The Government of the People’s Republic of China and Gavi, the Vaccine Alliance undertook a co-funded five-year, $76 million project in June 2002 to expand Hepatitis B vaccination and to purchase auto-disable (AD) syringes for infants in 12 Western provinces and national poverty counties in ten Central provinces. This project, which was eventually expanded to 2011 as a result of no-cost extensions, included several unusual features for Gavi support:
- The Government of China co-financing 50% of the project costs from inception;
- Establishment of a project office in China and;
- Provision of funding for local procurement of locally produced vaccines and injection safety equipment.
Objectives and approach
This evaluation examines the implementation, effectiveness, impact and sustainability of this project to draw lessons to inform the introduction of other vaccines in China, as well as future design and implementation of Gavi support to other countries.
Gavi’s support to China was evaluated along five criteria – relevance, implementation / efficiency, effectiveness, impact and value-added, and sustainability.
The evaluation methodology drew upon both qualitative and quantitative data. Data for this evaluation was collected from a variety of sources, including:
- Key documents, including project documents such as the project proposal, Memorandum of Understanding, Inception Report, and Annual Progress Reports, meetings minutes, and correspondence between Gavi and the GOC, as well as national strategy documents, regulations, and policies.
- Key informant interviews with representatives of international partner organizations, Ministry of Health (MOH,) Chinese Center for Disease Control and Prevention (CCDC,) and health officials and health workers at provincial, prefecture, county/district, township and village levels. Interviews with international partner informants were largely conducted by telephone, while interviews with Chinese officials were conducted in person. The evaluation team visited three provinces, with visits to lower administrative levels, and health facilities in each.
- Quantitative data related to immunization coverage, national health and immunization budgets, and commodities prices. Some of the data requested were unavailable, particularly in the area of immunization budgets.
Findings and recommendations
The evaluation concludes that the Gavi-Government of China Hepatitis B project achieved and surpassed its original objectives. The design and objectives of the project were well-aligned with the Government of China and Gavi’s needs and priorities. The provision of free vaccines represented removal of a serious financial barrier, while the project placed caps on user fees further aimed to ensure affordability and minimise potential negative effects of fees. Despite some delay due to SARS, implementation occurred as planned and the evaluators found that the project office played a critical role in effective implementation.
The project achieved and has since surpassed its stated objectives of increasing HepB3 coverage to over 85% and timely birth dose coverage to over 75%, at both the national and provincial level, except for one province. All provinces achieved HepB3 coverage rates over 95% by 2009. Timely birth dose coverage across the western provinces was 84% in 2009, a 27% increase from 2004. Further progress was made, and in 2011, timely birth dose coverage in western provinces was 90%, with only one province unable to reach the 75% coverage goal. Additionally, substantial coverage gaps between western and eastern provinces were narrowed. Although the project did not achieve its original objective of exclusive use of AD syringes for all immunisations, significant progress has been made, particularly in project areas.
A forthcoming study finds that 3.82 million chronic infections and 685,000 future Hepatitis B related deaths were prevented in project areas during the project period. Although this estimate includes immunisation that would have occurred without the project and it is not possible to isolate the impact of Gavi’s specific contribution, the evaluators conclude that the project contributed to the decrease in HBsAg prevalence in children under five years by securing full integration of Hepatitis B vaccine into the EPI programme for children nationwide, emphasising the importance of timely birth dose and supporting social mobilisation and public education to increase immunisation coverage in project areas.
They conclude that the success of this project is a validation of the originally-conceived model for Gavi support – time-bound support for country-led programs that generate genuine commitment, and are incorporated both programmatically and financially into the health system.
The Secretariat’s responses to the recommendations related to future design of Gavi support are outlined in the Management Response.