New Products into Old Systems

1
New Products into Old Systems

• The initial impact of the Global Alliance for
  Vaccines and Immunizations (GAVI) from a country
  perspective

2
Caveats

• Snapshot of the early days of GAVI
• Four countries
• Fieldwork constraints

3
Methods

• Review of information on GAVI website,
  unpublished GAVI reports
• Interviews at country level
• Senior MoH officials
• Representatives from donor and international
  agencies
• