Halfway THERE. Delivering on the promise of immunisation for all

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1 Halfway THERE Delivering on the promise of immunisation for all

2 Halfway THERE Delivering on the promise of immunisation for all

3 Save the Children works in more than 120 countries. We save children s lives. We fight for their rights. We help them fulfil their potential. Acknowledgements This report was written by Kirsten Mathieson from Save the Children UK, with input from Lara Brearley and Simon Wright. We would like to thank Untitled Collective for developing the graphics included in the report. We are grateful to the GAVI Alliance for providing data and other information that contributed to the analysis in the report and for their valuable feedback. We would also like to express our sincere gratitude to the many external peer reviewers from a number of organisations, including ACTION, Bill & Melinda Gates Foundation, Decade of Vaccines Secretariat, GAVI civil society steering committee Secretariat, GlaxoSmithKline, Médecins Sans Frontières, PATH and UNICEF. Published by Save the Children 1 St John s Lane London EC1M 4AR UK +44 (0) savethechildren.org.uk First published 2013 The Save the Children Fund 2013 The Save the Children Fund is a charity registered in England and Wales (213890) and Scotland (SC039570). Registered Company No This publication is copyright, but may be reproduced by any method without fee or prior permission for teaching purposes, but not for resale. For copying in any other circumstances, prior written permission must be obtained from the publisher, and a fee may be payable. Cover photo: A child in South Sudan is immunised by a community health worker. (Photo: Jenn Warren/Save the Children) Typeset by Grasshopper Design Company Printed by Page Bros Ltd

4 CONTENTS Introduction 1 GAVI s strategic goals for Taking stock at the midpoint of GAVI s strategy 2 1 Predictable and sustainable financing for immunisation 3 Donor commitments 3 GAVI Matching Fund 5 Country co-financing 6 2 Making vaccines more affordable 8 3 Introduction and coverage of new vaccines 11 4 Supporting countries to strengthen health systems and promote equity 13 Performance-based funding model 13 Funding to strengthen health systems 14 Delivery of health system strengthening support to GAVI countries 14 GAVI s approach to equity 16 Equity policy framework 17 Addressing data challenges for equity 18 Country-tailored support to promote equity 18 Support for civil society engagement 19 5 GAVI governance 21 Constituency representation on the GAVI board 21 Gender representation on the GAVI board 23 Representation on the GAVI executive committee 23 Conclusion and recommendations 24 Endnotes 26

5 GAVI AND PARTNERS PROGRESS This year marks the mid-point in GAVI s strategy. Here is a snapshot of progress made to date and where more progress is needed. PREDICTABLE AND SUSTAINABLE FINANCING $ $ + $ $ Donor commitments Donors have so far delivered on 2011 promises but 7 donors haven t pledged for the full period and 5 still need to convert all pledges into signed agreements. MATCHING FUND A lot of progress has been made on the GAVI Matching Fund; but 43% of its full potential ($112m) is still to be realised. Country co-financing Countries are performing well on commitments with 87% making timely payments last year; but 8 were late with payments or in arrears. VACCINE AFFORDABILITY AND INTRODUCTIONS $ Vaccine prices Progress has been made to bring vaccine prices down for GAVI procurement; but they must come down further to levels affordable by countries, including for countries that will graduate from GAVI support. Vaccine rollouts Impressive progress has been made in rolling out vaccines to countries, with GAVI on track to exceed 2015 targets; but it s important to ensure high and equitable coverage of these new antigens. HEALTH SYSTEM STRENGTHENING AND EQUITY $ HSS funding GAVI has generally performed poorly on its 15 25% cash-based spending target; while this target has been reached for 2013, the HSS proportion is very low (7%). HSS support HSS support needs to improve, including: modifying PBF criteria; ensuring outputs address broader health system bottlenecks; and requiring HSS applications to include civil society. promote equity GAVI s progress here has been poorer than in other areas; while there are recent improvements with the new country-tailored approach, equity needs to be a top priority in their next strategy. GAVI GOVERNANCE Board composition Imbalances in board composition need to be addressed, including poor CSO representation and over-representation from unaffiliated members not accountable to any constituency. Gender representation Last year GAVI achieved its target of greater than 40% representation from both genders on the GAVI Board. iv

