Santiago Cornejo GAVI HSS and Future Joint Programming with the World Bank and the Global Fund to fight AIDS, TB and Malaria Cusco, 10 November 2009

Overview  What is GAVI?  Why GAVI HSS?  What and how of GAVI HSS support  Current status and emerging issues from ongoing work  Joint systems platform for programming and funding

Overview  What is GAVI?

GAVI mission statement To save children’s lives and protect people’s health by increasing access to immunisation in poor countries.

Strategic goals  Accelerate the uptake and use of underused and new vaccines and associated technologies and improve vaccine supply security.  Strengthen the capacity of the health system to deliver immunisation and other health services.  Increase the predictability and sustainability of long–term financing for national immunisation programmes.  Increase and assess the added value of GAVI as a public- private global health partnership through efficiency, advocacy and innovation.

The GAVI Alliance Board structure

GAVI’s programmes of support for countries  New and underused vaccines  Immunisation services  Health system strengthening  Civil society organisations  Injection safety

Countries eligible for GAVI programme support in 2009 Data source: GAVI Alliance The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the GAVI Alliance concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not be full agreement.

Number of countries eligible for GAVI support and approved by July 2009 Source: GAVI Alliance, July 2009

US$ 4 billion committed to countries (as of 31 Dec 2008) Source: GAVI Alliance data as at December 2008

Immunisation coverage with DTP3, hepatitis B and Hib vaccines in GAVI-supported countries, Source/credits: WHO-UNICEF coverage estimates for , as of August 2008; WHO-ICE T coverage projections for , as of September 2008

Overview  Why GAVI HSS?

What are we trying to do? VACCINES CHILDREN ‘Saving children's lives and protecting people’s health by increasing access to immunisation in poor countries’

14 Criticisms of GAVI phase 1 GAVI study 2004 – barriers to increasing coverage: 1.Unpredictable funding at peripheral level 2. Transport 3. Shortage of human resources 4. Health workforce motivation Not harmonized or aligned approach – admin burden to countries WORLD HEALTH REPORT 2000 BELLAGIO STUDIES MACRO ECONOMICS AND HEALTH 2001 INTERNATIONAL TASK FORCE ON GLOBAL PUBLIC GOODS 2006 GLOBAL IMMUNIZATION VISION AND STRATEGY Health systems must be strengthened for: a) MDG 4+5 scaling up b) new technology introduction Disease specific approaches are not sustainable and can weaken health systems

New technologies need strong systems  High staff turnover and low training  Salaries / incentives not paid on time  Poor supervision  Interrupted vaccine supply  Lack of data for planning  No outreach transport  Weak planning and management  Low demand and poor quality  Lack of inter-sectoral partnership  Evolution of EPI

Overview  What and how of GAVI HSS support

17 GAVI Health Systems Strengthening: $800 million ‘Hard to get, easy to use’ Armenia MoH  ‘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  Coordinated by dept of planning  Three non-exclusive themes:  Health workforce  Supply, distribution and maintenance  Organisation and management

GAVI HSS principles 1.Country driven 2.Country aligned 3.Harmonized 4.Predictable 5.Additional 6.Inclusive and collaborative 7.Catalytic 8.Innovative 9.Results orientated 10.Sustainability conscious

Parameters  Align with National Health Plan for duration and content  Endorsed by MoH, MoF, and HSSC  Country ‘budget envelope’ based on number of newborn children and GNI per capita: a) Countries with GNI / capita <$365 = $5 / newborn / year b) Countries with GNI / capita >$365 = $2.50 / newborn / year  Only 3 mandatory indicators

Technical support (TS) & pre review  GAVI does not have country presence  Partners support countries to implement, monitor and evaluate HSS activities  Proposal preparation grant $50,000 per country  Pre review critical documents

Overview  Current status and emerging issues from ongoing work

45 / 72 countries now applied for HSS  $525 million ‘committed’; $258 million disbursed  75% funding for ‘operational’ level (district and below)  16% funding for upstream level (above district)  9 % management

Analysis of 49 proposals ($427 million) Source: WHO / Unicef / UNFPA University of Queensland analysis of first 49 GAVI HSS proposals

Emerging Issues  Finalizing an evaluation of the window and in- depth, real time tracking of finances and implementation to guide the design  Issues: -Historical context of vertical EPI (country/partners) -IRC review and redesign -Fund disbursement -M&E -Partnership and technical support

Overview  Joint systems platform for programming and funding

Current attempt- IHP compact Health Systems Support Financing oriented to MDGs Govt. $ GAVI HSS $ GFATM HSS $ Bilateral Donor $ IDA $ Bilateral & Multilateral Partners 1 plan 1 policy 1 monitoring framework 1 fiduciary framework 1 coordination body One Country Health Plan Implementation MDG-related outcomes M&E Compact

Recent developments: High level taskforce (HLTF) on innovative financing and IHP+ ministers review, UNGA announcement  IHP+ ministers requested GAVI, GFATM and WB to explore mechanism for joint programming  HLTF welcomed proposals to explore the feasibility of GFATM, WB and GAVI Alliance systems investments, WHO facilitation  World Health Assembly resolution and GAVI consultations  UNGA announced expanded IFFm for HSS of $1 billion

Opportunities  Political, financial and increased effectiveness, in line with IHP+ principles  Leverage new resources  Increase sustainability of the GAVI Approach  Increase efficiency in aid flows  Reduce fragmentation and thus transaction costs  Reduce fiduciary risk  Increase inter-secretariat efficiency For immunisation and the GAVI Alliance: increase resources for ‘systems components’ of new vaccine introduction; ensure immunisation specific outputs are key deliverables

Principles  Flexible/differentiated approach for different countries – NOT one size fits all  IHP+ principles  Improve information sharing between the 3 agencies  Focus on country results and value for money  Common frameworks for HSS assessment, monitoring and funding (approval)  Strong analytical basis for HSS

Purpose  ‘To improve health outcomes through strengthening countries’ health systems to deliver health services equitably and sustainably (focussing on all health MDGs), and to use resources more effectively and efficiently’  Reduced transaction costs for countries accelerated progress towards MDGs  Practical step to make global health aid architecture more effective and responsive  Increased global focus on HSS Fund one health plan, use one monitoring framework using one funding modality where possible

Possible Components of a Joint Approach to HSS 1.Support for national health / plan / strategy development with harmonised technical support 2.Joint HSS Processes – including Joint Assessment of National Strategies for funding HSS components 3.Common monitoring framework using annual review processes for monitoring performance 4.Common funding/disbursement channels

Challenges (!)  Complexity of harmonisation between funding entities  Criteria for budget envelopes  Ensuring investment leads to programme specific outcomes  Ensuring performance based approach  Different paradigms on HSS

Accountability Better health outcomes – whose health?

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