22-23 June 2016 SUBJECT: Report of: Authored by: HEALTH SYSTEM AND IMMUNISATION STRENGTHENING SUPPORT Hind Khatib-Othman, Managing Director, Country Programmes Aurélia Nguyen, Director, Policy and Market Shaping Emma Clarke, Judith Kallenberg, Alan Brooks, Marya Getchell Agenda item: 12 Category: For Decision Strategic goal: SG1 - Vaccines, SG2 - Health systems, SG3 - Financing Executive summary 1.1 The purpose of this report is to present the PPC recommentations: (a) (b) From the review of Gavi s Health System Strengthening (HSS) grants, Vaccine Introduction Grants (VIGs), operational support for campaigns (Ops), and other grants supporting immunisation programmes, collectively referred to as Health System and Immunisation Strengthening (HSIS) support; and For the co-financing of measles and measles-rubella (MR) follow-up campaigns, subsequent to the Board s approval of the Measles and Rubella Strategy in December 2015. 1 Health System and Immunisation Strengthening (HSIS) Framework 1.2 Despite impressive progress in increasing access to vaccines since the launch of Gavi in 2000, one in five children in Gavi-eligible countries still do not receive a full course of basic EPI vaccinations. To address this inequity, Gavi s 2016-2020 strategy places a stronger emphasis than ever before on reaching the fifth child. This is in line with the central aspiration of the Sustainable Development Goals (SDGs) to leave no one behind. 1.3 HSIS support is a key instrument for delivering on these ambitious goals. A review of this funding modality was initiated in 2015, with a view to optimising HSIS for the 2016-2020 strategic goals. Under the guidance of a Steering Committee (SC), chaired by Gunilla Carlsson, the Secretariat assessed new evidence, lessons learned, and country- and stakeholder perspectives. 1 The Measles and Rubella Strategy indicated that a co-financing requirement for measles and measles-rubella follow-up campaigns would be introduced, and that the amount and mechanism for this requirement would be determined in 2016 (December 2015 Doc 07, Gavi s Measles and Rubella Strategy, sections 5.12-5.13). 1
1.4 In October 2015 the PPC provided guidance on the initial directions of the review, and in May 2016 the PPC reviewed the final recommendations from the SC for a new HSIS Support Framework. The Framework aligns Gavi s HSIS Support with the goals of the 2016-2020 strategy through improvements in five areas: (a) Programming: Gavi s current HSS support has a broad focus on addressing bottlenecks to immunisation outcomes, and has not insisted on strategic prioritisation in the use of funds or on addressing programme capacity constraints. The new Framework introduces a focus for Gavi s limited resources on prioritizing the unreached through investing in sustainable and equity-focused approaches, rooted in evidence, and bolstering of commensurate program management capacity. (b) Grant architecture: The effectiveness and efficiency of HSIS support have been hindered by a complex grant architecture that does not sufficiently promote holistic planning or responsiveness to new data and evidence during the grant cycle. The new Framework promotes more efficient use of funding and reduced transaction costs by integrating planning and budgeting for all HSIS support. It facilitates increased responsiveness to new evidence and experience during the grant life cycle through a more flexible and iterative approach focused on implementation and lessons. (c) Allocation of HSS resources across countries:the current formula uses two indicators: 2 Gross National Income per capita (GNI p.c.) and population size. The new Framework proposes an updated methodology that aligns with a focus on coverage, equity, and sustainability in each country. It incorporates indicators for the primary population in need of immunisation (the size of the birth cohort), the strength of the immunisation system (as measured by the number of under-immunised children) and ability to pay (as measured by GNI p.c.). (d) Sustainability: The Framework incorporates a strengthened, crosscutting focus on sustainability both in the programming of grants (e.g. investing in long-term systemic issues early on in Gavi engagement, and reducing support for recurrent costs such as human resource compensation as countries approach transition) and in the allocation of resources (e.g., by progressively reducing the funding levels for VIGs and Ops in the case of countries approaching transition). (e) Global envelope for HSS support: It is proposed to move away from the concept of a proportional ceiling 3, and instead set a minimum absolute amount for HSS disbursements (including performance 2 Country funding for other HSIS grants (e.g. VIGs, Ops) is not pre-determined because these allocations are driven by country demand (e.g. for new vaccine introductions and campaigns). 3 Currently, as per a November 2010 Board decision, the cash programmes envelope, excluding operational grants, for campaigns is limited to 15-25% of Gavi s overall programmatic expenditures on a 3-year rolling basis 2
payments) for grant programme years in the 2016-2020 strategic period. This will strengthen predictability and timely allocation of Gavi resources to countries and prevent fluctuations in HSS funding if vaccine expenditures change. The recommended amount, US$ 1.3 billion, is based on the December 2015 financial forecast approved by the Board, and projected to be within 15-25% of programmatic expenditure in the 2016-2020 period. The Board would retain the possibility to allocate additional funding to HSS. 1.5 The proposed changes will require new ways of engaging with countries including putting greater reliance on country level planning processes and on responding to implementation related experiences during the grant cycle. The Secretariat and partners are already working with a subset of countries to transition to such an approach and capture early learnings.the proposed changes require strengthened Secretariat and partner capacity for engaging in countries planning processes and for engaging throughout the grant cycle to support implementation. 4 1.6 The PPC expressed appreciation for the inclusive review process and welcomed the new Framework, noting the following (a detailed record of the discussions will be captured in the PPC minutes): (a) Implementation: The PPC stressed the importance of beginning implementation of the proposed changes as soon as feasible, given the ambitious targets set for coverage and equity in the 2016-2020 period. Members also highlighted the importance of clear communication to countries and Alliance partners about the changes in this funding modality. (b) Performance based funding (PBF): The PPC supported the proposal to conduct a rigorous evaluation of Gavi s PBF approach to HSS once there is sufficient experience. (c) CSO engagement: The CSO constituency representative emphasized that the Alliance should seek to further engage civil society organisations (CSOs) in HSIS, and countries should engage CSOs in the planning and budgeting process, as CSOs can play important roles in areas such as advocacy for domestic resources, community engagement, service delivery, and oversight. This is particularly important in the context of an increased focus on reaching marginalised or underserved populations, and in fragile or disaster affected countries. 