6 INTRODUCTION Recent data show a huge reduction in child mortality globally, from 12.6 million underfive deaths in 1990 to 6.6 million in This trend coincides with the expansion of coverage of essential health services, including immunisation, which has now reached 83% globally, up from 76% in This means that more and more children are now benefiting from immunisation one of the most successful and cost-effective health investments for child survival. This is a great achievement. However, many countries remain off-track to achieve the Millennium Development Goal (MDG) 4 target of a two-thirds reduction in child mortality rates by One in five children is denied their right to routine immunisations and other essential health services. They are the most vulnerable children and would benefit most from quality health services. Nearly 17% of deaths in children under five years of age are due to diseases that could have been prevented by vaccines. 3 Expanding immunisation coverage is therefore critical to accelerate progress on MDG 4. The Global Alliance for Vaccines and Immunisation (GAVI Alliance) was established in 2000 in response to this injustice, mandated to raise and channel funding for immunisation in more than 70 of the world s poorest countries. GAVI brings together the leading players in immunisation 4 the World Health Organization (WHO), the United Nations Children s Fund (UNICEF), the World Bank, the Bill & Melinda Gates Foundation, donor governments, developing country governments, civil society organisations, research and technical health institutes, and the pharmaceutical industry to fulfil its mission to save children s lives and protect people s health by increasing access to immunisation in poor countries. 5 On 13 June 2011, the governments of the United Kingdom and Liberia, with the Bill & Melinda Gates Foundation, hosted a pledging conference to galvanise funding and other commitments to support the realisation of GAVI s strategy. The Saving Children s Lives summit was a huge success, with pledges exceeding original targets to reach US$4.3 billion. Together with previously secured funding, GAVI s total funding for is US$7.4bn, 6 to facilitate implementation of the strategy. In addition, a number of pharmaceutical companies made pledges to lower vaccine prices. It was estimated that full implementation of the strategy could enable an additional 250 million children to be immunised by 2015, preventing almost 4 million deaths. 7 So far, an estimated 97 million additional children have been immunised, averting 1.1 million future deaths. 8 GAVI S STRATEGIC GOALS FOR GAVI s strategy includes four strategic goals: 9 Vaccines to accelerate the uptake and use of underused and new vaccines by strengthening country decision-making and introduction into national vaccination schedules. Health systems to contribute to strengthening the capacity of integrated health systems to deliver immunisation, including the objective of increasing equity in access to services (including gender equity). Financing to increase the predictability of global financing and improve the sustainability of national financing for immunisation. Market shaping to shape vaccine markets to ensure adequate supply of appropriate, quality vaccines for developing countries at low and sustainable prices. Realising these four strategic goals is critical to ensuring that GAVI makes progress towards its mission. In addition, strong governance is vital to provide the strategic direction needed to achieve 1

7 HALFWAY THERE these goals. Implementing the actions necessary to achieve the strategic goals is the collective responsibility of GAVI and its partners. Implementing the strategy and achieving its goals is also critical to realising globally-agreed immunisation goals, as set out in the Global Vaccines Action Plan (GVAP) The overarching aim of the GVAP is to achieve universal access to immunisation through more equitable access for all people by 2020 and beyond. 10 TAKING STOCK AT THE MIDPOINT OF GAVI S STRATEGY 2013 marks the midpoint in GAVI s strategy. The GAVI Mid-Term Review (MTR) meeting in Stockholm on 30 October 2013 will assess delivery on commitments made at the 2011 pledging conference. It will also assess progress made towards achieving the strategic goals. At the meeting, partners will also strategise on how to address challenges to achieving the goals, while looking forward to GAVI s next strategy for Save the Children has been monitoring progress on commitments made at the 2011 pledging conference. Last year, we published a briefing that tracked donor disbursements to GAVI, contributions to the Matching Fund, pharmaceutical commitments, demand for and rollout of new vaccines, and trends in GAVI s cash-based support to countries. 11 Now, at the midpoint in GAVI s strategy, we are not only monitoring whether all stakeholders are following through on their commitments, but we are reviewing and assessing progress made by GAVI and its partners on the four strategic goals, and GAVI s governance structures. This briefing therefore serves as a progress and accountability check on the performance of GAVI and its partners. We have analysed quantitative and qualitative data to evaluate progress and identify weaknesses and areas where efforts must be improved. This briefing has been timed to feed into the discussions at the MTR and the GAVI board meeting in November 2013, providing an independent perspective on progress. The briefing begins by looking at financing for immunisation, which is critical to funding the implementation of immunisation programmes. We then go on to look at progress on reducing the price of vaccines and vaccine rollouts in GAVI countries. A large part of the briefing focuses on how well GAVI has supported countries to strengthen their health systems and to promote increased and equitable coverage of immunisation both of which are critical for sustainable progress towards universal access to the full benefits of immunisation, integrated with other essential health services. We then look at GAVI s governance structures, which provide the strategic direction for its work to achieve its goals. We conclude with specific recommendations for the GAVI board and secretariat, GAVI donors, GAVI-supported countries, the private sector, and civil society organisations to help accelerate progress towards our shared goal: that all children enjoy the full benefits of immunisation. 2

8 1 PREDICTABLE AND SUSTAINABLE FINANCING FOR IMMUNISATION Adequate levels of funding are critical for the GAVI Alliance to be able to realise its goals. This requires sufficient global financing, coupled with sustainable domestic resources. GAVI s financing goal aims to increase the predictability of global financing and improve the sustainability of national financing for immunisation. 1 Global financing for GAVI comes from traditional government donors, philanthropic organisations (such as the Bill & Melinda Gates Foundation) and the private sector, while domestic contributions are levied through co-financing commitments by GAVI-eligible countries. DONOR COMMITMENTS Twenty-three government donors and philanthropists have made commitments towards GAVI s current strategy ( ) an impressive outcome of the GAVI pledging conference in June Some donors have made additional commitments since 2011: for example, Canada topped up its five-year commitment by around US$18m (a 10% increase); Germany extended its commitment through to 2015 and increased total pledges by US$107.9m (a 148% increase); and Japan extended its commitment to 2012 and 2013, tripling its contribution. 2 Denmark, on the other hand, has reneged on its original five-year pledge of US$28.3m, shortening the pledging period until 2013 only and reducing its total pledge by 40%. At the first anniversary of the pledging conference, in June 2012, Save the Children reported that not a single donor had reneged on the disbursement of its pledges. More than a year later, at the midpoint of GAVI s current strategy, it is encouraging that most donors remain on track. 3 All direct contributions by donors have been disbursed for 2011 and 2012, totalling more than US$1.7bn. An additional US$754m has been disbursed in direct contributions as of 30 September 2013, representing around 59% of pledges for the year. 4 So far, the Bill & Melinda Gates Foundation, Canada, Ireland, Luxembourg, and the UK have already fully disbursed their funds for 2013, while Germany and Australia have made partial disbursements. Eight donors with direct contributions scheduled for 2013 are still to disburse their funds. These are Denmark, the European Commission (EC), France, Japan, the Netherlands, Norway, Sweden, and the United States. Multi-year, long-term pledges and timely delivery on commitments by donors are crucial for financial predictability and the planning of immunisation programmes. They can also help determine future demand, and hence support GAVI s market-shaping activities. Of the donors that have made pledges towards GAVI s strategy, eight have not done so for the full five years. 5 The Republic of Korea has not pledged beyond 2012; Denmark, Japan and His Highness Sheikh Mohammed bin Zayed Al Nahyan have only pledged until 2013; and the United States, Ireland, Germany and the EC have only pledged until Only half of GAVI donors have pledged beyond and almost all of these pledges are through the IFFIm or AMC, which represent a smaller proportion of GAVI funding compared to direct contributions. 8 The UK is the only donor to have made a pledge through direct contributions beyond While donors have come a long way in the past few years in terms of their levels of investment in GAVI, it is important that they make longer-term investments so that GAVI has more predictable financing with which to carry out its mission. 3

