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Strengthen capacity
Strengthen
capacityVisit the gavialliance.org webpage to see current information on goal indicators and download in PDF/XLS
Strong health systems are essential to ensure access to vaccines for all children everywhere.
Drop-out rate between DTP1 & DTP3 (%)
This indicator measures the drop-out rate between coverage of the first dose of the diphtheria-tetanus-pertussis vaccine (DTP1) and the third dose of the same vaccine (DTP3).
WHO/UNICEF Estimates of National Immunization CoverageDTP3 coverage (%)
Coverage for DTP3 in 73 GAVI-supported countries was projected to reach 75% in 2012.
WHO/UNICEF Estimates of National Immunization CoverageEquity in immunisation coverage (%)
Proportion of countries meeting the minimum equity benchmark
In 2012, 54% of GAVI-eligible countries with available survey data had a differentiation of less than 20 percentage points between DTP3 coverage in the poorest quintile of the population and DTP3 coverage in the wealthiest quintile. GAVI aims to increase this to 62% of countries by 2015.
GAVI Alliance, 2013 (aggregated from various household survey estimates)Revision of DTP3 coverage indicator: maintaining the level of ambition
In 2012, WHO revised its 2010 coverage estimates for the third dose of diphtheria-tetanus-pertussis vaccine (DTP3), which were used to derive GAVI’s targets for vaccine coverage.
The decrease in coverage was mainly driven by significant drops in the 2010 coverage estimates in four large countries (Côte d’Ivoire, Chad, Nigeria and Pakistan), which represent a large proportion of the number of births worldwide.
As a result, in 2012 GAVI revised its targets for impact on DTP3 coverage and DTP1–DTP3 drop-out rate.
Target evolution for DTP3 coverage in GAVI countries
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Fifty-two countries
Fifty-two countries are currently receiving funding for health system strengthening (HSS) from GAVI.
Well-functioning health systems are a prerequisite for ensuring that life-saving vaccines reach all those who need them. All aspects of the health system have an impact on the success of immunisation programmes.
The aim of GAVI’s HSS support is to enhance the capacity of health systems to deliver immunisation. Throughout 2012, Alliance partners continued to work together to make sure that HSS support is translated into improved immunisation outcomes. Every effort is made to ensure that HSS grants adequately address any equity-related barriers (geographic, wealth and gender) to accessing health and immunisation services.
A new performance-based funding model for HSS was introduced at the end of 2012. The aim is to create incentives for using HSS support to boost immunisation coverage and to make access more equitable. In addition, GAVI is adopting ways of tailoring its approach to countries that are in short- or long-term fragile situations.
Rethinking HSS support for increased impact
Disbursements of HSS funds are steadily increasing. By the end of 2012, GAVI had disbursed approximately 80% of all approved HSS grants since 2007. However, GAVI expenditure on HSS to date falls short of the target (between 15% and 25% of total disbursements) set by the Board.
A new technical advisory group on health system strengthening was set up in 2012. This group provided advice to the CEO on GAVI’s future engagement in the Health Systems Funding Platform, as well as guidance on delivering technical support to countries, performance-based financing and country-tailored approaches to HSS.
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Myanmar
Myanmar
Strengthening the health system to support new vaccines
After decades of social and political isolation and reduced investment in public health infrastructure, Myanmar is now well placed to protect its children from a range of potentially fatal diseases. A turning point came in November 2012 with the simultaneous introduction of the five-in-one pentavalent vaccine and the measles second dose vaccine.
A delegation of Australian and New Zealand politicians, led by the GAVI Alliance Board Chair, Dagfinn Høybråten, visited Myanmar in November 2012 and witnessed the challenges facing the country first hand.
GAVI’s HSS support has helped to pave the way for the introduction of the new vaccines. Part of the funding has been used to upgrade Myanmar’s cold chain system, vital for keeping vaccines under the right conditions.
The grant has also funded the production of vaccination record cards, which will enable parents and medical professionals to keep track of who has received which vaccinations. Further, the cards contribute to improving vaccine surveillance data, which in turn will help to inform future programme planning and decision-making.
GAVI has supported Myanmar since 2002 by providing funding for hepatitis B vaccine and for programmes to strengthen the country’s health system.
