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Strengthen capacity
STRENGTHEN CAPACITY
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The success of national immunisation programmes depends upon strong health systems. Over 50 countries have received health system strengthening support from GAVI to ensure that vaccines are delivered to those who need them the most.
Drop-out rate between DTP1 and DTP3 (%)
DTP1 = one dose of diphtheria-tetanus- pertussis (DTP) vaccine
DTP3 = three doses of DTP vaccine
The drop-out rate measures the difference between coverage of one dose of diphtheria-tetanus-pertussis vaccine (DTP1) and coverage of three doses of the same vaccine (DTP3). The drop-out rate in 73 GAVI-eligible countries was projected at 8% in 2011 – in line with GAVI’s target.
WHO/UNICEF coverage estimatesDTP3 coverage (%)
DTP3 coverage climbed to a projected historic high of 81% in 72 GAVI- eligible countries in 2011. This is one percentage point above the 2011 target.
Strategic Demand Forecast v 4Equity in immunisation coverage (%) Proportion of countries meeting the minimum equity benchmark
According to available data, just over half of all GAVI-eligible countries (51%) have a differentiation of less than 20 percentage points between DTP3 coverage in the poorest quintile of the population and the wealthiest quintile. GAVI aims to increase this percentage to 62% by 2015.
Latest available household survey data from each GAVI-eligible country -
Strong health systems
Strong health systems – availability of financing, quality services, human resources, governance, information and technology – have an immediate and direct impact on immunisation.
Immunisation is often the backbone of child health interventions. In settings where the health system is weak and treatment is a challenge, preventative approaches such as immunisation become even more important.
The goal of GAVI’s health system strengthening (HSS) support is to strengthen the capacity of health systems to deliver immunisation. The support aims to resolve barriers to delivering immunisation, to increase equity in access to services and to support civil society involvement in immunisation planning and delivery.
GAVI has approved support for health system strengthening programmes in 54 countries. By developing tailored approaches for fragile and underperforming countries, GAVI is taking steps to further customise its HSS support.
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Bangladesh
Bangladesh
Advocacy key to immunisation success
Immunisation charts on the wall of the Upazila Health Complex in Kapasia, Bangladesh, tell a clear story: a steady rise in the delivery of pentavalent vaccine. As in much of Bangladesh, immunisation coverage in this district of 400,000 people is close to 90%.
Advocacy plays a key role in mobilising Bangladeshis to attend immunisation sessions. Each year, Premier Sheikh Hasina makes a televised national address to urge Bangladeshis to vaccinate their children. On Immunisation Day, the health ministry provides 20,000 mobile vaccination stations, in addition to 140,000 fixed immunisation clinics.
“Illiterate people have a 74% immunisation rate,” says Health Minister A.F.M. Ruhal Haque. “We have been able to convince them to come to the vaccination stations. That is the success of Bangladesh.”
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Nepal
Nepal
Harmonised health system delivers results
Nepal exemplifies how a harmonised health systems approach can deliver results. With a 65% drop in the number of deaths in children under five since 1990, Nepal is on track to meet Millennium Development Goal 4 on child mortality.
Nepal’s successes are rooted in a harmonised health sector, built on the principles of aid effectiveness.
Nepal is the first country to receive GAVI funding through the Health Systems Funding Platform. Together with Platform partners and other leading donors, GAVI aligns its support for health systems with Nepal’s health planning, budgetary and reporting frameworks and cycles.
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Harmonised platform for strengthening health systems to deliver immunisation
Harmonised platform for strengthening health systems to deliver immunisation
The Health Systems Funding Platform (the Platform) was initiated in 2009 as a mechanism for aligning donor support for national health system strengthening programmes. In line with the principles of aid effectiveness, the Platform aligns planning, budget financial management, monitoring and reporting to a country’s national health plan and budget cycles. It thereby aims to lower administrative costs, increase efficiency and reduce fiduciary risk.
Throughout 2011, GAVI continued to work to refine the new application procedures and helped a number of additional countries secure funding for their national health plans and strategies through the Platform. Application guidelines and forms became available in August, and eight countries applied for the first round of funding before the end of the year. These applications will be reviewed during 2012.
The Platform partners – GAVI, the Global Fund to Fight AIDS, Tuberculosis and Malaria; the World Bank and WHO – also worked to harmonise and align monitoring & evaluation and fiduciary frameworks in countries that are already receiving HSS support, including Guinea, Niger and Senegal.