4 Ongoing changes in the Secretariat including those already approved by the Board to strengthen grant management capacities and skillsets, and increased focus across the Alliance on accountability for country-level results through the PEF, will be critical for the success of the new approach. While additional resources are not requested at this time, this will be a key area for continuing consideration and assessment as the Alliance begins to implement the HSIS Support Framework. 3
(d) Human resources for health: It was noted that Gavi can be a key contributor to the implementation of the Global Strategy on Human Resources for Health (HRH), without being a major investor in this area, such as by assessing where HRH-related challenges pose a risk to immunisation performance. Relatedly, it was highlighted that health worker education to reduce missed opportunities for vaccination is critical for improving routine coverage. Measles and measles-rubella (MR) periodic follow-up campaign cofinancing: 1.7 Gavi s new Measles and Rubella Strategy, approved by the Board in December 2015, recognises that countries with low routine measles coverage rely on periodic follow-up measles or measles-rubella (MR) supplementary immunisation activities (SIAs or campaigns) to avoid measles outbreaks and thus introduced Gavi support for such campaigns. A core element of the Strategy was the introduction of co-financing to increase country ownership of these campaigns, with the amount and mechanism to be determined in 2016. The HSIS review considered several ways to structure such a requirement. 1.8 The PPC supported cost-sharing for periodic follow-up campaigns (e.g. for measles and MR) to strengthen country ownership of such campaigns, through a modification to Gavi s Co-Financing Policy. It recommended that low-income countries co-finance 2%, and transitioning (Phase 1 and Phase 2) countries co-finance 5% of the costs of vaccines used in such campaigns. The PPC did not support an approach whereby the co-financing requirement would be increased because of underperformance in previous campaigns or in routine measles coverage. (a) This change will come into effect for campaigns planned for implementation from 1 January 2018 onwards. This ensures that there is sufficient time for governments in Gavi-eligible countries to include the necessary resources in their 2018 budgets, to be developed in 2017. 1.9 To promote high quality campaigns, the PPC stressed the need for early national planning to ensure timely and sufficient government allocation of resources, strengthened microplanning, systematic assessment of the campaign preparation progress, improved implementation support, use of subnational coverage data and modelling of susceptibles, and intracampaign monitoring and supervision. To enable sufficient preparations, it will be critical that operational support from Gavi is disbursed in a timely fashion (at least 6 months in advance of the campaign) and that in-country partners (e.g. WHO, UNICEF, and CDC) provide high quality technical support as highlighted in the Alliance KPIs. 4
1.10 The PPC also recommended that the future review of Gavi s performancebased funding (PBF) approach to HSS consider further performance payments for improved measles immunisation as appropriate. 5 1.11 Documentation: The report to the PPC, attached as Appendix 1, describes the rationale and context for proposed changes to Gavi s HSIS support, reflecting the SC s recommendations. The HSIS Support Framework, attached as Annex A to the PPC paper, sets out the proposed approach and, if approved, would serve as the basis for the development of implementation guidelines for countries, Alliance partners, and the Secretariat. Implications for previous Board decisions and Board-approved policies, and proposed implementation plans for phasing in the proposed changes are set out in Annex B to the PPC paper. An amended Co- Financing Policy, reflecting the proposed requirements for co-financing periodic follow-up measles and measles-rubella campaigns, is attached as Appendix 2 to this paper. The projected financial implications of these cofinancing requirements are provided in Appendix 3. Recommendations 2.1 The Gavi Programme and Policy Committee recommended to the Gavi Board that it: (a) Approve the Framework guiding implementation of Gavi s Health System and Immunisation Strengthening support attached as Annex A to Doc 04 to the PPC; (b) Approve the Implications for previous Board decisions and Boardapproved policies, as well as the implementation plans as set out in Annex B attached to Doc 04 to the PPC, noting that the PPC recommended implementation immediately following the Board decision, taking into account feasibility for countries and realistic timelines for ensuring smooth and efficient scale up of implementation; (c) Approve the modifications to Gavi s Co-Financing Policy regarding cofinancing for measles and measles-rubella follow-up campaigns as set out in Appendix 2 to Doc 12; (d) Agree that an amount of at least US$ 1.3 billion is available for HSS disbursements (including performance payments) for grant programme years in the 2016-2020 strategic period, with additional funding being subject to future Board decisions. 5 The current PBF approach includes performance payments for MCV1 coverage. Additional indicators for consideration could include indicators of campaign quality (e.g. coverage) or indicators of measles control (e.g. proportion of zero dose cases among confirmed measles cases). 5
Attachments Appendix 1: Health System and Immunisation Strengthening: Report to the PPC, 12-13 May 2016, Doc 04, including attachments A and B thereto Appendix 2: Co-Financing Policy Appendix 3: Projected financial implications of co-financing measles and measles-rubella follow-up SIAs, version 2 Additional reference materials can be found in the relevant meeting folders on mygavi: 1) May 2016 PPC, Agenda Item 4, Health System and Immunisation Strengthening Support 2) December 2015 Board, Agenda Item 7, Gavi s Measles and Rubella Strategy 3) October 2015 PPC, Agenda Item 12, Review of Gavi s Direct Financial Suport to Countries 6