synergies between the gavi alliance and health systems strengthening dr. craig burgess, gavi...
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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 cohort
2. Reward: Reward good performance Incentives - $20 per additional child vaccinated DQA during the 2nd year of support
3. 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
TR
IES
Arm
enia
Bh
utan
Bu
rkina F
aso
Gh
ana
Sri L
anka 2
Ug
and
a 2
Ho
nd
uras
Mad
agascar
Malaw
i
Pakistan
2
Rw
and
a
Zam
bia
Yem
en
Nicarag
ua
Nep
al 2
Mo
zamb
iqu
e
Bo
livia
Ug
and
a 1
Ch
ad
Gu
inea B
issau 2
Nig
eria
Tajikistan
2
CA
R 2
Eritrea
No
rth S
ud
an 2
Afg
anistan
Tajiskistan
1
No
rth S
ud
an 1
Cam
bo
dia 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
AfghanistanBurundiC
AR II
DR
CEritreaLiberiaSudan N
. IIC
ambodia I
Chad
Guinea Bissau II
Nigeria
Sierra Leone Tajikistan IIC
AR I
Cam
bodia IIG
uinea Bissau ISudan N
. ITajikistan I
Armenia
Burkina FasoBhutanC
ameroon
EthiopiaG
eorgiaG
hanaH
ondurasKenyaKorea D
PRKyrgyzstanM
adagascarM
alawiN
epal IIN
icaraguaPakistan llR
wandaSri Lanka IIU
ganda IIVietnamYem
enZam
biaBeninBoliviaC
UBA
Mozam
biqueN
epal IPakistan ISri Lanka ITanzaniaU
ganda I
Operational constraints
Systemic 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