9 Total GAVI funding We need to build momentum for Pre-2007 GAVI strategy mid point Beyond 2015 $4.2 bn $7.4 bn 47 % so far disbursed $4.6 bn Total raised so far for next strategy Yearly breakdown of funding received to date and confirmed pledges committed for remainder of strategy $1.1bn $1.3 bn $1.7 bn $1.6 bn $1.5 bn Donor commitments $ Top 5 donors by amount BMGF 224.1m UK 300.6m UK 583.6m UK 627.8m UK 574.3m UK 206.2m BMGF 278.8m BMGF 270.1m BMGF 250.0m BMGF 247.0m Norway 111.7m Norway 144.2m Norway 174.1m Norway 174.1m Norway 194.7m Sweden 95.0m USA 130.0m USA 145.0m USA 174.0m France 143.8m France 92.9m Italy 88.8m Australia 108.8m Italy 88.6m Italy 89.3m signed agreements No pledges No pledges Percentage of pledges for that have been converted into signed agreements. 91% Percentage of outstanding pledges to convert: USA Germany Sweden Japan France 59% 57% 56% 33% 16% Denmark His Highness Sheikh Mohammed bin Zayed Al Nahyan Japan Republic of Korea Denmark European Commission His Highness Sheikh Mohammed bin Zayed Al Nahyan Ireland Japan Republic of Korea USA 4 Source: GAVI data (accessed 5 October 2013). Total GAVI funding includes US$7.2bn from confirmed direct contributions, International Finance Facility for Immunisation (IFFIm), Advance Market Commitment (AMC) and the Matching Fund, and a US$200m allowance for future private and public contributions.

10 Nearly all donor pledges to GAVI around 90% have been converted into signed agreements, showing further commitment on the part of donors and supporting predictable funding. But five donors still need to do this. 10 Furthermore, pressure must be placed on donors who have not provided funding for the full period to step up and extend their pledges. It is also important to look beyond 2015 to GAVI s next five-year strategy, and donors whether existing or new must make long-term commitments. GAVI MATCHING FUND The GAVI Matching Fund is an innovative financing model designed to harness private sector engagement. 11 Financial contributions from the private sector are then matched by the UK Department for International Development (DFID) or the Bill & Melinda Gates Foundation, up to a total of US$130m. If fully realised, the Matching Fund has the potential to raise up to US$260m to support GAVI s work a relatively minor but nonetheless significant amount. Eleven private sector donors have now contributed to the Matching Fund nearly a fourfold increase in the number of donors since the fund was established in This has brought the Matching Fund total up to more than US$148m (including private sector contributions and the amount matched). 12 This is more than a twelvefold increase in the amount raised since While the Matching Fund has made great progress since its establishment particularly during the past year 43% of its potential (about US$112m) remains untapped. Though the Matching Fund would account for less than 4% of total GAVI funding for if fully realised, 13 it represents an important commitment from the private sector. With less than half the five-year strategy period left, it is important to maintain momentum to fully realise this opportunity. MATCHING FUND CONTRIBUTIONS Amount committed so far by private sector donors and matched by DFID/BMGF and amount still to be raised to reach the target of $260m $ + $ $112 m Total unraised $148m Total raised so far Source: GAVI data (accessed 5 October 2013). 5

11 HALFWAY THERE COUNTRY CO-FINANCING Co-financing commitments by GAVI-supported countries are important. GAVI investments are meant to be catalytic, but the long-term and vast majority of the costs of immunisation should be borne by countries themselves. Co-financing helps countries prepare to sustain investments when they graduate from GAVI support. 14 GAVI s co-financing policy came into effect in and requires all countries applying for new GAVI vaccine support to co-finance a portion of the costs. 16,17 The number of countries co-financing their immunisation programmes has increased over the years. In 2008, 32 countries had made commitments, but in just five years this has now more than doubled to 67 countries currently committed to make payments. Co-financing commitments to date amount to US$125m for the strategy, and more than US$209m in total since While this represents a relatively small proportion of total GAVI vaccine support (around 8% in 2012), as countries contributions grow and they are responsible for more of the costs, it represents an increasingly shared responsibility for immunisation programmes. The majority of countries have followed through on their co-financing commitments, with 87% making timely payments last year. However, this represents a slight decline from 94% in Some countries have been late in making payments or have made only partial payments for instance, in 2012, disbursements from six countries were late, while an additional three were still in arrears on their full 2012 commitment. 19 In order to hold countries accountable for their commitments, GAVI has the option of suspending support for the particular vaccine (or vaccines) in question if payments remain in arrears. 20 Country co-financing Increase in the number of countries co-financing their immunisation programmes and percentage of countries fulfilling commitments, towards target of 100% each year. $ 2008 $21m 2009 $31m 2010 $32 m 2011 $38 m 2012 $60 m Total number of countries % 10 % 12% 6% 4% 9% 75% 90% 88% 94% 87% Percentage of countries with: Commitments fulfilled Late payments Arrears Source: GAVI data (accessed 5 October 2013). 6

