Health system and immunisation strengthening

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

Since 2000, basic immunisation coverage in Gavi-supported countries has increased from 59% to 80%. At the same time, the population has increased significantly. But in the last few years, progress has stalled. Health systems in the poorest countries are still not reaching almost one in five children with a full course of basic vaccines.

These remaining pockets of under-immunised children are often the hardest to reach. Many live in urban slums or in remote rural areas, unregistered with health clinics and beyond the reach of health workers. Others are born into marginalised communities where parents may be unaware of the benefits of vaccination.

Vaccinating a child in a health clinic is just the final destination of a complex journey that spans a sequence of essential steps, from training health workers and maintaining the cold chain to collecting data and raising awareness of the benefits of vaccination.

All of these activities have to be in place if vaccines are to be delivered even to the poorest and hard-to-reach communities. Importantly, they also provide a platform for delivering other essential primary healthcare services.

Improving coverage and equity is one of the central tenets of our 2016-2020 strategy. To reach the children who are missing out we have adopted new and enhanced strategies, including a new approach to strengthening health systems.

Gavi’s health system and immunisation strengthening (HSIS) framework, launched in 2016, brings together all types of Gavi support. This ensures more long-term predictability and allows for more integrated grant planning and budgeting. It also shifts decision-making processes closer to countries.

Having an overview of all support means future vaccine introductions can be timed and sequenced appropriately. Health system strengthening activities are better able to boost routine immunisation and support new vaccine launches.

This approach also allows us to measure progress through one single grant performance framework (GPF). The GPF covers the entire portfolio of grants for each country, tracking key inputs, activities, intermediate results and intended outcomes.

The bulk of our investment in health system strengthening is directed towards improving coverage and equity through key strategic focus areas, or SFAs. These are the areas we believe are most likely to contribute to sustainable improvements.

So far, the following SFAs have been introduced:

• data;
• supply chain;
• in-country leadership, management and coordination of immunisation programmes; and
• demand promotion and community engagement.

In the first year of our 2016–2020 strategy, we saw improvements in several areas of our health system strengthening (HSS) efforts. 90% of countries’ applications for HSS support were recommended for approval on first review, showing a clear commitment to improving coverage and equity. Eighteen countries applied for support for more modern, energy-efficient cold chain equipment through our innovative platform. There was an increase in the proportion of Gavi-supported countries meeting our benchmark for data quality.

Still, coverage rates for a full course of basic immunisation in Gavi-supported countries have remained unchanged over the past few years. This is a clear indication that some delivery systems are still weak.

Measuring progress

We track our efforts to strengthen health systems through five key indicators:

1. Supply chain performance

This indicator allows countries to evaluate their supply chain performance over time against best practice standards, as well as to identify and respond to shortcomings. It assesses features such as vaccine control, storage capacity, vaccine management, human resources and information systems.

In 2016, 15% of Gavi-supported countries met the 80% benchmark for effective vaccine management. While this is below the target of 20%, there are encouraging signs that our supply chain strategy is making a difference.

2. Data quality

We measure data quality by tracking the degree of consistency between available estimates of coverage. Read more about our support to improving data quality.

3. Coverage with a first dose of pentavalent vaccine and percentage difference between the first and third dose

Measuring coverage with a first dose of basic vaccines and the “drop-out” between the first and last dose provides a good indicator of the ability of health services to deliver immunisation services. High first-dose coverage combined with low drop-out rates suggests a strong health system.

In 2016, coverage with a first dose of pentavalent vaccine in Gavi-supported countries stayed flat at 87% for the third consecutive year. The difference between coverage with the first and third dose increased from 6 to 7 percentage points.

4. Integrated health service delivery

This indicator measures the integration between immunisation with three key vaccines and antenatal care. If these services achieve similar levels of coverage, it generally means that the linkages and coordination between them are strong.

In 2016, 26% of Gavi-supported countries met the benchmark for integrated service delivery – the same proportion as the previous year. Direct support for integrated service delivery is a recent development for the Alliance, and results will likely take several years to materialise.

5. Civil society engagement

We use three criteria to assess the level of civil society engagement:

• inclusion of civil society organisations (CSOs) in national immunisation plans with clearly stated activities;
• defined allocations in the EPI budget for CSO plans and activities; and
• documented evidence that CSO plans have been completed and/or are being implemented.

In 2016, 4 of the 10 countries for which data was available met all three criteria. CSOs featured in the immunisation plans of seven of these countries. Seven had clear budget allocations for plans and activities and six showed evidence of plans being implemented.