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Performance-based aid

Protecting children from harm

by Edward Harris

In depth

Showing off an immunisation certificate in Burkina Faso

Showing off an immunisation certificate in Burkina Faso

The GAVI Alliance is an international private public partnership with the mission to save children’s lives and protect people’s health by increasing access to immunisation in poor countries. GAVI’s innovative approach to align incentives with results helps to drive up immunisation rates, while supporting national ownership and ­contributing to long-term capacity development. By Edward Harris

Since 2000, the GAVI Alliance has supported developing countries to immunise 326 million children who otherwise would not have been vaccinated. GAVI thus helped to prevent more than 5.5 million deaths. Many more children were protected from disease and disability.

Our success is based on a mixture of measures:
– we raise money for immunisation,
– we influence vaccine markets to reduce prices and ensure a stable supply, and
– we support countries to immunise as many children as possible in co­operation with other international and national agencies.

The bulk of our budget – $ 7.6 billion in the years 2010 to 2015 – is used for purchasing vaccines. But the crucial challenge is to reach as many children as possible. One way of doing so is performance-based financing. It has helped to lift the share of children who receive routine immunisation worldwide from about 67 % in 2000 to more than 80 % today.

At its start more than a decade ago, GAVI’s Performance-Based Financing Approach (PBFA) was called the Immunisation Services Support (ISS). It was one of the first programmes of its kind. According to the World Health Organisation (WHO), this approach, by 2011, had contributed to reaching an additional 90 million children with lifesaving immunisation.

Supporting countries to build their health systems, the ISS programme linked financing for health programmes to improvements in immunisation coverage, defined as the share of children who get three doses of vaccine against diphtheria, tetanus and pertussis (DTP3). GAVI paid government agencies in developing countries $ 20 for every additional child reached above baseline. Country partners had complete control over how and when to use the funding, provided their DTP3 coverage rates kept rising. This approach proved to be quite powerful. It empowered country partners to identify and plug gaps in their healthcare systems.

Tanzania’s rural district of Mpwapwa, for example, used $ 13,000 of ISS funds to first discuss the benefits of immunisation with local people and then to train health workers, fix refrigerators for vaccines and even purchase bicycles to deliver the vaccines. The sum may seem modest, but it was used in a very effective way in an area where quick and flexible support was needed.

In the Democratic Republic of Congo (DRC), the PBFA supported a WHO/UNICEF strategy to boost immunisation in low-performing districts, paying for vehicles and transportation, personnel, training and staff supervision. After just one year, 70 % of the children in the districts concerned had DTP3 immunisation by their first birthday. The average for other districts is merely 54 %.

GAVI needs hard data to make good decisions. This is true for development programmes in general, but it is especially important when payments are linked to results.

Measuring results remains a critical issue. The challenge is that, to reach the last fifth of children around the world who do not receive routine immunisation, it is necessary to work with people in remote regions. Some of the communities concerned are nomadic, or even live in areas of war.

Broadly speaking, GAVI uses two sets of data to measure improvements in routine immunisation coverage:
– The preference is to rely on national immunisation data because doing so serves national ownership and the long-term development of national capacities.
– We also use WHO/UNICEF estimates to verify the results countries report. WHO/UNICEF estimates systematically examine data from multiple sources.

GAVI also uses data from independent surveys where appropriate. That makes sense where reliable data is particularly hard to get. The US government funds Demographic and Health Surveys (DHS). They are excellent but infrequent. In some cases, GAVI supports countries that want to boost their statistical capacities or even run their own surveys.

Categories of countries

Multiple reviews of GAVI’s PBFA have served to improve the approach over time. This year, GAVI will begin rolling out its latest generation PBFA. In the future, countries will be divided into three categories, according to their baseline DTP3 coverage:
– Category A countries are defined as having a coverage of 90 % or more at the start of the programme. They will get 20 % of their possible total as a fixed payment, another 40 % for maintaining or increasing DTP3 coverage and the final 40 % for ensuring that 90 % of their districts have at least 80 % coverage. The point is that high national immunisation rates often hide the fact that coverage remains much lower in some remote areas. GAVI emphasises reaching out to the poorest regions. Unsurprisingly, a country’s disease burden is typically concentrated in its pockets of low immunisation coverage. This is where children are still at risk of being killed by diseases that vaccines would prevent. By rewarding a country for achieving high coverage rates in all districts GAVI is introducing a strong equity component.
– Category B countries initially have DTP3 coverage rates of 70 % to 90 %. They receive 40 % of the possible total as a fixed payment each year, plus $ 20 per additionally immunised child. They get another $ 20 per additionally immunised child with the first dose of measles vaccine. The reason is that outbreaks of measles are a classic sign of gaps in routine immunisation. GAVI’s new emphasis on measles will generate extra interest in this highly contagious disease, which remains one of the largest vaccine-preventable killers of children. Thanks to immunisation, global measles mortality dropped by 90 % between 2000 and 2010. But gaps in immunisation remain. Among people who are displaced, malnourished or who have poor access to healthcare, measles can kill up to 25 % of infected children.
– Category C countries have a DTP3 coverage baseline below 70 %. These countries receive 60 % of the possible total as a fixed payment, plus another $ 20 per child additionally immunised with DTP3 and another $ 20 per child additionally immunised against measles.

The new approach includes several ways to fine tune measures to the needs and conditions of particular country partners. GAVI recognises that performance-based financing cannot be done in a one-size-fits-all approach.

Developing countries tend to face heavy reporting burdens that result from donor reporting requirements. This criticism is not directed specifically at GAVI, but it matters. GAVI is keen on cooperating with other donors and pooling funds in support of coherent national policies. This is being done in Rwanda and Nepal, for instance. GAVI is not interested in creating parallel systems. It is important to reduce transaction costs and strengthen developing countries’ policy ownership.

A great challenge, however, is how to best apply PBFA in countries with fragile statehood, underperforming countries and countries with huge populations that make logistical challenges particularly great.

GAVI has certainly had some success in troubled countries such as Afghanistan or Somalia. Working with WHO and UNICEF in Afghanistan, for example, we have been supporting this war-wrecked country with Immunisation Services Support (ISS), our early PBFA, since 2001. Since then DTP3 coverage has risen from 33 % in 2001 to 66 % in 2010. With the help of local civil-society organisations, Afghanistan has also introduced new and more efficient vaccines, saving tens of thousands of lives every year.

Nonetheless, an evaluation showed that conflict and post-conflict countries tend to benefit less than others from PBFA. GAVI is currently undertaking a systematic policy development process to determine the most effective and appropriate way to provide support to such countries in a way that is tailored to meet their specific needs and circumstances. This is important because these countries typically have low coverage rates and are especially in need of preventing diseases.

Despite the challenges, GAVI remains optimistic. Immunisation programmes in many countries have contributed to reducing child mortality from more than 12 million deaths in 1990 to about 7.6 million in 2010. Innovative performance based approaches, such as GAVI’s pioneering work, have helped contribute to this large global reduction in child mortality.