Synergies between the GAVI Alliance and health systems strengthening

Dr. Craig Burgess, GAVI Secretariat

29 May 2008

Overview

1. GAVI Alliance: recognising importance of systems2. Integration of immunisation3. Immunisation services support (ISS)4. Health Systems strengthening (HSS)

An innovative public-private partnership”To save children’s lives and protect people’s health through the widespread use of vaccines”

GAVI Alliance strategic goals

1. Strengthening the capacity of the health system to deliver immunisation and other health services in a sustainable manner

2. Accelerate the uptake and use of underused and new vaccines and associated technologies and improve vaccine supply security

3. Increase the predictability and sustainability of long-term financing for national immunisation programmes

4. Increase the added value of GAVI as a public-private global health partnership through efficiency, advocacy and innovation

Estimated costs & financing gaps for immunisation, 2006-15

Source: Global Immunisation Vision and Strategy – WHO costing

Estimated portfolio - systems / new vaccines ratio

1/3 systems / 2/3 new vaccines

New vaccines figures taken from May 2007 GAVI Board financial forecasts

44% 43% 32% 29% 28% 27% 27%HSS + ISS / total GAVI

support

Routine / campaigns / immunisation days Scale up rapidly and delivery costs shared ’Schedules’ provide contacts with health system Multi-valent vaccines Reach Every District strategy G.I.V.S.- Integrating immunisation in a health systems context- Other linked interventions

IntegrationNot an end in itself or an objective. Rather as a means to achieve more effective and efficient service delivery

Linking immunisation with other interventions

Vitamin A

Malaria Control

De-worming

IPTi

ITNs

Future

?HPV?

Timing and scheduling of service delivery crucial

Immunisation services support (ISS)Performance based flexible funding$218 million disbursed by Dec 2007 1. Investment: 3 years, proportional to birth cohort2. Reward: Reward good performance

Incentives - $20 per additional child vaccinated DQA during the 2nd year of support3. What was it spent on?: Per diem, recurrent

expenses, training, outreach, demand generation, supervision, M+E, vehicles, cold chain, capital expenditures

Projections

Source – WHO Report on GAVI Progress 2000-2006 & Projected Achievements 2007-2010, 15 November 2007

Coverage of DTP3 Hepatitis B and Hib immunisation in GAVI-eligible countries

11

GAVI HSS

‘To achieve and sustain increased immunisation coverage, through strengthening the capacity of the health system to provide immunisation and other health services (with a focus on child and maternal health)’

Maximum impact at periphery Three non-exclusive themes:

Health workforce Supply, distribution and maintenance Organisation and management

$800 million approved by board for investment

GAVI HSS principles

Interventions complementary to work of other stakeholders1. Country driven2. Country aligned3. Harmonized4. Predictable5. Additional6. Inclusive and collaborative7. Catalytic8. Innovative9. Results orientated10. Sustainability conscious

UNICEF/Giacomo Pirozzi

Rate and pace of uptake of HSS unpredicted51 countries applied for HSS40 approved or pending approval

HSS IRC Nov 2006 Board approved 5 countries

Feb 2007

$92.1 million

Approved

HSS IRC April 2007 Board approved 4 countries

May 2007

$77.6 million

Approved

HSS IRC June 2007 Board approved 7 countries

July 2007

$95.9 million

Approved

HSS IRC Nov 2007 Board approved 13 countries

November 2007

$135 million Approved

HSS IRC April 2008 11 countries pending approval

June 2008

$94.6 million pending

TOTAL - $495 million approved or pending approval

Analysis of 49 proposals ($427 million)75% funding for ‘operational’ level (district and below)16% funding for upstream level (above district)9 % management

Source: WHO / Unicef / UNFPA University of Queensland analysis of first 49 GAVI HSS proposals

Technical Support-Largely domestic, limited dependence on consultants

ON

LY R3 A

ND

R4

CO

UN

TRIES

Arm

eniaB

hutanB

urkina FasoG

hanaSri Lanka 2U

ganda 2H

ondurasM

adagascarM

alawi

Pakistan 2R

wanda

Zambia

Yemen

NicaraguaN

epal 2M

ozambique

Bolivia

Uganda 1

Chad

Guinea B

issau 2N

igeriaTajikistan 2

CA

R 2

Eritrea N

orth Sudan 2A

fganistanTajiskistan 1

North Sudan 1C

ambodia 2

Status of Application FormA A A A A A A A A A A A A A A R R R A A A A A A A A R R RFragile NF NF NF NF NF NF NF NF NF NF NF NF NF NF NF NF NF NF F F F F F F F F F F F

## ## ## ## ## ## ## ## ## ##TRUE ## ## ## ## ##FALSE## ## ## ## ## ## ## ## ## ## ##MOH EPI ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ##FALSE## 7 39% ## ## ## ## ## ## ## ## ## ## 6 55%MOH Planning ## ## ## ## ## ## ## ## ## ##TRUE ## ## ## ## ##FALSE## 9 50% ## ## ## ## ## ## ## ## ## ## 3 27%Academia ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 6 33% ## ## ## ## ## ## ## ## ## ## 2 18%Civil society ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 8 44% ## ## ## ## ## ## ## ## ## ## 7 64%Other internal ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 5 28% ## ## ## ## ## ## ## ## ## ## 7 64%

Bilateral staff ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 11 61% ## ## ## ## ## ## ## ## ## 4 36%

Multilateral staff ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ##WHO CO ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 16 89% ## ## ## ## ## ## ## ## ## ## 8 73%WHO RO/HQ ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 8 44% ## ## ## ## ## ## ## ## ## ## 6 55%

UNICEF Unspecified ## ## ## ## ## ## ## ## 3 17% ## ## 1 9%UNICEF CO ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 11 61% ## ## ## ## ## ## ## ## ## ## 7 64%U`NICEF R/HQ ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 1 6% ## ## ## ## ## ## ## ## ## ## 2 18%

World Bank ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 6 33% ## ## ## ## ## ## ## ## ## ## 5 45%

Other Multi ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## 2 11% ## ## ## ## ## ## ## ## ## ## 5 45%

Consultant ## ## ## ## ## ## ## ## ## ## ## ## ## ## ## ##FALSE## 9 50% ## ## ## ## ## ## ## ## ## ## 3 27%

Constraints: Contextualised, comprehensive, but with blind spots

Service delivery

Health Workforce

HIS

Infrastructure

Financing

Leadership and Governance

Demand

System research

Service delivery

Health Workforce

HIS

Infrastructure

Financing

Leadership and Governance

Demand

Implementation research

AfghanistanBurundiCAR IIDRCEritreaLiberiaSudan N. IICam

bodia IChadGuinea Bissau IINigeriaSierra Leone Tajikistan IICAR ICam

bodia IIGuinea Bissau ISudan N. ITajikistan I

Armenia

Burkina FasoBhutanCam

eroonEthiopiaGeorgiaGhanaHondurasKenyaKorea DPRKyrgyzstanMadagascarMalawiNepal IINicaraguaPakistan llRwandaSri Lanka IIUganda IIVietnamYem

enZam

biaBeninBoliviaCUBAMozam

biqueNepal IPakistan ISri Lanka ITanzaniaUganda I

Operational constraintsSystemic constraints

Fragile StatesNon fragile States

R A R A Figure 1

Non Fragile Fragile

S

O

Challenges

• Immunisation – systems dynamics (MoH & partners) • Changing the ‘project’ mentality

• Monitoring frameworks • Fiduciary risk

• Adapting performance based funding

• Knowledge sharing