Supporting the introduction of life-saving vaccines is not enough if the vaccines cannot reach the children who need them


A health worker administers a vaccine in Ethiopia.
Credit: Gavi/2013/Jiro Ose.

Strong health systems are needed to deliver and scale-up new vaccines and to improve immunisation coverage and equity.

Gavi, the Vaccine Alliance supports the world’s poorest countries where health system conditions can vary. From inadequate infrastructure, lack of trained healthcare workers and interruption in the supplies of essential commodities to a lack of data to track progress and no fridges to store vaccines, weak health systems represent a critical barrier to Gavi’s mission

For example, in some Gavi-eligible countries, a mother will walk hours in the heat with her new-born child only to be sent home because no trained health worker is available to administer vaccines, the facility ran out of syringes, or a power outage jeopardised the vaccine cold chain.

Barriers to immunisation

In 2004, a report by the Norwegian agency for development cooperation (Norad) identified several examples of how poor health systems undermine the performance of immunisation programmes in developing countries:

- unavailability of staff, transport and funds for immunisation activities at district level;

- few and under-trained health workers at district and service delivery level;

- failure to track available data on district immunisation coverage and vaccine stock levels;

- low staff morale, lack of career prospects and the international migration of health professionals;

- in post-conflict situations, immunisation is hit by the lack of health infrastructure and a shortage of skilled human resources.

WHO defines six building blocks that contribute to a strengthened health system:

  • Health service delivery: a network of integrated and people-centred health facilities to provide access to primary and secondary care;
  • Health workers, in the right place, at the right time with training, experience and incentives;
  • Logistics and supply systems, including an adequate cold chain in place to deliver vaccines;
  • Health financing to raise sufficient funds for health and improve financial risk protection;
  • Health information and monitoring to generate quality data and to measure what is being done and achieved;
  • Leadership and governance to ensure that a strategic policy framework exists and there is proper accountability and oversight.

In addition to these six requirements, community mobilisation and demand generation are other areas of importance for a strong health system.

Gavi’s health system strengthening support is focused on improving immunisation coverage and equity through investments in health systems


Nurses prepare to vaccine and immunise children in Kenya.
Photo: Gavi/2013/Evelyn Hockstein.

Gavi’s five-year strategic plan for 2011-15 includes a strategic health system goal. Strategic Goal 2 aims to “contribute to strengthening the capacity of integrated health systems to deliver immunisation by resolving health systems constraints, increasing the level of equity in access to services and strengthening civil society engagement in the health sector.”

Countries are required to use Gavi health system strengthening (HSS) funding to target “bottlenecks” or barriers in the health system that stand in the way of increased access to immunisation and other child and maternal health services. Support is based on performance and linked to improvements in immunisation coverage and equity of access. In line with International Health Partnership (IHP+) principles, funding is also dependant on country proposals’ alignment with the annual planning and budgeting process of their national health plans.

Specifically, countries are encouraged to use HSS support to fund activities that fit within the six building blocks identified by WHO, as well as community mobilisation and demand generation, as the key areas of a strengthened health system to improve immunisation outcomes. To guide countries to categorise their chosen activities within these areas, Gavi HSS application guidelines include an illustrative grant categorisation table.

Barriers to improving immunisation coverage and equity

In early 2014, the Results for Development Institute conducted a review of barriers to improving immunisation coverage and equity in Gavi countries. Countries reported barriers related to all health system components. It was recommended that Gavi should remain flexible in its HSS activities, and tailor solutions to country context.

HSS support tackles inequities in access to immunisation between the poor and the rich (socio-economic), between low- and high-coverage districts (geography) and between the sexes (gender).  For example:

  • Gender: sending female health workers to homes in cultures where mothers are not allowed to go to health facilities with children
  • Geography: improving access to vaccines for remote communities through outreach campaigns
  • Socio-economic: providing incentives for poorer communities to bring children to health clinics for their vaccine rounds.   

