The impact of the Global Polio Eradication Initiative on the financing of routine immunization: case studies in Bangladesh, C te d'Ivoire, and Morocco.

The impact of the Global Polio Eradication Initiative on the financing of routine immunization: case studies in Bangladesh, Coˆte d’Ivoire, and Morocco Ann Levin,1 Sujata Ram,2 & Miloud Kaddar2 Abstract To determine if the Global Polio Eradication Initiative (PEI) affected financing of routine immunization programmes, we compared sources and uses of funds for routine immunization programmes and PEI activities in Bangladesh, Coˆte d’Ivoire, and Morocco for the years 1993–98. We also examined funding trends for these years in these countries and assessed the effect of the initiative on the availability of specific resources in national immunization programmes, such as cold-chain equipment and personnel time spent on activities related to national immunization days and surveillance of poliomyelitis and acute flaccid paralysis. We found that all three governments and the majority of donors and international organizations continued to fund routine immunization programmes at levels similar to those before the PEI. Trend analysis also indicated that financing for routine immunization in each of the countries continued to increase after the PEI was introduced. The results show that the PEI did not reduce funding for routine immunizations in these countries. Keywords Poliomyelitis/prevention and control; Immunization programs/economics; Financing, Government/trends; Financing, Organized/trends; Health expenditures/trends; Comparative study; Case report; Bangladesh; Morocco; Coˆte d’Ivoire (source: MeSH, NLM). Mots cle´s Poliomye´lite ante´rieure aigue¨/pre´vention et controˆle; Programmes de vaccination/e´conomie; Financement par gouvernement/orientations; Organisation financement/orientations; De´penses de sante´/orientations; Etude comparative; Cas clinique; Bangladesh; Maroc; Coˆte d’Ivoire (source: MeSH, INSERM). Palabras clave Poliomielitis/prevencio´n y control; Programas de inmunizacio´n/economı´a; Financiamiento gubernamental/ tendencias; Organizacio´n del financiamiento/tendencias; Gastos en salud/tendencias; Estudio comparativo; Informe de caso; Bangladesh; Marruecos; Coˆte d’Ivoire (fuente: DeCS, BIREME ). Bulletin of the World Health Organization 2002;80:822-828. Voir page 828 le re´sume´ en franc¸ais. En la pa´gina 828 figura un resumen en espan˜ol. Introduction Considerable progress has been made in eradicating polio- myelitis, thanks to the Polio Eradication Initiative (PEI), led by WHO, the United Nations Children’s Fund (UNICEF), and a number of bilateral donors. However, the initiative has required considerable financial and other resources from ministries of health and other local and external sources, which raised the question as to whether resources for routine immunizations were adversely affected by the focus on the PEI. In the 1990s, global funding for routine immunization programmes in developing countries declined sharply for several reasons, including funding reductions from the United States Agency for International Development (USAID) after the cold war ended; competition from health services, such as those for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and other health priorities; and a reduction in UNICEF funding after Universal Child Immunization ended in 1990. During the 1990s, initiatives to control and eliminate diseases also became more frequent. The PEI began in 1988 and has since reduced the global incidence of poliomyelitis. The WHO Region of the Americas was the first region to certify eradication in 1994, although one outbreak of vaccine-derived poliomyelitis has since occurred. The WHO Western Pacific region was certified poliomyelitis free in October 2000, and the WHO European Region was declared poliomyelitis free in June 2002. The two regions with the highest incidence of poliomyelitis are the WHO African Region and the WHO South-East Asia Region, although the frequency of cases is much lower than a decade ago. Critics of eradication initiatives have argued that they divert resources and undermine efforts to maintain and strengthen routine health services. In the least-developed countries poliomyelitis eradication has had both positive and negative impacts on the development of health systems (1, 2). The positive impacts on routine health services resulted from the emphasis on social mobilization and improving manage- ment as part of the targeted initiatives. In poorer countries, however, targeted immunization programmes diverted re- sources away from routine services, especially during mass immunization campaigns. Other studies also found that poliomyelitis eradication efforts had both positive and negative impacts. The develop- ment and strengthening of acute flaccid paralysis surveillance in the Philippines, for example, improved surveillance for other diseases (3), whereas poliomyelitis eradication initiatives in the 1 Senior Research Associate, Family Health International, 4301 Connecticut Avenue, Northwest, # 280, Washington, DC 20008, USA (email: alevin@pcdc.org). Correspondence should be addressed to this author. 