14 May 2008, 15:04
by Robert Walgate
The US$ multi-billion a year GAVI Alliance is spending a fraction of its budget to help its vaccines get to the end of the track, by strengthening health systems in a group of countries in central America, Africa and Asia. But what does it mean by ‘innovative’? Does that mean science?
It may be counter-intuitive to see a big vaccination funding programme like the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation) supporting health system strengthening – because the classic model for the vaccine preventable diseases is to have separate, vertical programmes, sometimes even with the vaccinators flying in from abroad.
But GAVI is different: it provides support directly to country governments, not through other agencies. Also its large budget and global nature encourages vaccine manufacturers to take a positive view of developing country markets – and thus add relevant, affordable products to their portfolios.
Moreover, GAVI is evidence-based, so RealHealthNews asked Craig Burgess, responsible for the GAVI health system strengthening programme – which purports to embrace ‘innovation’ in health systems – to tell us more.
Craig Burgess: Well just as a backdrop, health system strengthening is not new – you could say that primary healthcare is a large part of health system strengthening: it means having a more holistic view of health and the delivery of healthcare packages.
GAVI Phase One, 2000-5, was really highlighting the introduction of new vaccines [such as Hepatitis B and the Haemophilus influenzae b vaccine], and increasing immunisation coverage, mainly focusing on DTP 3 [diphtheria-tetanus-pertussis] vaccine.
But there was a study done in 2004, commissioned by GAVI, through Norad [the Norwegian aid agency], which looked at the main barriers to the increasing coverage in a sustainable manner.
>RHN: This was done by academics?
CB: By a group that was commissioned by Norad. They looked at the main barriers to increasing immunisation – but there were no surprises.
Basically, they came up with issues that were broader and wider than the immunisation programme alone. They include human resources and motivation, transport, fund flow issues to peripheral level, management processes especially at district level and below, infrastructure, etc. etc. – there is a whole range of problems.
“It’s no longer good enough just to make sure the vaccines are available at the Ministry of Health’s door. There’s a whole range of barriers between the Ministry of Health’s door and the kid’s arm or leg.”
So it was felt that as GAVI increases it’s portfolio of relatively or more expensive new vaccines, such as rotavirus and pneumococcus and Hib to certain extent, and others, to protect that investment we need to make sure we contribute to [health system strengthening].
It’s no longer good enough just to make sure the vaccines are available at the Ministry of Health’s door. There’s a whole range of barriers between the Ministry of Health’s door and the kid’s arm or leg, as the case may be. So we’re looking at ways in which we can overcome some of those.
So in 2005 a group of people in the secretariat and also partners drafted an investment case for the GAVI Board to look at an investment of US$800 million for the 72 GAVI countries eligible for our funding, to overcome some of these health system barriers.
Now initially, the Board felt it was a controversial decision, because some members felt it was a bit of ‘mission creep’ and importantly that it was hard to measure impact and monitor attribution – because you’re in a broader range of activities. It’s not as precise as just measuring DTP3 immunisation coverage – there’s a whole range of other indicators needed.
But having said that, other Board members really want it recognised that overcoming health systems barriers is an important aspect of delivering vaccines and other child healthcare packages. So on the basis of that, an investment case was approved for US$500 million, between now and 2015.
“US$500 million has been made available; countries are to identify the key health system bottlenecks or barriers to delivering immunisation, and come up with a proposal.”
The vision is until 2015, but countries can apply but with the understanding that they will be evaluated in 2009, and again in 2012 to look at process and impact as well.
So since then, US$500 million has been made available; countries are to identify the key health system bottlenecks or barriers to delivering immunisation, and come up with a proposal that has to be linked to their national health plans, so they can’t be stand alone projects: they have got to be aligned to harmonise with the national health plan.
>RHN: When you say countries, you mean you expect the governments to apply?
CB: The government. We deal with sovereign nations, so the minister of finance, the minister of health has to sign of on the proposal, but having said that, it’s a group of partners at country level who coordinate and help draft, implement, and monitor proposals.
So they submit proposals to the GAVI secretariat, and an independent review committee reviews whether it’s a robust proposal or not, whether it fits into the objectives of overall health in that country and indeed whether it helps or is implemental to overcome some of the health system barriers to delivering immunisation and vaccinations.
>RHN: I’d like to know a bit more about exactly who the partners are. I guess it varies from government to government. What kind of people are they, what kind of institutions? And secondly, this word ‘innovative’, which you use in your documentation on health system strengthening, what do you mean by that, and what makes a proposal innovative?
