Rachel emphasized that sustainable financing for immunization is critical to build resilient health systems and achieve Universal Health Coverage. She noted that in 2023, more than 111 million children in Africa missed out on routine vaccines and unless governments increase domestic investments in immunization, this number will continue to grow.

Dr. Mike presented data from 10 African countries highlighting the following:

• Most countries have not met the 15% tax revenue target of the GDP as recommended by the Addis Ababa Action Agenda.
• None of the countries have met the $86 per capita spending on health recommended by WHO to achieve Universal Health Coverage.
• South Sudan relies on donor funding for 89% of its health financing.
• In Nigeria, 75% of health financing is out-of-pocket spending by citizens.
• High donor dependency and debt burdens are limiting country capacity to increase domestic resources for health.

Key recommendations include:

• Implementation of public finance reforms
• Improved domestic resource mobilization through tax reforms
• Sustainable debt management and improved efficiency in public spending
• Political commitment to prioritize health and immunization
• Expanding local manufacturing of vaccines and health commodities

Dr. Menson noted that Gavi has disbursed over $1 billion in health system strengthening support since 2000 and continues to incentivize countries to invest in immunization through its co-financing policy. He shared that in 2024, Gavi expects to collect $103 million from countries’ co-financing, which is the highest in Gavi’s history. He also noted that Gavi’s new 2026–2030 strategy (Gavi 6.0) aims to:

• Extend eligibility to countries with GNI per capita of ≤ $2,300

• Support countries in fragile and conflict settings with multi-year waivers and transition extensions

• Continue support for zero-dose and under-immunized children

• Pilot new financing instruments for non-Gavi eligible countries

Dr. Menson highlighted Nigeria’s Direct Facility Financing (DFF) model in Taraba as a promising example of strengthening domestic financing for immunization.

Jimmy noted that the Government of Uganda has increased domestic financing for immunization from $2.6 million in 2021 to $8.1 million in 2024. He attributed this to high-level political commitment and collaboration between the Ministry of Health, Ministry of Finance and development partners. Uganda’s efforts have focused on increasing budget allocations and improving efficiency and accountability through Public Finance Management reforms. He noted that challenges remain such as:

• Competing priorities including Ebola and Mpox outbreaks

• Limited sub-national capacity to plan and implement immunization

• Community resistance and vaccine hesitancy in some districts

• Cross-border movement and unregistered children

Emily noted that Malawi has maintained high immunization coverage (>90%) despite relying on donors for 70% of financing. She shared key lessons from Malawi:

• Use of earmarked taxes such as sugar tax to fund health

• Integration of immunization services with other health programs

• Leveraging donor support for health systems strengthening

• Regular National Health Financing Dialogues with Ministry of Finance and CSOs

Participants responded to the question: “How have fiscal challenges impacted immunization in your country?”

Top responses included:

• Reduced immunization coverage

• Increased dependency on donor funding

• High dropout and zero-dose rates

• Delays in disbursement of funds

• Limited community outreach

Suggested solutions included:

• Increasing domestic financing for immunization

• Earmarking taxes for health

• Strengthening DFF and facility-based planning

• Leveraging community structures to deliver services

1. Sustainability Challenges
Countries continue to rely heavily on donor funding for immunization. The COVID-19 pandemic, economic downturn, and increasing debt burdens have further constrained government spending on health.

2. Innovative Solutions
Countries are exploring innovative solutions such as earmarked taxes (e.g., sugar taxes), social health insurance schemes and local manufacturing to increase domestic resources.

3. Accountability and Transparency
Improving efficiency and transparency in the use of immunization resources is critical. This includes timely disbursement of funds, reducing wastage and community-led accountability mechanisms.

4. Regional Collaboration
Countries can learn from each other. Sharing experiences on what works can help identify scalable solutions. Successful models include:

• Uganda’s increased budget allocations

• Nigeria’s Direct Facility Financing

• Malawi’s use of earmarked taxes

• Strengthen Domestic Resource Mobilization:
  Countries should increase budget allocations for immunization and explore innovative financing mechanisms including earmarked taxes.

• Improve Public Finance Management:
  Reforms should be implemented to ensure efficiency, accountability and timely disbursement of funds to sub-national levels.

• Build Resilient Health Systems:
  Governments should invest in strengthening health systems to increase coverage, reduce inequities and respond to emergencies.

• Enhance Regional Collaboration:
  Development partners should support regional platforms for cross-country learning, peer-to-peer exchange and knowledge sharing.

• Foster Public-Private Partnerships:
  Governments should explore opportunities for private sector engagement in financing and delivering immunization services.

• Address Vaccine Hesitancy:
  Countries should strengthen community engagement and address misinformation to increase demand for vaccines.

• Empower Civil Society Organizations:
  CSOs should be engaged in planning, budgeting and monitoring of immunization programs to enhance accountability.