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Performance-based funding
Performance-based funding: rewarding immunisation results through HSS
In order to better link HSS support to improved immunisation outcomes, GAVI has introduced a new performance-based funding instrument whereby a portion of the HSS support awarded will depend on country performance against set indicators.
In their first year of support, countries will receive a fixed payment to invest in their health systems. From the second year onwards, the annual grant will consist of both a fixed and a performance-based payment, determined by country performance against immunisation coverage and equity indicators.
Performance-based payments for countries with immunisation coverage levels below 90% will be calculated according to the number of additional children vaccinated with DTP3 and measles vaccine, provided that coverage increases. Countries with DTP3 coverage above 90% will be rewarded if they maintain or increase their coverage, and if coverage remains at or above 80% in 90% of districts. Countries that perform exceptionally well may receive annual payments that are greater than their country ceiling.
HOW performance-based funding WORKS
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Pakistan
Pakistan
Female health workers help to expand child immunisation coverage
In front of a poster announcing the arrival of a vaccinator in the Punjabi village of Chinkowindi, Rashida Parveen welcomes villagers bringing children for vaccination.
Rashida is part of a cadre of some 100,000 community-based “Lady Health Workers”, known as LHWs, in Pakistan who go door-to-door advising families about immunisation, nutrition, hygiene, care for women during and after pregnancy, and family planning. They inform them about the facilities available at nearby health centres and when vaccinators visit, LHWs call on homes with babies, urging families to have them vaccinated.
“At first, they were a little wary about immunisation,” Rashida says of her community members. “They thought we would force people into family planning. But now that they know us they have confidence in us and treat us with respect. And they understand how important it is to vaccinate their children.”
With low immunisation coverage rates in Pakistan, the Ministry of Health has involved LHWs in immunisation activities with the support of a GAVI HSS grant. So far, almost 15,000 LHWs have been trained to provide routine immunisation.
Following a series of attacks in December, GAVI and its partners are committed to working with the Government of Pakistan to support the security of health workers as they carry out their vital work.
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Partnerships key to improving data quality
Partnerships key to improving data quality
Access to accurate data is essential to properly assess immunisation coverage and the impact of immunisation programmes. GAVI tracks available immunisation coverage data disaggregated by income, geographic location and sex in order to help identify inequities in access.
Discrepancies often exist between coverage data reported by countries, WHO/UNICEF Estimates of National Immunization Coverage (WUENIC) and household surveys. A new “grade of confidence” rating scale, introduced in 2012 by WHO and UNICEF, has shown that confidence in WUENIC estimates for the majority of GAVI-supported countries is low.
GAVI works closely with countries and global partners to improve the quality of reported data.
In 2012, the Board identified data quality as a priority area of focus, and allocated increased resources for data quality improvement activities through the 2013–2014 business plan. The Secretariat called for a data summit to discuss ways to strengthen data systems and capacity at country level; to improve the frequency of and methodology for household surveys; and to advance innovation in the use of biomarkers, triangulation (validating data against other data sources) methods and other new technologies.
In 2012 GAVI also successfully piloted a revised Immunisation Data Quality Assessment tool (IDQA) in Bolivia, Ghana and Uganda. The pilot exercise not only provided insights into improving the data quality systems in countries, but also built partnerships, strengthened in-country capacity and provided valuable information to help finalise the tool. GAVI will implement the IDQA tool in GAVI-eligible countries from 2013 onwards.
Equity – advancing access to life-saving vaccines for all
Although global child mortality is declining, every year close to seven million children still die before their fifth birthday.
Almost one in five children lacks access to the basic childhood vaccines that are taken for granted in most rich countries. The ones who are missing out tend to be those who live in the poorest households and/or in the most remote locations. These children are also more prone to fall sick and less likely to have access to healthcare than their richer peers. Up to one fifth of all child deaths are from diseases that could have been prevented by vaccines.
Through collaboration with its partners, GAVI strives to address inequities in access to immunisation between the poor and the rich (wealth equity), between low- and high-coverage districts (geographical equity) and between the sexes (gender equity).