2 Consultant, Partners for Health Reform Project, Abt Associates Inc., Bethesda, MD, USA. Ref. No. 01-1341 Policy and Practice 822 Bulletin of the World Health Organization 2002, 80 (10) Lao People’s Democratic Republic, Nepal, and United Republic of Tanzania had both positive and negative impacts on the health system, depending on the level of development of the health system, the management capacity of personnel, and the level of integration of the health infrastructure (4). Positive impacts weremore likely when sufficient planningwas in place. It should be noted, however, that these three countries may not have been representative of other countries in their respective regions. In the present study, we examined whether trade-offs occurred for routine immunization programmes, when governments, donors, and international organizations pro- vided funding for the PEI. Data collection We collected data in Bangladesh, Coˆte d’Ivoire, andMorocco— chosen as part of a larger study on the financing of immunization programmes — since the countries had a mix of financing sources and were located in different geographical regions. However, the countries all had diphtheria, pertussis, and tetanus coverage rates greater than 60% and are not representative of countries with programmes that function less well. We collected information on sources and uses of funds for routine immunization programmes and poliomyelitis eradication activities by the governments, donors, and other contributors (5–7). Although poliomyelitis eradication activ- ities only began in 1995–96, funding for surveillance and planning activities began in 1993–94. The sources of financing included national governments, local (regional) governments, donors, international organizations, and the private sector. Morocco differs from the other two countries since it was already conducting national immunization days before the PEI was started as a means of supplementing routine immunization activities. National immunization days were used to improve immunization coverage, since disparities in coverage rates existed, particularly in rural areas. When the initiative began, poliomyelitis immunization for children aged 1–5 years old was included in national immunization days. Expenditure was divided into recurrent and capital expenses. Recurrent expenditures occurred within one year or less, such as personnel salaries and supplies. Capital expendi- tures were for items that lasted longer than a year, such as equipment and land. Interviews were conducted with key informants to obtain in-depth information on the immuniza- tion programmes and long-term prospects for financing. Better estimates of the role of governments in financing these activities were obtained by including the value of personnel time in the analysis, although the analysis did not attempt to separate out the contributions from different levels of staff. Funding data for trend analyses were converted to United States dollars so that data from different sources could be compared. Nominal dollars — which give the value at current prices — were used because inflation of the United States dollar was low during 1993–2000. The short-term effects of the initiative on financing routine immunizations were examined by trend analysis when information was available. To determine whether the rate of funding for routine immunizations had decreased, routine immunization funding was compared with that for poliomye- litis eradication activities.We also examinedwhether the rate of funding increase slowed once poliomyelitis eradication activities were introduced. In addition, specific funding sources were investigated to determine whether individual flows increased or decreased over the same period. The contributions of the governments of Bangladesh, Coˆte d’Ivoire, and Morocco for routine immunization programmes and national immunization days were examined separately to assess how governments allocated national immunization programme resources to immunization and poliomyelitis eradication activities. The study also examined whether the governments contributed to the PEI, and examined whether this had long-term effects on financing for their routine immunization programmes. The possibilities for long-term financing for routine immunization, poliomyelitis eradication, and other health activities were determined from discussions with contributors and key informants, such as ministry officials and donor representatives. Spending trends for routine immunization and the PEI The trends in expenditures on routine immunization and poliomyelitis eradication in Bangladesh and Coˆte d’Ivoire were examined to assess whether expenditures for routine im- munization changed as poliomyelitis