CB: First of all the partners are the GAVI alliance partners that you’ll see on our website – basically a reflection of Board membership at country level. It’s individuals, UNICEF, the World Bank, bilateral donors, civil society, and their representatives in developing country, plus the private sector – they are all part and parcel.
>RHN: So it’s the people already on Board in GAVI?
CB: Yes, but it may well include those that are involved with immunisation and child healthcare at country level. It’s a health sector planning committee at national level.
>RHN: So these would be composed of what kind of people?
CB: For the technical component, this is technical groups that know quite a bit about immunisation and planning, but ratifying and signing off on the proposals, it would be the representatives of offices, for example.
>RHN: Let me explain the background to my question. RealHealthNews is about the connections between research, policy making and action for health for the poorest in developing countries. So through policy, we’re concerned about the relationship between that evidence making process and effective action. So the question that’s occurring to me about your programme is, how strong is the evidence you have for the interventions that you end up funding?
CB: First of all you’re asking about the innovation. What is new about it is that it is getting all partners together around a table speaking about a common objective or goal, which has not necessarily taken place before.
“Innovation is actually encouraged, by which we mean strengthening actions that are working already – or innovatively looking at ways to reach more children.”
Before, bilaterals would just work bilaterally with the government, so one government might have a whole host of partners to deal with. But our approach gets them around one table and looks at one common objective.
Innovation is actually encouraged, by which we mean strengthening actions that are working already – or innovatively looking at ways to reach more children. Finding the hard to reach where they live: how do we reach them, what are the innovative ways of doing that?
>RHN: Does the innovation mean research?
CB: No, not necessarily. Although operational research can be encouraged, innovation is looking at catalysing change as well, changing mindset. We had our Nepali colleague come in January and emphasise new ways emerge of doing things and mindset changes within the government.
>RHN: So bright new ideas basically from those groups?
CB: Or not necessarily wanting to reinvent the wheel, but building also on things that work, reviewing things that work through analysis of the health system bottlenecks and not duplicating what is already being funded; and certainly not displacing any funds that already exist, it should be additional funding as well.
So if you look at the website, look at the guidelines. Principals there are encouraged to look at the guidelines, only ten pages long, but they summarise things quite well.
CB: The other thing you have to bear in mind is that the window for the first funding round only opened in 2006, and we’ve had four rounds since then, so it’s only a year. And what we’re discussing just now is really things on paper, the proposals that have been submitted.
Yet in the space of a year, 40 countries have applied out of the 72, and 29 have been approved out of those 40. And that represents a funding of about US$400 million.
>RHN: That’s a lot of money.
CB: It’s a lot of money, but the independent review committee goes to great lengths to ensure that there are direct links between this investment and outcomes, so that is the important thing, the outcomes should be immunisation related.
It’s not like a bucket, although some countries want to put the funding into a pool mechanism, which is allowed, but there should be discrete reporting every year on it and discrete output indicators as well.
I just want to emphasis that it’s only been going about a year and funds have gone to countries since May or June last year. When we talk about implementation our first record of proper implementation will come around in June this year.
>RHN: So then you’ll begin to see the results in terms of immunisation levels?
CB: No, that’s the issue, because that’s an impact, it’ll take several years to see that and this why people often get frustrated. Countries need long term predictable funding.
>RHN: So the outcome measures will be what in June?
CB: It will be more looking at process indicators, how many cars are being bought, how many people are being trained, much more process indicators.
“The impact indicators that we look at are immunisation coverage, under five mortality and numbers of districts achieving certain coverage level.”
The impact indicators that we look at are immunisation coverage, under five mortality and numbers of districts achieving certain coverage level. I don’t think we’ll see impact on that directly on this investment for several years yet, so there’s a whole range of activities that need to take place before you can really see impact per say and I think that’s one thing that donors sometimes get frustrated by; they want instant impact and that encourages a short term mentality. What we’re trying to do is get away from that and look at long term planning and long term predictable funding.
>RHN: Is there any concern for thinking about the advantage of doing effective proper academic research on what will work and what doesn’t work in improving health systems? For example, not just monitoring the effectiveness, but also trying to attribute the effectiveness, the changes and indicators to particular interventions, with a proper understanding of evaluation?
CB: There are three things. One is the ongoing monitoring, which is on a yearly basis and countries report on what they have done with the funds, what activities they’ve undertaken.
The second is an evaluation, and that’s being designed this year and will start next year. That will look exactly at some of the aspects of the processes, not necessarily the implementation. The latter will probably happen in 2012 when we really look at what has worked, what hasn’t worked.