12 Country commitment to immunisation also requires secure and sufficient budgeting. A national budget line for immunisation, for instance, has been linked to higher spending in this area. 21 While this does not guarantee expenditure, it acknowledges the importance of immunisation and can improve accountability. 22 A large majority (88%) of current GAVI-eligible countries had a line item in their national budget for the purchase of vaccines in 2012, increasing from 79% of countries in However, five GAVI-eligible countries 24 still do not have a specific line item for vaccines. As country co-financing commitments continue to increase, governments should be encouraged to allocate sufficient funding to invest in both the purchase of vaccines and the broader health system costs of delivery and other essential health services. Financial planning is particularly important as countries prepare for graduation from GAVI support, so that they are able to sustain immunisation programmes. 1 PREDICTABLE AND SUSTAINABLE FINANCING FOR IMMUNISATION 7

13 2 MAKING VACCINES MORE AFFORDABLE In order for the resources pledged to enable more children to be immunised, the cost of vaccines must be brought down. A sufficient, timely and sustainable supply of vaccines is critical to meet rising demand. The lower the cost of vaccines, the more vaccines GAVI can purchase, and the more children can be immunised. Low prices are also imperative to enable countries to sustain immunisation coverage, particularly as they graduate from GAVI support. The market-shaping goal 1 within GAVI s current strategy has the ultimate aim of ensuring appropriate and affordable vaccines for the developing world. Delivering on this goal is the responsibility of both GAVI and pharmaceutical companies. At the pledging conference in 2011, a number of pharmaceutical companies made promises to lower vaccine prices. Progress has been mixed in terms of the extent to which prices have been lowered, special conditions on some price reductions (eg, volume guarantees and advance payment), and following through on promises (some manufacturers have reduced prices while others have not). For the pentavalent vaccine, the Serum Institute of India made a commitment to lower the price of its vaccine from the already lowered price of US$1.75, and Panacea Biotec made a commitment to lower the price of its product by up to 15%. But neither company has reduced the prices as yet. 2 In 2013, no subsequent supply agreement was agreed with Panacea Biotec; meanwhile, the Serum Institute actually increased its pentavalent price slightly. 3 vaccine prices Progress in bringing down vaccine prices for GAVI procurement. Prices must come down further to levels affordable by countries, including for those graduating from GAVI support. $ $ Pentavalent Rotavirus Pneumococcal Yellow fever Meningococcal A This is a weighted average price per dose, averaged across all presentations for which prices are available. 8 Source: UNICEF Supply and Logistics (accessed 2 September 2013)

14 On the other hand, Crucell has lowered its price from US$ per dose in 2012 to US$ per dose in 2013 (for the 1-dose presentation), and Biological E. Ltd from US$1.60 per dose in 2012 to US$1.19 per dose in 2013 (for the 10-dose presentation). 4 Commitments by GlaxoSmithKline (GSK) and Merck & Co Inc. to lower prices for the rotavirus vaccine from the 2011 price of US$7.50 per dose have been implemented. In 2012, GSK signed an agreement to supply the vaccine at 1.88 per dose 5 a third of the former price while Merck & Co Inc. agreed to supply it for US$3.50 US$5.00 per dose. 6 In 2011, it was expected that Bharat Biotech, the Serum Institute and Shantha Biotechnics would start producing the vaccine in the coming years. Bharat Biotech is underway with its product and has agreed to a price of US$1 per dose when it becomes available. 7 Pneumococcal vaccine prices have also been reduced in 2013, albeit slightly and with conditions attached to some products. Both GSK and Pfizer have recently agreed new supply agreements beginning in 2015 and 2016 respectively. Under the agreement, GSK will reduce its price from US$3.50 per dose to US$3.40 per dose. Pfizer has agreed to reduce its price from US$3.50 per dose to US$3.40 per dose, which will be applied to all doses remaining to be procured in 2013, reducing it further to US$3.30 per dose from Prices have also dropped for the HPV vaccine, with the GSK product offered in 2013 at US$4.60 per dose and the Merck product offered at US$4.50 per dose representing a two-thirds reduction from the previous lowest public price. For measles, meningitis A, and yellow fever vaccines, though prices are relatively low compared with newer vaccines, 2013 prices have actually increased slightly. As countries graduate from GAVI support, not only do they face the huge financial cost of having to pay for vaccines without GAVI subsidies, they no longer have access to GAVI-negotiated prices. GAVI has secured continued access to negotiated prices for graduating countries for some vaccines from specific manufacturers for example, Crucell and Sanofi Pasteur for their pentavalent vaccine, and Sanofi Pasteur for yellow fever. Countries graduating from GAVI support also have access to the GAVI AMC price for the pneumococcal vaccine. It will remain important for countries to access the lowest possible prices, so mechanisms such as tiered pricing 9 from some companies and pooled procurement should be available to them even if they can no longer receive the GAVI-negotiated price in the long term. 10 It is also important for non-governmental and non-profit health organisations, which are critical in delivering vaccines in some contexts, to be able to access the lowest vaccine prices. GAVI has recently reported a 35% reduction in the cost of fully immunising a child with the pentavalent, pneumococcal and rotavirus vaccines. 11 This represents great progress and adds to the judgement that GAVI offers good value for money. However, when considering the full vaccine package and the trajectory over many years, the situation is less optimistic, as Médecins Sans Frontières (MSF) has shown. With more vaccines being added to recommended immunisation schedules, the total cost of fully immunising a child has actually risen significantly, from around US$1.50 ten years ago (for the prevention of six diseases) to nearly US$40 today (for the prevention of 11 diseases). 12 While these new vaccines are important, as they mean that children are protected from more diseases, the cost of these new vaccines and the increasing cost of the whole package is a major concern in terms of affordability and sustainability. The need to lower vaccine prices is therefore even more vital, particularly for countries graduating from GAVI support. An important way of bringing prices down is through increased competition in the market. The entry of new producers, particularly from emerging markets where manufacturing costs may be lower, can contribute to this. The pentavalent vaccine, for example, is produced by companies in emerging markets as well as in industrialised countries, 13 which has contributed to bringing prices down. Also, when the vaccine became available from emerging market producers, GSK and Crucell later announced a price reduction for their products. 14 This is not to say that the situation is as simplistic as that, and other factors undoubtedly influence decisions, but the entry of emerging market producers certainly has the potential to help lower prices. For the rotavirus and pneumococcal vaccines, on the other hand, production lies exclusively with two industrialised country producers, and prices remain high. There is hope that this will change as emerging marking producers begin producing this vaccine in the coming years. 2 MAKING VACCINES MORE AFFORDABLE 9