eradication activities were introduced. Morocco was not included, as there was insufficient information on past expenditures. In Bangladesh, expenditures between 1993 and 1997 on routine immunization comprised an approximately constant 6–7% of total health- sector expenditures (Table 1). Funding for poliomyelitis eradication was also fairly constant at 2% of total health expenditures. However, the annual increase in expenditure was only 1.6% for poliomyelitis eradication, while those for routine immunization and the health and population programme increased by 11–12% (Table 1). In Coˆte d’Ivoire, expenditures on the PEI, routine immunization, and the health sector increased between 1996 and 1998 (Table 2). In this country, PEI expenditures were equivalent to NID spending because no information was available on spending on surveillance. Expenditures on routine immunization as a percentage of health sector expenditures remained the same during this period.The expenditures on the PEI increased more rapidly during this period (22–27%), although the value in United States dollars of the expenditures was relatively low and ranged from only 1.1% to 1.8% of total health sector expenditures. The funding for the entire national immunization programme increased at a slower rate (9.1%) than the health budget as a whole (11.3%). Funding trends for routine immunization and polio eradication For all three countries, we examined funding trends for the PEI and for routine immunization by source, to determine whether some sources reduced their funding for routine immunization after the PEI was introduced. In Bangladesh, funding for routine immunization either stayed the same or increased for most funding sources (Table 3), and the government of Bangladesh increased its funding for routine immunization, despite some fluctuations. The level of funding of other agencies, such as USAID and WHO, did not significantly change during the period. The three-yearmoving averages of funding contributions were US$ 315 099, US$ 319 230, and US$ 300 064 for USAID 823Bulletin of the World Health Organization 2002, 80 (10) Polio eradication and the financing of routine immunization andUS$ 143 749, US$ 158 151, andUS$ 184 890 forWHO (the amounts refer to averages of data from three years, beginning with the base year, base year + 1, and base year + 2. Although UNICEF funding for the routine immunization programme did decrease in 1997–98, this could be attributed to the introduction of the sector-wide approach in the health sector, rather than to a reallocation of funds to the PEI. The Swedish International Development Agency and other donors that previously funnelled contributions to routine immunization (for cold-chain equipment and vaccines) through UNICEF, instead provided their aid as sector-wide pooled funding. The exact contributions for the Swedish International Development Agency could not be quantified, since the Agency was still making contributions to the routine immunization programme indirectly. Since UNICEF no longer had funds to purchase vaccines, the government of Bangladesh used its World Bank loan instead to purchase vaccines. Funding for the PEI stayed at about the same level for most sources (Table 3), with the exception of the government of Bangladesh, which gradually decreased its contributions. In Coˆte d’Ivoire, the government, the European Union Development Fund, and the German Development Bank all increased funding for routine immunization between 1996 and 1999 (Table 4). The contribution from WHO remained the same, while that for UNICEF declined slightly, for unknown Table 1. Annual expenditure for polio eradication, routine immunization, and the health and population programme,a Bangladesh, 1993–97, all sources of funding Health activity Annual expenditureb Average annual change (%) 1993 1994 1995 1996 1997 Polio eradication Annual expenditure (US$ in thousands) 0 7 104 7 601 7 306 7 430 – Annual change (%) NAc NA 7.0 –3.9 1.7 1.6 Routine immunization Annual expenditure (US$ in thousands) 19 833 24 869 19 292 25 379 27 826 – Annual change (%) NA 25.4 –22.4 31.6 9.6 11.1 Total: polio eradication and routine immunization Annual expenditure (US$ in thousands) 19 833 31 974 26 893 32 685 35 257 – Annual change (%) NA 61.2 –15.9 21.5 7.9 18.7 Health and population programme Annual expenditure (US$ in thousands) 268 100 343 400 357 311 399 591 412 574 – Annual change (%) NA 28.1 4.1 11.8 3.2 11.8 % of expenditures on PEI to total health programme NA 2.1 2.1 1.8 1.8 2.0 % of expenditures on routine immunization to total health programme 7.4 7.2 5.4 6.4 6.7 6.6 a Includes all expenditures on health, including routine immunization and the Global Polio Eradication Initiative. b Expenditures have been converted to US$ (thousands) to account for inflation during the study period. c NA = data not available. Table 2. Annual expenditure for polio eradication, routine immunization, and the health sector, Coˆte d’Ivoire, 