Strengthening health delivery systems

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Gavi supports countries in identifying and tackling the weak links in health systems that obstruct delivery of vaccines to the people who need them

Business challenge

Strengthening health delivery systems

Vaccines are one of the most effective and cost-efficient means to save lives, improve child health and advance towards the Millennium Development Goals for child and maternal mortality. But fulfilling that potential depends on the ability of health systems to deliver vaccines where, and on the scale, they are needed.

Service delivery in many low-income countries suffers from a lack of, or inability to retain, trained health workers, gaps in the cold chain or weaknesses in health system management.

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Gavi's value added

Gavi strategy: the health systems goal

Gavi's commitment to making developing countries' health systems more effective in delivering vaccines to even the most remote district is enshrined in the second goal of its 2011-2015 strategy. This sets out three objectives: contibute to resolving constraints in delivering immunisation; increase equity in access to services (including gender equity); and, strengthen civil society engagement in the health sector.

Gavi allocates approximately 15% of its total funding support to cash-based programmes designed to encourage countries to strengthen immunisation delivery.

Tackling institutional barriers

Progress in immunisation delivery has often been impeded by broader health system constraints ranging from the poor distribution and motivation of health workers to a lack of adequate infrastructure and poor management of services.

Gavi has therefore provided health system strengthening support (HSS) to enable countries to tackle institutional barriers holding back progress. In line with the "country ownership" principle of Gavi's business model, countries design programmes to address what they see as their real needs rather than problems identified externally. This also ensures that programmes are aligned with national policies.

Countries mainly use HSS funding to deliver immunisation and maternal and child health (MCH) services, sometimes in selected districts. In particular, the Vaccine Alliance is now focusing its effort on strengthening immunisation supply chains to not only reach more people currently missed by immunisation services, but to reach them with a full set of safe and viable vaccines. Examples of HSS support include:

  • training nurses to administer the two shots and an oral dose required for pneumococcal vaccine;
  • giving expert health workers incentives to stop them leaving for other jobs;
  • ensuring there are sufficient carrying dispensaries (polysterene cool boxes) to maintain the cold chain for delivering vaccines from central to district level;
  • increasing the number of incinerators to dispose of waste;
  • conducting laboratory surveillance to monitor the impact of vaccinations.

CSOs are frequently the backbone of developing countries' health systems, delivering up to 60% of immunisation services; the Vaccine Alliance's funding support is designed to encourages CSO engagement in the national planning and implementation process.

Vaccine Alliance partners launch their supply chain strategy, with four new initiatives to help countries put the fundamentals in place for improved immunisation supply chains.

Health workers travel often by any means possible to reach and immunise rural communities.

Health workers travel often by any means possible to reach and immunise rural communities.
Credit : GAVI/2013/Evelyn Hockstein

Recent investments in immunisation programmes worldwide have the potential to substantially decrease illness and death associated with an increased number of preventable diseases. However, as immunisation programmes expand to include new vaccines and strive to reach larger populations in more remote areas, programmes are increasingly constrained by poor infrastructure and inefficient immunisation supply chains. Furthermore, with vaccine volume expected to quadruple between 2010 and 2020, the need for meaningful, systematic improvements in immunisation supply chain infrastructure and systems is clear.

The 3+1 approach

Developed by WHO, UNICEF, Bill & Melinda Gates Foundation and Gavi, the global immunisation supply chain strategy encompasses an end-to-end perspective from the manufacturer to the health worker. It focuses most intensively on the country level from port-of-entry (or national store for domestic vaccines) to the beneficiaries.

Our ‘3+1’ approach to the supply chain strategy focuses on ‘3’ key elements of immunisation supply chain management, which will enable the successful roll-out of new vaccines and provide more equitable access to hard-to-reach populations. The additional ‘+ 1’ initiative includes an in-depth analysis and redesign of country immunisation supply chains to improve their performance.

The ‘+1’: system redesign

The ‘+1’: system redesign

Many in-country immunisation supply chains continue to operate with a network design that was promoted since the early days of Expanded Programme on Immunisation (EPI) over 30 years ago. While this design has contributed to the success of EPI, it has reached its limits. Increasing performance beyond existing levels to support the ambitions for raising coverage and introducing new vaccines is going to be difficult without rethinking the network design for the future.

Initially, four to six countries will be prioritised for support for system redesign either because they have already started a supply chain change process, because they are planning to introduce significant numbers of new vaccines, or because there are particular issues with the current design. With these countries, the Vaccine Alliance partners will provide technical support, focusing on change management to help the countries achieve a successful redesign of their immunisation supply chain system.

In support of these 3+1 initiatives, the Vaccine Alliance partners and other implementing partners are committed to providing on-going direct technical support, developing relevant tools and resources, establishing financial support mechanisms and undertaking policy changes that might be necessary to institute these fundamental changes.

Supply chain managers

Supply chain managers

The first initiative focuses on supply chain management and establishing or reinforcing the post of immunisation supply chain manager and ensuring that these managers have the appropriate level of expertise, authority and resources to oversee the supply chain within a strengthened overall management system. The Vaccine Alliance will support countries to hire and strengthen supply chain managers by providing focused technical assistance, tools, access to training and other resources.

Supply chain management and improvement plans

Supply chain management and improvement plans

The second initiative is designed to help countries develop concrete national supply chain management plans, building upon and expanding the scope of the current Effective Vaccine Management assessments and improvement plans. These comprehensive national supply chain management plans will be integrated into the broader immunisation and health sector plans. The Vaccine Alliance will provide guidance and technical assistance to countries as they develop and implement these plans.

Supply chain dashboards

Supply chain dashboards

The third initiative supports countries to develop management dashboards including key supply chain indicators for use at all levels of the supply chain. These dashboards will help managers monitor supply chain performance and implement improvements listed in the comprehensive plans. The Vaccine Alliance will provide guidance and technical assistance on data standards and use. Dashboards will be developed by national partners to ensure each dashboard is relevant and feasible in that particular country.

Benefits to immunisation programmes

In addition to tailored technical support and financial assistance, national immunisation programme leaders and supply chain managers will have access to more effective management tools, increased numbers of trained personnel and better technologies to help them reach their programme goals. The increased focus on supply chains will enable programmes to not only reach more people currently missed by immunisation services, but to reach them with a full set of safe and viable vaccines.


The Vaccine Alliance has helped strengthen health systems and immunisation services in more than 60 countries and increased injection safety.


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