15 HALFWAY THERE Another part of the picture is investments by pharmaceutical companies in R&D for the development of new vaccines to protect against more diseases. This can, however, be costly, considering the complexity of these newer vaccines. GAVI and the pharmaceutical industry recognise that companies will want to recoup costs of R&D for products and will want to ensure a sustainable supply mechanism, which will affect the level of price reductions by manufacturers. Pharmaceutical companies have made good progress, but they must do even more to bring vaccine prices down further to affordable levels. And companies that have made commitments must follow through on these. GAVI must also continue to deliver on its market-shaping goal, working with UNICEF to procure a sustainable supply of vaccines at a low enough cost. Countries must also be able to maintain access to affordable vaccines as they graduate from GAVI support. 10

16 3 INTRODUCTION AND COVERAGE OF NEW VACCINES Equitable progress towards universal coverage of the full benefits of immunisation is vital to reduce the burden of preventable mortality. GAVI s vaccine goal contributes to this by focusing on accelerating the uptake and use of underused and new vaccines, filling the gap in immunisation coverage of routine vaccines, and expanding vaccine schedules for instance, to include rotavirus and pneumococcal vaccines. To measure progress against this goal, GAVI looks at the number of countries introducing new and underused vaccines, 1 as well as the coverage of these antigens in these countries. Funding secured at the pledging conference in 2011 has provided GAVI with the resources to be able to increase its support to countries to roll out new vaccines eg, rotavirus and pneumococcal. These vaccines have been prioritised due to their potential impact on reducing child mortality. 2 As a result, funding to introduce these new vaccines 3 more than quadrupled between 2010 and 2011, representing an increase from 10% to 42% of total GAVI funding during that time. In 2012, funding for new vaccines continued to rise, accounting for 47% of total GAVI funding. Prior to 2011, only four GAVI countries had rolled out the rotavirus vaccine, 4 but this number has now increased to 14 and is expected to increase to 34 by the end of For the pneumococcal vaccine, country uptake has increased tenfold since 2011, when only three GAVI countries provided it in their schedules. An additional 21 countries have been approved by GAVI and are expected to roll out the pneumococcal vaccine by the end of 2014, which will bring the number up to 51. If progress remains on track, GAVI will exceed its targets to roll out the rotavirus vaccine in 33 countries and the pneumococcal vaccine in 45 countries by Although there has been overall progress in the number of countries rolling out (or expected to roll out) these vaccines, there have also been challenges. Some countries have had to delay introduction due to vaccine supply shortages, despite being approved by GAVI. This raises the issue of predictability and security of supply 6 and the responsibility of pharmaceutical companies to meet supply commitments. GAVI should also work towards broadening the manufacturer base in order to help alleviate this. 7 More competition can help bring vaccine prices down, and help secure a greater supply of vaccines. While the pentavalent vaccine had already been introduced in the majority of GAVI countries (62) 8 prior to 2011, ten additional countries have introduced it since then most recently Somalia and Indonesia in South Sudan is planning to introduce the vaccine in 2014 and will be the last GAVI country to do so. This represents a great success story of GAVI support. In addition to expanding the package of interventions provided in the national schedule, it is also vital that population coverage with the vaccine continues to expand. In most countries that have rolled out the pneumococcal and rotavirus vaccines with GAVI support, national immunisation coverage for these antigens has increased since introduction and is currently high. In some countries where coverage is low, this is often because the vaccine was only recently introduced. 10 Of the 30 GAVI countries that have introduced the pneumococcal vaccine, 2012 coverage data are available for 19 of them. Of these, 12 have achieved coverage of more than 80%, with six achieving more than 90%. 11 Six countries currently have coverage below 60%, but some of these only introduced the vaccine in 2012 (the same year for which coverage data are available), while other countries have had phased introductions. 12 For rotavirus, while data are only available for 10 of the 14 countries that have rolled out 11