1995–98, all sources of funding Health activity Annual expenditurea Average annual change (%) 1995 1996 1997 1998 Polio eradication Annual expenditure (US$ in thousands) NAb 2 009c 2 442d 3 099 – Annual change (%) NA NA 21.5 26.9 24.2 Routine immunization Annual expenditure (US$ in thousands) NA 7 224 7 409 7 876 – Annual change (%) NA NA 2.6 6.3 4.4 Total: polio eradication and routine immunization Annual expenditure (US$ in thousands) NA 9 234 9 852 10 976 – Annual change (%) NA NA 6.7 11.4 9.1 Health sector Annual expenditure (US$ in thousands) 132 572 182 566 173 542 175 559 – Annual change (%) NA 37.7 –4.9 1.2 11.3 a Expenditures have been converted to US$ (thousands) to account for inflation during the study period. b NA = data not available. c It was assumed that the government contribution towards operational expenses was the same as that in 1998. d It was assumed that the German Development Bank contributed US$ 278 840 (amount contributed the previous year). 824 Bulletin of the World Health Organization 2002, 80 (10) Policy and Practice reasons. The contributions of the government of Coˆte d’Ivoire for poliomyelitis eradication also increased (Table 4). While the contributions of a few donors, such as USAID (through WHO), were lower for 1999 than those for 1998, Japan and UNICEF have filled the gap when required. The contributions of the government of Coˆte d’Ivoire to both routine immunization and national immunization days increased. The government of Japan pledged to support the PEI and designated its contribution for the cold chain, while the GermanDevelopment Bank, which has a history of supporting routine immunization but not poliomyelitis eradication, designated its contribution for routine immunization. In Morocco, the government was the main financier of both the routine immunization programme and the PEI, in contrast to the situation in Bangladesh and Coˆte d’Ivoire. In 1995 Morocco began to finance all of its vaccines using its World Bank loan (a non-International Development Associa- tion loan). The contribution of international agencies to the immunization programme comprised only about 4% of total costs (6). The contributions of the government of Morocco increased for both routine immunization and PEI activities (Table 5, Table 6). For the routine immunization programme, the increases occurred because population growth required additional resources and programme improvements required more funds (6). For the PEI, an acceleration in the implementation of activities increased contributions. Long-term prospects for financing routine immunizations In Bangladesh, long-term prospects for financing routine immunizations and health systems have changed little since the PEI was introduced. Two donors, the government of Japan and Rotary International, used not to fund routine immuniza- tion activities, and even though they currently provide funds for poliomyelitis eradication activities, this situation will probably change. Rotary International has a particular interest in funding poliomyelitis eradication activities and other specific programmes, such as AIDS Education, and is unlikely to finance other immunization activities. Also, even though the government of Japan has provided funding for routine immunization vaccines since 1995–96, interviews of staff of the Japan International Cooperation Agency in Dhaka, Bangladesh, in February 1999 indicated that this contribution would end in a few years (Y. Ando, personal communication, 1999). The effect of the PEI on the long-term financing prospects for Coˆte d’Ivoire is unclear. If a donor uniquely funded the PEI, loss of this funding would not impact funding for other programmes. Also, the government of Coˆte d’Ivoire has gradually increased its contribution for polio- myelitis eradication activities and this additional funding could be available for other health sector activities after the PEI finishes. In Morocco, the most favourable long-term prospects are for the additional resources generated by the government for poliomyelitis eradication vaccines. When the PEI ends, it is possible that the additional contributions of the government could be transferred to the routine immunization programme, since the funds may have been ‘‘institutionalized.’’ The government could have directed the additional poliomyelitis eradication funds for the national immunization programme to purchase other vaccines and supplies instead, such as hepatitis B vaccines and disposable syringes. However, it is less likely Table 3. Funding sources for routine immunization and polio eradication activities, Bangladesh, 1993–97 Source Fundinga for routine immunization 1993 1994 1995 1996 1997 Government of Bangladesh 9 329 16 657 15 260 16 387 17 676 World Bank 2 876 4 872 2 989 2 414 9 342 UNICEFb 11 461 6 246 6 382 10 419 179 USAIDc 265 300 379 278 242 WHO 134 200 96 357 100 Government of Japan 0 0 0 475 494 Total funding for routine immunization 24 067 28 275 25 108 30 333 28 034 Source Fundinga for polio eradication 1993 1994 1995 1996 1997 Government of Bangladesh 0 3130 1113 1003 723 UNICEF 0 1193 349 312 343 CDCd 0 315 315 315 735 USAID 0 121 165 198 125 WHO 0 603 603 572 4 Rotary International 0 1637 1601 1497 1608 Government of Japan 0 0 3281 3213 4437 Total funding for polio eradication 0 7001 7429 7113 7976 a Funding data have been converted to US$ (thousands) to account for inflation during the study period. The figures in this table do not include all expenditures and are therefore lower than the total expenditure figures in Table 1. b UNICEF = United Nations Children’s Fund. c USAID = United States Agency for International Development. d CDC = United States Centers for Disease Control and Prevention. CDC contributed funds for national immunization days through UNICEF and consequently it is not known whether double counting occurred for this funding. 825Bulletin of the World Health Organization 2002, 80 (10) Polio eradication and the financing of routine immunization that these resources could have been generated without high- level support, such as that of the PEI and the royal family’s strong support and advocacy of the national immunization days. Discussion Government financing Our findings indicate that since poliomyelitis eradication activities were introduced in Bangladesh, Coˆte d’Ivoire, and Morocco, government financing for routine immunization activities increased. In Coˆte d’Ivoire and Morocco, the governments also increased their contributions to the PEI. The results suggest that no trade-offs were made in Coˆte d’Ivoire and Morocco, and that instead the governments increased their overall financing of both routine immunization and poliomyelitis eradication. In Bangladesh, the government concentrated its limited resources on routine immunization rather than on poliomyelitis eradication activities. This was an appropriate choice for the government, since the routine coverage did not increase during 1993–97. External financing Financing of routine immunization programmes by most external sources of funding stayed the same (Bangladesh) or increased (Coˆte d’Ivoire) over the five-year study period. The only organization that decreased its contributions to routine immunization during this period was UNICEF, but the decreases were probably associated with factors other than the reallocation of funding to the PEI. Some donors (e.g. Rotary International) concentrated their funding on either routine immunization or on poliomyelitis eradication activities and did not need to make any funding trade-offs. Three important funding sources for the PEI in the countries studied, the United States Centers for Disease Control and Prevention (CDC), the government of Japan, and Rotary International, focused most of their resources on this initiative. It should be noted that CDC and the government of Japan did not finance the PEI programme in Morocco. In only one case was funding also provided for routine immunization — Japan financed the purchase of measles vaccine in Bangladesh — but this contribution was relatively small. Other donors provided funding only for routine immunization activities (e.g. the German Development Bank in Coˆte d’Ivoire and the Swedish International Development Agency in Bangladesh). Only a few organizations (USAID, WHO, and UNICEF) funded both activities in at least two of the three countries. None appeared to be reducing their funding significantly for routine immunization activities, with the exception of UNICEF in Bangladesh and Coˆte d’Ivoire. In Bangladesh and Coˆte d’Ivoire, funding for routine immunization activities frommost sources generally stayed the same or increased. Where funding decreased, the decline was attributed to reasons other than the reallocation of funds to the PEI. In Morocco, where most of the funding was from the Table 4. Funding sources for routine immunization and polio eradication in Coˆte d’Ivoire, 1996–99 Source Fundinga for routine immunization 1996 1997 1998 1999 Government of Coˆte d’Ivoire 5 170 5 303 5 617 5 870 European Union Development Fund 1 720 1 764 1 869 1 953b German Development Bank 299 306 325 7 280c WHO NAd NA 27 29 UNICEFe 34 34 37 11 Total funding for routine immunization 7 224 7 409 7 876 15 144 Source Fundinga for polio eradication 1996 1997 1998 1999 Government of Coˆte d’Ivoire Operational costs NA NA 294 711 Personnel 610 626 752 691 Rotary International Donations through WHO 1 161 375 279 509 Local donations 0 26 12 8 Government of Japan 0 1 166f 1 120g h USAIDi through WHO NA NA 624 298 WHO-Coˆte d’Ivoire NA NA 9 8 UNICEF 50 50 50 218 Total funding for polio eradication 1 821 2 243 3 140 2 443 a Funding data are given in US$ (thousands). b Financing was blocked due to fraud. c The increase in financing was due to the purchase of cold-chain equipment. d NA = data not available. e UNICEF = United Nations Children’s Fund. f Contribution for cold chain. g National Immunization vaccine and operating costs. h According to WHO, 1998 funds from the government of Japan were used in 1999 to buy vaccines and for operational costs. i USAID = United States Agency for International Development. 