The Alliance is strengthening its support to countries where immunisation coverage is below 70%, and in those countries where inequities in coverage are most severe. Although all partners will be involved, from 2013 WHO will take the lead in working with low-coverage countries and UNICEF with countries facing inequities related to wealth, geography or gender.
Recent changes in GAVI’s structures and systems have resulted in marked improvements in the Alliance’s capacity to address gender issues. Successes highlighted in the 2012 evaluation of the GAVI Alliance gender policy include strengthened gender requirements in application and reporting forms, inclusion of a gender expert on each Independent Review Committee panel and a more equal gender balance on the GAVI Alliance Board. The GAVI Alliance gender policy requires that a gender balance is obtained in all areas of GAVI’s work, including its governance structures.
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Mozambique
Mobile phones
to transform vaccine management in Mozambique
Mobile technology has the potential to revolutionise the management and delivery of immunisation services in many of the world’s poorest countries. In 2012, Mozambique’s Department of Health and the GAVI Alliance, in partnership with Vodafone, a GAVI Matching Fund partner, agreed to embark on a pilot project starting in 2013.
The aim is to use mobile phones to improve data accuracy, increase immunisation rates, reduce the report lag time from the field and reduce stock wastage. Plans for the project include registering parents and caregivers and then using mobile phones to inform them about the importance of immunisation and alert them when it is time for their children to be immunised.
In addition, health workers will be provided with mobile phones equipped with special software that enables them to access patient information, schedule appointments, monitor stocks and order vaccines.
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StoriesStrengthening the vaccine supply chain
Many children do not get the vaccines they need because the supply chain – the system that moves vaccines from the point of manufacture to the point of administration – does not function as it should. The situation is acute in some developing countries, where vaccine supply chains are often inefficient and outdated and do not take advantage of modern technology. As a result, clinics may run out of vaccines and vaccines can lose their potency because they get too cold or too hot or are allowed to expire.
During 2012, GAVI started working with its partners to develop an end-to-end supply chain strategy for vaccines. The strategy draws upon practice and technology in other sectors and examines the flow of vaccines, information and money up and down the entire chain. One of the options that GAVI is looking at is a barcode track and trace system. This would allow vaccines to be tracked in much the same way as a supermarket tracks products across the world.
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The Alliance is strengthening
Support to civil society
Civil society organisations (CSOs) play a vital role in advocating for and contributing to higher and more equitable immunisation coverage in many of the world’s poorest countries. In some GAVI-supported countries, CSOs provide up to 60% of immunisation services.
GAVI first opened a funding window for CSO support in 2007 on a pilot basis in 10 countries. A 2012 independent evaluation of the pilot programme concluded that CSO support had been instrumental in achieving immunisation objectives. However, the evaluation noted that issues relating to programme design and implementation had weakened the overall impact.
The outcome of the evaluation informed GAVI’s decision to provide CSO support not as a separate funding stream, but as an integrated part of HSS support channelled through national governments.
While funding through national governments is the default approach, it is possible in exceptional circumstances to engage global or national CSOs directly. Such CSO recipients will be accountable in the same way that governments are.
In 2012, GAVI also committed US$ 1.2 million to support CSO engagement in national health policy dialogue. Catholic Relief Services has been contracted on behalf of the GAVI CSO constituency for this purpose.
Implementation of this type of support has started in seven countries: Burkina Faso, the Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Malawi and Pakistan. GAVI plans to scale up this support to include other countries.
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Ghana and Tanzania
Ghana and Tanzania
lead the way in dual vaccine introductions
2012 proved to be a headline year for vaccine introductions with two GAVI-supported countries launching two vaccines at the same time. In April, Ghana introduced both pneumococcal and rotavirus vaccines into its routine immunisation schedule – the first simultaneous vaccine launch in a GAVI-supported country.
Joint vaccine introductions complicate the planning process, and members of Ghana’s immunisation team were justifiably proud of their achievement. Keen to share their experience with other countries, in 2012 Ghana hosted colleagues from the Tanzanian Ministry of Health and Social Welfare to share experiences as Tanzania prepared for its own dual vaccine launch.
