Is Gavi doing enough to support national health systems?

Save the Children believes that all global health funding has a responsibility to make sure it leaves a stronger health system in the countries it supports. Ebola taught us that only measuring specific outcomes can distort a health system. As a major player in global health, Gavi has a huge responsibility in this area. Health systems are vital to support the delivery of immunisation, to achieve and sustain high and equitable coverage, and importantly to ensure that Gavi has positive effects on the overall health systems of countries which can deliver a broader package of interventions in health.

As Seth Berkley (Gavi CEO) has himself said, “The power of routine immunisation is that it already reaches millions through established structures in places where few others exist. As programs expand to protect more children, they can help form the backbone of Universal Health Coverage (UHC).”

Gavi’s success must be judged on its effects on health systems, as well as vaccines delivered

We need to make sure that global health funds, such as Gavi are not undermining progress in other areas of the health system, but rather helping to improve those systems. Based on the latest Gavi Board decisions this doesn’t seem the case.

Last December we argued for stronger indicators that would measure delivery of Gavi’s 2016–20 strategy including their health systems support. It’s disappointing that the indicators approved by the Board failed to include an explicit health systems indicator, or a way to check that increased government funding of immunisation isn’t merely money being shifted away from other primary care services.

The proposed ‘Health system and immunisation strengthening support’ (HSIS) framework goes to the Gavi Board this week for decision. We do not believe that it goes far enough in demonstrating support for strengthening health systems and at worse this could be seen to be a rebranding exercise rather than meaningful change. The new framework continues to include many elements that are not actually health system strengthening (HSS). Moreover, proposed funding appears insufficient to truly deliver on the ambition of the new strategy.

Funding must increase for HSS specifically. Gavi’s resource allocation formula should also better reflect the strength of health systems and equity, and should allow a nuanced approach to dealing with the many countries along the spectrum of development from humanitarian and fragile contexts through to countries preparing for transition from Gavi support. We call on Gavi to ensure that support is aligned with national health and immunisation plans and to assess the impact of its broader funding and support on health systems.

Reaching Every Last Child

Globally, 18.7 million children are still excluded from receiving basic immunisation. Children from the poorest households, from marginalised ethnic groups, living in neglected or rural areas, or affected by conflict are being left behind. Save the Children and RESULTS UK recently launched an Immunisation Equity Scorecard that looks at countries’ progress on national immunisation coverage and equitable access. Twenty out of 40 countries in the Scorecard with disaggregated data have poor equity performance and 20 have not made any progress in closing the coverage gap between the richest and poorest households.

Delivering services equitably will require sufficient funding, including critical investment to build stronger health systems. While national governments have the primary responsibility for this, Gavi funding will continue to play a role for the time being. This must be fit for purpose to support countries to reach every last child. Gavi’s 2016–20 strategy has a much stronger focus on equity. This is very welcome but Gavi must now show how things will be different during this strategy period to help drive this. The ambition of the strategy must translate into impact at country level to reach every last child.

 

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Comments

  • Simon Wright

    Very important points, Kirsten. If Gavi seeks (as it does) to increase domestic resources for immunisation but does not seek to increase overall health budgets then it is advocating for immunisation in competition with other health topic. Gavi may “succeed” but at the expense of funding for skilled birth attendance, malaria treatment or some other health priorities. Gavi (and all the multlateral funds) should be accountable for their impact on health systems.

  • Simon Wright

    I understand that, faced with the same issue, the Global Fund made a different decision and seeks to increase overall health resources in countries, not just for its topics. http://www.theglobalfund.org/en/domesticfinancing/

  • craig burgess

    Thank you Kirsten, this is a great article.
    To give you a flavor of just how contentious an issue it is, read the GAVI 2005-2006 board HSS investment cases / minutes, as well as the GAVI 2007 board minutes, where the board was evenly split on whether to continue / expand HSS investment. The Atlantic Ocean often separated points of view, but all the pro and con arguments are there.

    What is often missing (my opinion) is constructive dialogue between ‘disease control’ thinkers and ‘systems thinkers’ in the same room at the same time. Unfortunately invites to meetings often generate a ‘group think’ where the two separate communities get siloed and are funded separately, so only have to meet and jointly plan infrequently.

    I hope UHC and PHC agendas can somehow bring the groups together and gently introduce the idea of integration at all levels.