17 HALFWAY THERE the vaccine, coverage is above 70% for half of them. In the other five countries where coverage is lower, this is again due to the fact that the vaccine was only rolled out in It is important that the introduction of new vaccines is balanced with support to strengthen basic immunisation and the wider health system, to ensure high, equitable and sustainable coverage of all antigens. High and equitable coverage of existing vaccines should be a priority, with new antigens progressively added as system capacity increases. For new (and existing) vaccines to have an impact on child survival, they must reach the children who need them most. Vaccine rollouts Increase in the number of countries rolling out pentavalent, pneumococcal and rotavirus vaccines and progress towards targets set for each by Pre Pentavalent Pneumococcal Rotavirus Target Projected Since we are at the midpoint of 2013, some rollouts for the year are projected. Six of the countries rolling out pentavalent did not require GAVI support. For rotavirus rollouts, figures are based on GAVI approvals, but dependent on supply confirmation. Due to large birth cohorts, three countries have phased state introductions of pentavalent: Nigeria , India , Indonesia Source: Vaccine Information Management System (VIMS) database (accessed 19 August 2013) and GAVI data (accessed 10 September 2013).

18 4 SUPPORTING COUNTRIES TO STRENGTHEN HEALTH SYSTEMS AND PROMOTE EQUITY A strong health system is critical to achieve and sustain high coverage of immunisation and other essential health services. A vaccine cannot inject itself; it needs to be administered by a qualified, motivated and properly remunerated health worker, supported by a well-functioning health system in reach of every person. GAVI s mission cannot therefore be achieved by buying vaccines alone. In order to increase access to immunisation services, it is crucial to strengthen the health system within which immunisation systems operate. GAVI recognises this important linkage and that progress in immunisation coverage is generally hindered by broader health system barriers. This is captured in GAVI s health system goal, which aims to contribute to strengthening the capacity of integrated health systems to deliver immunisation. This goal has three key objectives: (1) to contribute to resolving constraints in delivering immunisation; (2) to increase equity in access to services (including gender equity); and (3) to strengthen civil society engagement in the health sector. 1 PERFORMANCE-BASED FUNDING MODEL Performance-based funding (PBF) rolled out in provides the framework for the implementation of GAVI s health system strengthening (HSS) support. 3 Through performance-based funding, HSS cash support is split into two different types of payments: (1) a payment for satisfactory progress in implementation and achievement of intermediate results; and (2) a payment based on improvements in immunisation outcomes, reviewed after one year of implementation. While the aim is to incentivise countries to improve immunisation outcomes by strengthening health systems, a major concern of this approach is the time frame. Performance payments come into effect after the first year, which means that countries have one year to show results. For sustainable health system improvements, countries must first analyse and identify health system bottlenecks and develop strategies to address these. There is a potential time lag on outputs and outcomes to address systemic issues such as human resources for health, supply chains, etc. By having a one-year time frame to show results, this may lead countries to look for quick wins focused on the immunisation system specifically, rather than addressing structural bottlenecks in the wider health system. The period for showing results should be based on types of activities being funded, possibly looking at progressive, step-wise change rather than final outcomes based on immunisation coverage. At the GAVI board meeting in November 2011, a specific imperative was agreed, that HSS funding must be explicitly linked with immunisation outcomes. 4 While this is important, particularly considering GAVI s mandate, the right balance must be struck so that HSS support leads not only to better access to immunisation, but to better access to other health services. The immunisation outcome criteria may mean that the activities prioritised by governments only serve to strengthen immunisation systems exclusively, rather than strengthening the broader health system so that it can deliver better immunisation outcomes. Performance-based funding is also applied to equity, whereby additional funds are provided to countries if they meet specific equity targets. Similarly, it 13