Civil society organisations (CSOs) are critical to the delivery of immunisation services, as well as mobilising populations to create demand for immunisation and putting immunisation on the agenda at both the national and global level. Gavi recognises the role of CSOs as a catalytic partner and countries can now request support for CSOs as part of their HSS application.

Performance based funding is designed to create incentives for countries to improve immunisation outcomes by strengthening health systems

A nurse administers the PCV vaccine in Lao.

A nurse administers the PCV vaccine in Lao.
Credit: Gavi/2013/Bart Verweij.

Gavi supports HSS through a performance based funding (PBF) approach that links funding to immunisation outcomes. As agreed by the Gavi Board in November 2011, countries approved for HSS grants in 2012 and onwards will be implementing their grants with PBF.

With PBF, Gavi HSS support will be split into two different types of payments:

  1. A programmed payment, based on progress in implementation and on the achievement of intermediate results;
  2. A performance payment, based on improvements in immunisation outcomes.

To document and demonstrate these results and improvements, countries must report on intermediate results. These include indicators linked to community mobilisation and demand generation, the availability of staff and supplies in health centers, and data quality. Learn more about PBF here.

Data quality

With data quality integral to PBF, Gavi supports countries in improving their reporting mechanisms and data quality so they can access programmed payments and earn performance payments.

Assessing and improving data quality is essential both for tracking progress towards the health systems goal and monitoring health systems grants to countries.

To improve results measurement and monitoring, the Vaccine Alliance is working with WHO, the Global Fund and other agencies to strengthen country health information systems. The approach builds on the International Health Partnership (IHP+) approach to strengthen country-led platforms for the monitoring, evaluation and review of both national health and programme-specific strategies, including immunisation.

Quality and timely immunisation coverage data are essential for programme planning and monitoring. Accelerating the availability of this data requires:

  1. A routine approach to assessing the quality of immunisation coverage data;
  2. The development and implementation of data quality improvement plans;

an approach for monitoring progress in data quality improvements. In most Gavi-eligible countries, immunisation coverage data are derived from two sources: country administrative data reporting system and population based surveys.

To accelerate access to quality immunisation coverage data, Gavi has instituted two new requirements for countries applying for all types of Vaccine Alliance support, both HSS and new and underused vaccine support:

  1. Countries must have routine mechanisms in place to independently assess the quality of administrative data and track changes in data quality over time
  2. Gavi requires regular household surveys to assess immunisation coverage, equity and factors associated with non-immunisation. Two surveys every five years—one with a full birth history and an interim coverage survey in the middle of the five year period—is an appropriate standard for most countries. At minimum, a nationally representative immunisation coverage survey every five years is required.

Collaboration on PBF at sub-national level

While Gavi’s current PBF approach is applied to HSS grants at the national level, the Vaccine Alliance also encourages countries to use PBF at sub-national levels. At the same time, countries are encouraged to consider alignment with other existing PBF schemes in their country, such as the World Bank’s results-based financing (RBF) programmes.

In 2012, RBF experts from around the world met in Oslo to review common experience with RBF programmes and to determine a roadmap for scaling these up. Gavi, the Global Fund, UNICEF and others agreed to collaborate with the World Bank on its RBF programme in selected countries.

RBF programmes pay providers or recipients of health services after pre-agreed results have been achieved and independently verified. RBF is a change from paying for inputs to paying for services delivered. The collaboration will be tried and tested in a few select countries in 2014.

Benin is the first country where a Gavi HSS grant was proposed by the country aligned with the World Bank’s RBF programme, which the Global Fund also supports.

Gavi’s health system strengthening is based on the principles of the International Health Partnership (IHP+) in line with the Paris Declaration on Aid Effectiveness 

Pneumonia vaccine launch in Uganda.

Pneumonia vaccine launch in Uganda.
Credit: Gavi/UNICEF/2013/Michele Sibiloni.