From 2012 onwards, GAVI will review applications on a rolling basis, enabling countries to submit proposals at a time appropriate to their own planning cycles.
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Managing risk in cash support programmes
Managing risk in cash support programmes
The GAVI Secretariat makes every effort to mitigate against the misuse of GAVI’s cash-based support, and has established a series of financial control mechanisms and safeguards as part of its Transparency and Accountability Policy (TAP).
How the Transparency and Accountability Policy (TAP) works:
By the end of December 2011, the TAP team had completed financial management reviews in a total of 37 GAVI-supported countries, 9 of which were conducted in 2011. GAVI has identified six cases of potential or confirmed misuse of funds since its inception. Four of these investigations have been concluded, while investigations in Côte d’Ivoire and Zambia are ongoing.
Following the GAVI Alliance Board meeting in July 2011, GAVI started to implement a series of new measures designed to further prevent misuse of funds. These include the recruitment of additional country responsible officers, more frequent scrutiny of programme reporting, involvement in the selection of independent auditors, and training in fiduciary risk mitigation for relevant staff members.
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Performance-based funding
Performance-based funding: linking HSS support to results
GAVI’s cash support is intended to help countries strengthen their immunisation services, health systems and civil society engagement in immunisation.
In 2011, the Board decided to channel all GAVI’s cash support via a single funding window, to be delivered through the Health Systems Funding Platform. Support will be performance-based, feed directly into national strategies, and be linked to improvements in immunisation coverage and equity of access.
The funding will be split into fixed and performance-related payments.
In the first year, countries will receive a fixed amount of funding from GAVI to invest in their national health systems. In subsequent years, they will receive both fixed and performance-related annual payments, provided they meet set targets for immunisation coverage and equity.
This approach will be gradually rolled out to countries as their existing GAVI cash support lapses. GAVI will tailor the support to country circumstances, and develop alternative funding mechanisms to support countries that are fragile, underperforming or very large.
Working with countries to improve data quality
GAVI receives data on country progress in immunisation from three different sources. Each country reports its own administrative coverage data, based on information compiled at the local, district and regional levels, directly to GAVI through joint reporting forms and annual progress reports. In addition, some countries conduct household surveys based on random samples, which are used to estimate immunisation coverage rates. As data gathering is often challenging for countries, WHO and UNICEF make annual estimates of their own based on a range of historical and current data, keeping in mind previous trends in immunisation coverage.
Efforts by countries and partners have led to improvements in the quality of routine immunisation data in the last few years. However, improving data quality is a long-term process and large discrepancies between different sources of data are still common. Given the critical importance of the accuracy and reliability of country administrative data, GAVI is increasing its investment in efforts to verify and strengthen the quality of reported data.
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Addressing gender-related barriers to immunisation
Addressing gender-related barriers to immunisation
According to a recent GAVI-funded review of gender issues in immunisation, conducted by WHO, boys and girls have the same likelihood of being immunised at the global level.* However, there is evidence that gender-related barriers are creating inequities in access to health services in some countries, especially those where women have a low status. Typically in these societies women lack access to health services, and their children – both girls and boys – are less likely to be immunised.
The GAVI Alliance strategy for 2011–2015 positions gender equity as an overarching principle for all of its work, and the gender policy recognises equal access to immunisation as a key factor for expanding immunisation coverage
and for making immunisation more equitable. GAVI encourages countries to use their HSS funds to overcome gender-related barriers to immunisation and to develop gender-sensitive health services. When applying for HSS support, countries are requested to identify any gender-related obstacles to accessing immunisation services and to outline a plan to tackle them.
Countries are advised to implement immunisation programmes and campaigns that reach out to both male and female caregivers of children. Also, GAVI recommends that they provide immunisation services in places that are accessible to both men and women.
In settings where mothers are unable to interact with male vaccinators due to cultural taboos, countries are encouraged to have female service providers for women.
Hilber AM, McKenzie O, Gari S et al. (2010). Gender and immunisation. Summary report. Geneva, Swiss Centre for International Health, 2010.GAVI moves forward on gender balance
With nine women and nine men, the Independent Review Committee (IRC) that is responsible for monitoring country progress in implementing GAVI support is GAVI’s first committee to have achieved a gender balance. This is in line with GAVI’s gender policy, which requires that a gender balance is obtained in all areas of GAVI’s work, including its governance structures.