19 HALFWAY THERE is important that countries have sufficient time to demonstrate results, as long-term sustainable progress towards equitable coverage will not happen immediately. Moreover, it is important to strike the right balance between rewarding countries that are making progress, and ensuring sufficient funding for countries that are struggling to address inequalities and therefore may require additional support. FUNDING TO STRENGTHEN HEALTH SYSTEMS Under GAVI s first health system objective, support to countries is largely channelled through the HSS funding window. This support mainly funds activities that aim to address bottlenecks in the system and, as part of this, countries are also encouraged to request funding for technical support. The decision to invest resources in the health system first came in 2005 when GAVI allocated US$500m to the HSS window for An additional US$300m was added to this in Within a couple of years, however, it was found that GAVI was under-spending in this area 6 and a new decision was made to allocate 15 25% of total spending for cash-based programmes. 7 GAVI s HSS spending falls under this cash-based spending envelope, but no spending targets have been set for HSS specifically. 8 This was coupled with a new HSS resource allocation method, which meant a funding ceiling for each country based on population and gross national income (GNI), with a minimum of US$3m per country application. Since GAVI began providing this funding, 55 countries have benefited. Cash-based spending increased by 44% between 2007 and 2008, when it reached a peak at 34% of total spending. 9 Since then, cash-based spending has decreased as a proportion of total GAVI spending by around 44%. 10 In 2012, GAVI performed very poorly against its cash-based spending targets only 12% of total GAVI spending failing to reach even the lower end of its 15 25% target. It is doing significantly better this year, already having achieved the upper limits of the cash-based spending target as of the end of August But a breakdown of what this money was spent on 11 reveals that the proportion of funds going specifically to HSS is actually quite small. Less than a quarter of cash-based spending in 2013 has been on HSS, and HSS spending accounts for less than 7% of total GAVI spending. This figure has remained low since If one measures HSS-specific spending against the 15 25% target, performance is very poor. GAVI must increase its funding to support countries to strengthen their health systems, particularly in light of the strategic importance of a strong health system to ensure high, sustainable and equitable immunisation coverage. In order to measure progress on this, a specific target should also be defined specifically for HSS support. DELIVERY OF HEALTH SYSTEM STRENGTHENING SUPPORT TO GAVI COUNTRIES In terms of the mechanism through which support was channelled to countries, there was a major shift in 2009, when the momentum moved towards a joint platform for health system strengthening, in collaboration with the World Bank, the Global Fund and WHO. The resultant Health System Funding Platform (HSFP) aimed to harmonise HSS strategies between the different organisations. However, the HSFP did not take off after the Global Fund cancelled Round 11. In 2012, GAVI set up a technical advisory group on HSS to provide advice on GAVI s engagement. Earlier this year, GAVI decided to no longer funnel its support through the HSFP, but rather through the new HSS cash-based funding stream application. 13 The new application is aligned with the principles of the International Health Partnership (IHP+) and the Paris Declaration on Aid Effectiveness, which require funding to be aligned to national health systems and plans. 14 The last full review of GAVI HSS support took place several years ago, 15 but recent anecdotal evidence shows that this funding is being used for a range of activities, with some countries focusing very specifically on immunisation-specific activities and others taking a more comprehensive approach. A recent desk review of current HSS grants (carried out by the GAVI secretariat) found that countries tend to prioritise activities that are closely linked with immunisation. 16 In Myanmar, for example, funding is being used to upgrade the cold chain and produce vaccination record cards. Meanwhile, in Pakistan, funding is being used to train Lady Health Workers to provide routine immunisation. 17 In other countries, HSS funding has been more successful in improving access to broader health 14

20 Health system strengthening and equity Annual GAVI cash-based spending (and HSS portion of this) and delivery on reaching upper target of 25% of total GAVI spending. Introduction of GAVI policies and activities for HSS and equity. $ 2008 $138m 23% Equity Gender policy came into effect 2009 $34m 9% HSS Health system funding platform (HSFP) initiated Evaluation of GAVI s HSS support $63m 17% $153m 25% $94m 25% Target Exceeded $206m 34% 2010 HSS 2011 GAVI strategy approved $44m $50m with health system strengthening goal 6% 8% $82m 13% $163m 25% Board decision on cash-based spending target (15 25% of total spending) Decision for all GAVI countries to be eligible for HSFP Review of HSS grants to ensure alignment with HSFP principles Equity Equity objective included under HSS goal in strategy $72m 10% $172m 25% HSS Board approval of performance-based funding (PBF) approach Board decision to channel cash support via single funding window (through HSFP) Country engagement to refine application procedures to secure funding for national health plans (through HSFP) Alignment of M&E and fiduciary framework with HSFP partners Support to civil society organisations (CSOs) aligned with HSFP Equity Countries encouraged to use HSS funds to overcome gender-related barriers & develop gender-sensitive health services 2012 HSS 2013 Technical advisory group set up on $52m 5% HSS: to advise on HSFP engagement, technical support to countries, PBF $64m $116m and country-tailored approaches 7% 12% PBF model introduced for HSS $242m 25% Decision for continued channeling of CSO funding through governments Funding allocated to support CSO engagement in national health policy dialogue Equity External review of gender policy Public consultation on countrytailored approaches Equity as key theme at GAVI Partners Forum Board approval of country-tailored approaches $232m 25% Target Exceeded $274m 30% HSS Country ceilings set for HSS cash support, based on population and GNI per capita Desk review of current HSS grants carried out Country-specific HSS evaluations to be carried out ( ) HSS to be essential part of country evaluations ( ) Equity GAVI-funded, PATH-led project initiated on GAVI s approach to equity Public consultation on revised gender policy Implementation of data improvement activities ( ) Equity to be component of some country HSS evaluations ( ) Implementation of country-tailored approach ( ) Implementation of PBF for countries that reach equity targets ( ) Cash-based spending HSS spending Cash-based spending target (25%) GAVI data (accessed 5 October 2013); GAVI board papers and online documents. Data for 2013 is as at 30 September