With UNICEF support, GAVI co-organised the exchange visit, which allowed the teams to discuss in detail how best to tackle issues such as planning, ensuring adequate cold chain capacity and appropriate training of health workers, dealing with waste disposal, and the unique communication challenges posed
by multiple vaccine introductions.Tanzania successfully launched both vaccines in December 2012, during the GAVI Partners’ Forum.
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Bangladesh, Honduras, Madagascar and Nicaragua
Bangladesh, Honduras, Madagascar and Nicaragua
awarded for expanding vaccine coverage
Four GAVI-supported countries received awards at the 2012 GAVI Alliance Partners’ Forum for their impressive progress in expanding routine immunisation.
With 89% coverage for DTP3 in 2011, Madagascar won the award in the medium coverage category, and Nicaragua was awarded for best performance in the high coverage category. Honduras, which had close to universal coverage in 2011, received the award for very high coverage.
In the large country category, Bangladesh was recognised for being the most consistent performer since 2009 with an average immunisation coverage of above 90%.
In all, a total of 13 countries received awards for their achievements in areas such as co-financing, civil society commitment, equity and reducing child mortality.
Dr Marina Xioleth Rodriguez, Director-General for Health Promotion in Honduras, received her country’s award from Dr Babatunde Osotimehin, Executive Director of UNFPA.
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Country-by-country
Country-by-country approach to support fragile states
In December 2012, the GAVI Alliance Board approved a policy that provides for tailored approaches to fragile states and for time-limited responses to be used in countries in short-term emergency situations. The objectives of the policy are to improve immunisation coverage in countries where circumstances are especially difficult, and to protect immunisation systems in GAVI-supported countries in the event of an emergency.
A number of GAVI-supported countries face exceptional challenges, which limit their ability to access and implement GAVI support for immunisation over the medium to longer term. The new policy enables GAVI to develop a tailored approach for these countries, adjusted to their specific contexts and needs.
Among other factors, the policy aims to identify countries experiencing inequities in access based on gender, income and geographic location. Each country-tailored approach will include an analysis of the country situation with regards to gender equity and immunisation, both in terms of service delivery and access.
Similarly, the new policy, as applied to countries experiencing time-limited man-made or natural emergencies, will allow GAVI to provide one-off flexibilities in order to help protect immunisation systems and existing GAVI support to these countries.
Both fragile states and those in short-term emergency situations may be able to use existing support more flexibly or access limited additional funding for immunisation, decided on a case-by-case basis.
Rwanda
RWANDAN FATHER
gets his daughter immunised
In the heart of Rwanda’s capital, Kigali, lie the neat red clay roads and huts of Biryogo. Here the Ministry of Health, with support from the Catholic Church, runs a children’s clinic for the local community.
The waiting room is crowded with mothers dressed in rainbow colours with their babies. Everyone holds an immunisation card. Outside on the veranda, Bashir is waiting with his wife Mariam and their daughter Nadjiha.
“When our daughter was born, the nurses at the maternity hospital told us that we should take her to the clinic to be vaccinated. Everyone in our community has their children vaccinated. You don’t see diseases anymore,” explains Bashir. “I took the day off work so I could be here. I love my wife and daughter. I want them to be healthy.”
Immunisation against rotavirus, which claims the lives of close to 3,500 Rwandan children every year, is one of the services provided at the clinic. The vaccine was introduced with support from GAVI in May 2012.
In 2012, Rwanda also received GAVI support for pentavalent and pneumococcal vaccines.
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TAP
THE Transparency and Accountability Policy (TAP) IN ACTION
Mitigating risk in cash-based programmes
GAVI employs a number of safeguards to prevent the misuse of its cash-based support. A Transparency and Accountability Policy (TAP) governs the management of all cash support to countries.
By the end of 2012, the GAVI Secretariat had completed detailed financial management reviews in 47 GAVI-supported countries. Nine new financial management assessments were conducted in 2012 alone. Wherever possible, GAVI conducts these assessments in collaboration with other development partners.
Since GAVI’s inception, seven cases of potential or confirmed misuse of cash-based support have been identified. Investigations have been concluded in six of these cases, while one investigation into suspected misuse of funds is ongoing.
Cameroon and Niger, where investigations into misuse of funds were initiated in 2011, have since reconfirmed their commitment to take all necessary measures to resolve matters, including repaying the missing funds.