Gavi health system strengthening (HSS) support is intended to address weaknesses identified by implementing countries. They are encouraged to use recent immunisation programme and health sector analyses, National Health Sector Plans and similar inputs to identify weaknesses and gaps in current funding.


HSS should be consistent with the existing objectives, strategies and planning cycles of government health sector policy, aligned with government management systems and financial procedures, and reflected in national budgets wherever possible.


HSS should add value to (not compete with) current or planned efforts to strengthen the health systems by national governments, civil society and health sector partners.


HSS support is, in principle, available for the life of National Health Sector Plans (or equivalent).


HSS funds must be additional to the government's existing budget and not displace previously allocated health sector resources.

Inclusive and collaborative

All key stakeholders (beyond immunisation) should be involved in HSS. Government entities, national health sector coordinating bodies, partners, civil society, and the private sector should all be informed and involved, as appropriate, in the planning, implementation and evaluation stages.


HSS should not result in the creation of stand-alone, independently managed projects. Ideally, it should be an agent for catalytic change where possible - for example, testing pilot projects that could subsequently be scaled up by government.


Gavi encourages health service innovation. HSS can be used to test new strategies or approaches or to adapt learning and best practice from elsewhere.


Implementing countries must link strategies for tackling barriers to specific indicators that show how the use of HSS funds will improve immunisation and other forms of child and maternal health care. The results should be evident at local level. Progress towards agreed goals will be monitored by Vaccine Alliance partners including WHO, UNICEF, and the World Bank.


Implementing countries must take into consideration how the recurring financial and technical requirements of health service improvement of HSS support can be sustained beyond the period of Gavi support.

In addition to these principles, Gavi’s HSS cash support is intended to:

  • Be fully aligned with the OECD Development Assistance Committee (OECD DAC) principles and be accountable for measurement;
  • Share experience with other initiatives such as Partnership for Maternal, Neonatal and Child's Health (PMNCH), HMN, Global Fund for AIDS, TB and Malaria (GFATM) and the Global Health Workforce Alliance;
  • Identify best practices to share with implementing countries and other partners;
  • Contribute to the HSS architecture being designed by the World Bank, WHO, the Global Fund and other stakeholders.

Countries are using Vaccine Alliance support to strengthen their health and immunisation services at the national and sub-national levels

A health worker travels to administer vaccines in Afghanistan.

A health worker travels to administer vaccines in Afghanistan. Photo: UNICEF/2006/Lana Slezic.

By the end of 2013, Gavi had committed US$ 862.5 million in HSS grants from 2007 through 2017. HSS approvals from 2007-2013 total $591 million, of which 90% were already disbursed by the end of 2013.

In 2013, the $119 million disbursed to more than 25 countries represents a doubling of the 2012 disbursement level and is the highest level of disbursement since 2008.

HSS funds are used, among other activities, to support:

HSS studies and evaluation

In 2009, Gavi published an evaluation of its health system strengthening (HSS) support, reviewing the experiences of 21 countries.

The 2008 HSS tracking study is complementary to the HSS evaluation, helping to highlight implementation issues in six countries.

From 2013-2016, Gavi will fund full country evaluations in Bangladesh, India, Mozambique, Uganda and Zambia, including assessments of Gavi cash-based support.

Gavi is seeking to improve the monitoring and evaluation of HSS grants. For more information see HSS Supplementary Guidelines.

  • service delivery, focusing for instance on infrastructure investments and vehicles;
  • procurement and supply chain management;
  • human resources, emphasising training and
    supervision for community health workers and
    health professionals.

Here we list four country examples of how Gavi HSS support contributes to health system performance and improves immunisation:


Afghanistan’s physical geography and security issues limit access to health services and undermine efforts to ensure vaccines reach the nomadic Kochi population.

A Vaccine Alliance HSS grant is being used to fund the mapping of the Kochi’s travelling routes and training mobile health teams, incorporating at least one female health worker and vaccinator, to deliver health services to the Kochi. Given the Government’s limited capacity, this project has been outsourced through performance-based contracting to civil society organisations.