And the third is there is an ongoing tracking study, which is looking in real time over the next two years what is happening to money and what is happening to programmes in four to six countries. It will add weight to what is happening, what is working, what is not.
>RHN: Who is doing that and in what countries?
CB: We don’t know yet, because the request for proposals went out and proposals will be selected in two weeks time. It’s relatively early days yet, so the design of that work will be ongoing for the next six to nine months
>RHN: The design will be in six to nine months, and then how long will the studies take?
CB: Probably a year and a half or so.
>RHN: OK, so time to do the study properly.
CB: Yes, but all the information is available on the website and we’re encouraging various bodies including academic institutes to look at the proposals, analyse them, see what’s happening, see what’s not happening, it’s in the public domain so the academic institutes are really encouraged to do so.
>RHN: And are they applying?
CB: Academic institutes? Not actually applying, but the information is there for them if they want to look at some of the proposals.
>RHN: But can they make proposals to do some of this monitoring and measurement?
CB: I thought you meant analysis of proposals, and what is working and what doesn’t work.
>RHN: Yes, I do. Making an analysis of what interventions are causing what result, effectively.
CB: I think that’s more part of the evaluation that will take place in 2012.
>RHN: So that’s down the line.
CB: But I think the tracking study will do part of that, but many of our bilateral donors will be looking at the effectiveness of this in perhaps other shapes and forms and maybe asking groups to do that.
>RHN: It’s absolutely fascinating, but I do get the impression that it’s not entirely engaged with the scientific community as yet.
“[We’re supporting research] through networks, through WHO… there are networks of unfortunately mainly northern-based academic institutes, and that’s the down side of it”
CB: Through networks, through WHO, through the Alliance for Health Policy Research, there are networks of unfortunately mainly northern-based academic institutes, and that’s the down side of it, it’s the usual suspects, Liverpool, London, Harvard, John Hopkins, etc, etc.
>RHN: They’re involved with you?
CB: They have been involved, but what we’re looking more than anything is actually networks of academic institutes at regional and country level.
>RHN: Now, you mentioned the Alliance for Healthy Policy and Systems Research, you’re working with them too?
CB: Yes, we liaise with them and we contact them and they have attended various meetings as well and we encourage them to apply for requests for proposals.
>RHN: Do you think there’s going to be spin off from your health system strengthening to the delivery of other health goods?
CB: Definitely. I think if you look at the health system barriers to delivering vaccines they’re the same health system barriers as for other child healthcare interventions, so the GAVI synergy is with MDG 4 and 5, addressing some of those barriers. This is a contribution to alleviating some of those health system barriers in a very flexible way.
One thing I didn’t highlight is some of the major challenges – the first of which is monitoring: many Board members and institutions want a lot more information and detail about how money is being spent, and of course that generates a lot more work for countries to report on that. Other Board members and institutions are saying that is not appropriate, we should take an investment approach to it and look at the output only, and view it as an investment and look at what is done in terms of output and impact at a later stage – using not a GAVI specific mechanism but a country specific reporting mechanism.
And the other main challenge is reducing fiduciary risk as well. Do we go down the route of the Global Fund that spends US$30 million on accountancy companies at country level? There’s still frank fraud and there always will be frank fraud and misappropriation of funds, but it’s setting in place the alerting mechanisms that help us investigate appropriately, and take appropriate action.
Those are the two main challenges now, as well as helping support countries, through our partners, to actually implement many of these proposals.
READ ON: GAVI Health System Strengthening
>RHN: When you say they are challenges, you say these are question marks that you haven’t decided whether to face or not or you are going to face them?
CB: They are very much being faced, and they overlying challenge is working as an alliance. I sit in the secretariat, which is helping to facilitate these processes, but who actually does the work on the ground is a group of partners, so we are an alliance partnership, which includes the multilaterals, the bilaterals, etc, etc.
READ ON: Norad on GAVI HSS
But to try and get consensus in a very complex arena such as health system strengthening is difficult if not impossible, so it’s basically two steps forward, one step back and agreeing on say, the USAID or the Gate’s approach to monitoring, who want a lot more data, as opposed to perhaps the more northern European donors’ viewpoints that we should be more harmonised in the line with countries.
It’s difficult to reconcile that, and that’s often not a technical discussion that’s a political decision, and it’s why quite a few of our papers for options go up to the Board level for a political decision, once we’ve got that green light, they point us in the right direction.
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