826 Bulletin of the World Health Organization 2002, 80 (10) Policy and Practice government, any decrease in funding by donors would have been due to reasons other than financing the PEI. Prospects for long-term financing of routine immunizations In Coˆte d’Ivoire and Morocco, government funding for poliomyelitis eradication activities increased during the study period. To try to keep these funds after the PEI ends and have them allocated to the health sector, policy-makers and programme managers should make plans for the funds and begin lobbying to keep them within the health sector. However, much of the additional funding for the PEI is from donors that provide financing specifically for this activity and not for routine immunization; consequently, the prospects for maintaining funding from them after the initiative ends are not clear. The government of Japan may choose to shift its funding from poliomyelitis eradication to routine immunization, since it funds the latter activity in some countries, but it is not clear that it will do so. It is also possible that donors, such as Rotary International and other international organizations, will shift their funding to another disease eradication initiative, if one is initiated. Despite these concerns, some funds for the PEI were for capital expenditures on equipment and vehicles, which could be used by the routine immunization programme after the PEI ends. It is likely that there were costs in choosing to support poliomyelitis eradication activities in each country, rather than improving the routine immunization programmes. For example, the funds could have been used to introduce ‘‘new’’ vaccines such, as that for hepatitis B, or to provide more social mobilization activities for routine immunization. On the other hand, without high-level advocacy, it is possible that these other activities could not have attracted the additional funding that the high-profile PEI did and they would not have had sufficient finance. Limitations of the study One limitation of the study was that the three study countries were not representative of countries with lower immunization coverage rates. It is possible that the impact of the PEI on financing for routine immunizations would be more adverse in countries with weaker immunization programmes and low coverage. Also, we did not determine whether the policy and financing decisions of international agencies were made at headquarter or regional levels, since we investigated funding only at the country level. Finally, this study examined the impact of the PEI on funding for routine immunization and we cannot draw conclusions regarding its impact on the financing of other health services in the countries studied. n Acknowledgements This study was supported by the PEI funds of the Child Survival Division of USAID, Office of Health and Nutrition, and coordinated by the Partnerships for Health Reform. Implementation of the study in each country would not have been possible without the support of the ministries of health, national immunization programme coordinators, and colla- borating agencies. We also thank Marty Makinen of the Partnerships for Health Reform, and Bruce Aylward and Jean- Marc Olive of WHO for their comments. Finally, we express our appreciation for the continued support and encourage- ment of Ellyn Ogden, USAID Child Survival Division. Conflicts of interest: none declared. Table 5. Funding sources for polio eradication, Morocco, 1993–98a Funding source Funding for polio eradicationb 1993 1994 1995 1996 1997 1998 Government of Morocco Vaccines NAc NA 336 742 930 1131 Personnel NA NA 1855d 1910 1968 2027 Total NA NA 2191 2653 2898 3158 Donor UNICEFe 115 115 115 121 NA NA Rotary Internationalf 603 331 15 NA 24 NA USAIDg NA NA NA 64 93 57 Total 718 446 130 185 117 57 a WHO provided funding for National Immunizations days (6), but the exact amount contributed during the study period is not known. b Expenditures have been converted to US$ (thousands) to account for inflation during the study period. c NA = data not available. d The figure is based on the 1997 value, adjusted for a 3% annual inflation rate. e UNICEF = United Nations Children’s Fund. UNICEF funding supported surveillance and social mobilization activities. f Rotary International funding supported the purchase of vaccines (in 1993 and 1994), social mobilization activities (1995), and cold-chain equipment purchases (1997). g USAID = United States Agency for International Development. USAID funding supported information, education, and communication activities, including meetings. Table 6. Government expenditurea for routine immunization, Morocco, 1994–97 Expenditure 1994 1995 1996 1997 Personnel 4347 4477 4612 4750 Vaccines 719 893 1001 1287 Maintenance/overheads 165 170 175 181 Totals 5232 5541 5789 6218 Increase (%) NAb 5.9 4.5 7.4 a Expenditure is given in US$ (thousands). b NA = data not available. 