Even in countries where there is no discrepancy between the proportion of boys and girls immunised, gender-related factors can still prove a barrier to accessing immunisation services.

Given that Bangladesh mothers, as primary caretakers, predominantly bring their children to vaccination sessions, the Health Ministry has recognised they will feel more comfortable addressing a female health worker. Thanks to Gavi HSS support, Female Welfare Assistants are being trained in 13 targeted districts to provide health services, including immunisation, and also to conduct semi-annual Health Promotion days.


Liberia has used its Gavi HSS grant to improve data quality and address bottlenecks in its monitoring & evaluation (M&E) processes.

Countries need accurate and complete data to identify issues and solutions, eg, which districts have vaccine stock-outs or which health posts lack staff trained to run vaccination sessions. Liberia drew on a Gavi HSS grant to jointly-fund a Regional District Health Information System workshop, where M&E officers from each county were trained in new web-based software allowing them to store and send information online.

By facilitating the submission of more timely and accurate reports, decision-makers can quickly understand which immunisation programmes are successful and which face challenges.

A health worker prepares to vaccinate a child in Ethiopia.

A health worker prepares to vaccinate a child in Ethiopia.
Credit: Gavi/2013/Jiro Ose.


Before Gavi’s HSS grant, Ethiopias cold chain was poorly equipped to deliver vaccines from the central store to health districts. The country possessed only one refrigerated truck to transport vaccines while many refrigerators at the district-level were outdated and in need of repair.

With Gavi support, Ethiopia is securing five more refrigerator trucks – one for national use and four to transport vaccines between central and regional hubs – as well as 4,000 new fridges and 10,000 spare parts. The HSS grant is also funding the installation of solar panels so that even health facilities with no direct power source will be able to store vaccines in a fully functioning refrigerator.

Gavi recognised early on that strong health systems are essential to deliver and scale-up new vaccines and immunisation coverage

A health worker prepares to vaccinate a child in DRC.

A health worker prepares to vaccinate a child in DRC. Photo: Gavi/2008/Olivier Asselin.

This section outlines the evolution of the Vaccine Alliance’s health system strengthening (HSS) policies, from the opening of Gavi’s first HSS support window in 2005 to the introduction of performance based funding in 2012:

2005-2010: Gavi’s first HSS support window

In its first strategy (2000-2006), the Vaccine Alliance boosted the capacity of health and immunisation services through HSS.  Once HSS cash support was made available in 2006, many countries submitted applications.

Initially, support focused on strengthening the overall health system through service delivery, training and management. Almost all grants in this early period targeted primary care and public health aspects of the overall system, in particular the delivery of services at community level – often to remote or underprivileged populations.

By the end of 2008, six meetings of the Independent Review Committee (IRC) had approved 46 grants with cash disbursements for HSS totalling $230 million. In 2009, 16 country applications were reviewed of which 10 were approved in two rounds of IRC meetings.

2010-2012: the Health Systems Funding Platform

In 2009, following an HSS evaluation and at the recommendation of the High Level Taskforce on Innovative International Financing for Health Systems, the Health Systems Funding Platform (HSFP) was established as one way to accelerate progress towards health Millennium Development Goals 4 and 5 on reducing child and maternal mortality.

Gavi - together with the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) - developed two funding modalities for HSS support, which aimed at enabling countries to submit a funding request template or common proposal form to the two agencies.

The platform brought together Gavi, the Global Fund, and the World Bank, with facilitation from WHO, linking their support behind developing countries' national health plans. Its aim was to streamline HSS support and align with country budgetary and programmatic cycles.

For past material regarding the HSFP, including HSFP guidelines, country stories or progress reports please contact  


For questions on health system strengthening support (HSS), contact or your Gavi Senior Country Manager. To apply for HSS cash support, including CSO support, please click here.

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