For the first time in 2011, the IRC also included a gender and social development expert, who prepared a gender analysis and recommendations as part of the overall IRC report. “We are living what we preach,” says Dr Bola Oyeledun, the IRC Chairwoman.
The GAVI Alliance Board has also become increasingly gender balanced, following the adoption in 2010 of a set of guidelines requiring a 60/40 gender ratio on the Board. At the end of 2009, the Board consisted of 41 members and alternate members, 83% of whom were men and 17% women. By the end of 2011, the proportion had changed to 66% men and 34% women.
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Over 19 million children remain unimmunised
Over 19 million children remain unimmunised
WHO/UNICEF coverage estimates 2010 revision. July 2011
Ensuring every child’s right to health
Although immunisation rates are at their highest level ever, averaging over 80% across GAVI-supported countries, nearly one in five children is still not receiving routine vaccinations.
While equity between high- and low-income countries is at the core of GAVI’s mission, equity within countries is equally critical. GAVI’s aim is for all children, regardless of where they live, to enjoy the full benefits of immunisation.
In all countries, children in the poorest households are more likely to die before their fifth birthday than children in wealthier families.* Other children miss out on routine vaccination programmes because they are living in remote locations, urban slums or border areas.
Only 48 WHO member states have achieved the goal of 80% DTP3 coverage in all districts.** To help address this imbalance and to ensure that life-saving vaccines reach the poorest and most remote populations, GAVI continues to support the delivery of vaccines through health system strengthening, civil society support and immunisation services support.
GAVI also works with WHO to identify inequalities in immunisation coverage and to better understand why they exist. Armed with a stronger knowledge base, selected countries are being assisted to address gaps in their coverage.
* P Braveman. Health disparities and health equity: concepts and measurement. Annual Review of Public Health, 2006, 27:167–194.
** Global immunization vision and strategy. Progress report and strategic direction for the Decade of Vaccines. Geneva, World Health Organization, 2011 (Report to the 64th World Health Assembly; accessed 3 May 2012). -
Malawi
Malawi
Spreading the word on immunisation
In remote villages such as Chifuchambewa in eastern Malawi, vaccination experts from the Ministry of Health rely heavily on village leaders to spread the word about the importance of bringing babies for routine vaccination.
Medson Kolole, Chief of Chifuchambewa village, plays an active role in the health of his villagers. “One of the main roles of the village chief is to sensitise families about a healthy way of life,” he says. “We work closely with the community health workers – and they work with us. We respect them and follow their advice, especially about vaccinating our children.”
Pneumococcal vaccines, introduced in Malawi in November 2011, will help protect the country’s children against the world’s number one killer of children under five, pneumonia.
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Lessons learned to inform future support to civil society
Lessons learned to inform future support to civil society
In many countries, it is civil society organisations (CSOs), often working in close cooperation with government, that are ensuring that life-saving vaccines are delivered to the children that need them the most.
Recognising this critical role, GAVI introduced a pilot funding window in 2007 to support civil society coordination and involvement in immunisation and health system strengthening.
Although no new programme funding was approved in 2011, some existing CSO pilot programmes were extended. In March, Afghanistan and Togo received additional funding to further strengthen CSO involvement in health planning processes. Later in the year, GAVI extended its civil society support to Afghanistan and Pakistan to ensure that health system strengthening activities, and thereby service delivery, could continue uninterrupted.
During the year, GAVI embarked on aligning support to CSOs with the Health Systems Funding Platform, working in close collaboration with its CSO constituency.
An evaluation of GAVI’s support to CSOs was initiated in 2011. GAVI will draw on the conclusions of the evaluation to develop a framework that presents why and how GAVI works with and supports CSOs.
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Afghanistan
Afghanistan
Civil society drives health improvements
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As is the case in many fragile states, Afghanistan’s civil society organisations do much of the work of providing basic health services to the population.
Despite the fact that Afghanistan is still one of the world’s poorest countries, some of its basic health indicators have improved rapidly over the past decade. Immunisation coverage for DTP3 increased from 24% in 2000 to 66% in 2010. During the same period, child mortality dropped by over 10%.
“We would never have succeeded in making this progress unless we had close collaboration between the Afghan Government, the civil societies and communities. By working with CSOs at grass-root level, our work is owned by the people and sustained by the people,” says Afghanistan’s Minister of Public Health, Dr Suraya Dalil.