827Bulletin of the World Health Organization 2002, 80 (10) Polio eradication and the financing of routine immunization Re´sume´ Impact de l’initiative pour l’e´radication de la poliomye´lite sur le financement de la vaccination de routine : e´tudes de cas au Bangladesh, en Coˆte d’Ivoire et au Maroc Pour de´terminer si l’initiative pour l’e´radication de la poliomye´lite a eu un impact sur le financement des programmes de vaccination de routine, nous avons compare´ les sources et l’utilisation des fonds destine´s aux programmes de vaccination de routine et les activite´s de cette initiative au Bangladesh, en Coˆte d’Ivoire et au Maroc pendant les anne´es 1993 a` 1998. Nous avons e´galement examine´ les tendances du financement pour cette meˆme pe´riode dans ces pays et e´value´ l’effet de l’initiative sur la disponibilite´ de certaines ressources au sein des programmes nationaux de vaccination, comme l’e´quipement de la chaıˆne du froid et le temps consacre´ par le personnel a` des activite´s en relation avec la surveillance de la poliomye´lite et de la paralysie flasque aigue¨. Nous avons trouve´ que les trois gouvernements et la plupart des donateurs et des organismes internationaux ont continue´ a` financer les programmes de vaccination de routine au meˆme niveau qu’avant l’initiative. L’analyse des tendances a e´galement montre´ que le financement de la vaccination de routine dans chaque pays a continue´ a` augmenter apre`s le lancement de l’initiative. Les re´sultats montrent que l’initiative pour l’e´radication de la poliomye´lite n’a pas re´duit le financement des vaccinations de routine dans ces pays. Resumen Repercusio´n de la Iniciativa de Erradicacio´n de la Poliomielitis en la financiacio´n de la inmunizacio´n sistema´tica: estudios de casos en Bangladesh, Coˆte d’Ivoire y Marruecos A fin de determinar si la Iniciativa de Erradicacio´n de la Poliomielitis (IEP) afectaba a la financiacio´n de los programas de inmunizacio´n sistema´tica, comparamos la procedencia y el uso de los fondos destinados a dichos programas y a las actividades de la IEP en Bangladesh, Coˆte d’Ivoire y Marruecos durante los an˜os 1993–1998. Tambie´n examinamos las tendencias de la financia- cio´n a lo largo del citado periodo en esos paı´ses y evaluamos el efecto de la iniciativa en cuanto a la disponibilidad de recursos especı´ficos en los programas nacionales de inmunizacio´n, como el equipo de las cadenas de frı´o y el tiempo dedicado por el personal a actividades relacionadas con la vigilancia de la poliomielitis y la para´lisis fla´ccida aguda. Observamos que los tres gobiernos y la mayorı´a de los donantes y las organizaciones internacionales siguieron financiando los programas de inmunizacio´n sistema´tica en medida parecida a como lo habı´an hecho antes de la IEP. El ana´lisis de tendencias mostro´ adema´s que la financiacio´n de la inmunizacio´n sistema´tica en cada uno de los paı´ses siguio´ aumentando tras la introduccio´n de la IEP. Los resultados muestran que e´sta no mermo´ los fondos dedicados a la inmunizacio´n sistema´tica en esos paı´ses. References 1. The impact of the Expanded Programme on Immunization and the Polio Eradication Initiative on health systems in the Americas. Final report of the Taylor Commission. Washington (DC): Pan American Health Organization; 1995. 2. Taylor C, Cutts F, Taylor ME. Ethical dilemmas in current planning for poliomyelitis eradication. American Journal of Public Health 1997;87:922-5. 3. Tangermann R, Costales M, Flavier J. Poliomyelitis eradication and its impact on primary health care in the Philippines. Journal of Infectious Disease 1997;175 Suppl 1:S272-6. 4. Mogedal S, Stenson B. Disease eradication: friend or foe to the health system? Synthesis report from field studies on the polio eradication initiative in Tanzania, Nepal, and Lao PDR. Geneva: World Health Organization; 1999 (unpublished document of November 1999, available on request from the Department of Vaccines and Biologicals, 1211 Geneva 27, Switzerland). 5. Levin A, Siddiqi M, Howlader S, Routh S, Rasul I, Ram S. Case study on the costs and financing of immunization services in Bangladesh. Bethesda (MD): Partnerships for Health Reform, Abt Associates Inc.; 1999 Special Initiative Report No. 21. 6. Kaddar, M, Mookherji S, DeRoeck D, Antona D. Case study on the costs and financing of immunization services in Morocco. Bethesda (MD): Partnerships for Health Reform, Abt Associates Inc.; 1999. Special Initiative Report No. 18. 7. Kaddar M, Tanzi V, Dougherty L. Case study on the costs and financing of immunization services in the Coˆte d’Ivoire. Bethesda (MD): Partnerships for Health Reform, Abt Associates Inc.; 2000 Special Initiative Report No. 24). 828 Bulletin of the World Health Organization 2002, 80 (10) Policy and Practice