of these views, and they bear no responsibility for any errors.