21 HALFWAY THERE services, alongside improving immunisation outcomes (Box 1). In Cambodia, for instance, a recent HSS grant contributed to increased coverage and utilisation of services, measured by immunisation coverage levels, Integrated Management of Childhood Illness (IMCI) consultations, and the percentage of immunisations at fixed facilities. Upcoming HSS support in Afghanistan will focus on expanding coverage for immunisation and maternal and child health services, including through the training and placement of community health workers. 18 These are examples of a more comprehensive approach to improving immunisation outcomes while also increasing access to broader health services. HSS grants are also used to support countries to address inequalities. Around 80% of approved HSS grant proposals between 2006 and 2012 included some kind of activity addressing equity issues. Such activities included improving facilities, purchasing vehicles, training health workers to provide immunisation services in hard-to-reach, under-served and low-performing areas, in addition to outreach and awareness-raising activities. 19 More recent HSS grant applications have included a strategic focus on equity and an equity strategy. This is a result of application guidance that emphasises the need to focus on equity, as well as increased awareness due to country visits and workshops. This represents some good progress, but it is important to look not only at the quantity of grants addressing equity to some degree, but also at the quality and scale of activities. To ensure this, GAVI should provide further guidance for countries completing HSS applications to ensure that equity is a more integral component, and there should be clearly defined equity criteria for approval of grants. In parallel, and building on the work of the country-by-country approach, it is critical to provide technical support to help countries identify and address bottlenecks, while also ensuring that financial and vaccine investments reach those most in need and build a system capable of delivering integrated care. GAVI S APPROACH TO EQUITY All children, regardless of where they are born, should enjoy the full benefits of immunisation and other health services as part of their right to health. However, a fifth of the world s children 22.6 million are still missing out on this basic service. 22 This is due to large inequalities in coverage in many countries, many of which are dependent on GAVI support. GAVI was first established with the mandate of redressing inequalities in immunisation coverage bridging the gap in coverage between rich and poor countries. It has had some success in reducing BOX 1: STRENGTHENING HEALTH SYSTEMS TO REACH REMOTE AREAS IN KYRGYZSTAN GAVI has been supporting Kyrgyzstan with its immunisation efforts since This builds on the country s strong national commitment to immunisation, funding 60% of its programme through the national budget. Current support from GAVI is helping to strengthen immunisation and broader health services. GAVI support, coupled with the country s own commitment to a strong primary care system, has helped ensure that health and immunisation services are in reach of all communities. Overcoming geographic barriers to service provision is a big challenge for Kyrgyzstan, but strong government commitment has ensured that family health centres are available in all villages, while feldshermidwife posts provide basic healthcare to even the most remote areas. These have been critical to Kyrgyzstan achieving high immunisation coverage 96% according to the latest data. 20 Meanwhile, members of GAVI-supported village health committees go door-to-door in rural communities to educate people about the importance of immunisation and broader health prevention. Source: GAVI,

22 inequalities between countries eg, by shortening the time lag between vaccine introductions in developed and developing countries and raising average immunisation coverage in these countries. Despite this progress, inequalities still persist between and within countries. In many countries, national immunisation coverage is still very low: in 2012, coverage was below 50% in Chad, Central African Republic, Equatorial Guinea, Nigeria, Somalia, and Syria. 23 Meanwhile, some countries have very high inequalities in coverage for example, in Ethiopia, Liberia and Yemen, a child from a richer household is around 2½ times more likely to be immunised than a child from a poorer household, while the ratio is as high as 5:1 in Somalia and 9:1 in Nigeria, based on the latest data for these countries. 24 GAVI recognises this ongoing challenge and is increasingly focusing on incountry inequalities as evident by the equity objective in its current strategy 25 (which includes an equity target 26 ) as well as recent initiatives. For example, equity was chosen as a key theme at last year s GAVI Partners Forum, 27 and GAVI is starting to scale up its country support to focus on addressing inequalities. Up until now, GAVI has mainly focused on gender equity. This is identified as an overarching principle of the current GAVI Alliance strategy, and the goal of ensuring equal access to immunisations for boys and girls has been translated into policy. In addition to gender, GAVI identifies inequalities in terms of household wealth 28 and geographic location, 29 although it does not currently have a policy focusing on these elements. EQUITY POLICY FRAMEWORK GAVI s only policy explicitly addressing equity is its gender policy. This first came into effect in 2008 and was designed to promote increased coverage, effectiveness and efficiency of immunisation and related health services by ensuring that all girls and boys, women and men, receive equal access to these services. 30 In 2012, GAVI initiated a review of the policy, involving an external independent evaluation and numerous consultations. The evaluation found that the policy had been successful in terms of internal impact. It has resulted in improved capacity and gender mainstreaming within GAVI for example, leading to more gender-balanced representation on the board. Impact in terms of bringing about in-country change, however, has been less clear. For instance, the evaluation found that there were challenges around implementation of the policy at country level and a lack of awareness within countries of the linkages between gender barriers and immunisation. 31 A revised policy will go to the GAVI board for approval later in 2013 with a clearer focus on supporting countries to overcome gender-related barriers that prevent all children from accessing immunisation services, with increased accountability for results. A GAVI policy on gender is extremely important; however, the revised policy should be ambitious and go beyond being gender-neutral or gendersensitive, towards being gender-responsive and transformative. It should also aim to consider the impact of gender on all aspects of immunisations, not just the issue of whether girls and boys have equal access to immunisations. It should look, for example, at the impact on mothers as presumed caregivers, and the impact of gender-reinforcing attitudes in communications on immunisations. It is also vital to consider how gender equity is integrated with other equity considerations, such as wealth, ethnicity, geographic location, etc. The complex drivers of inequality in immunisation and broader health service coverage and outcomes are not confined to gender. GAVI must look at all dimensions of equity to ensure that every child and person can receive the immunisation and other health services they need. They must go beyond gender equity, and develop a broader equity policy, which is implemented via its financial support and strategies. This is critical to guide the implementation of the strategic objective on equity within the health systems goal and to ensure accountability for results. GAVI has recently initiated a project led by the Program for Appropriate Technology in Health (PATH) and in collaboration with key stakeholders to consolidate and clearly define GAVI s approach to equity from both a policy and a programmatic perspective. This initiative also seeks to consider actions for addressing in-country disparities. This could be a good starting point towards the development of a broad equity policy. To maximise impact, it is important that this project comes up with a clear set of recommendations for GAVI (and potentially other partners) to inform a wider consultative process of policy development and implementation. 4 SUPPORTING COUNTRIES TO STRENGTHEN HEALTH SYSTEMS AND PROMOTE EQUITY 17

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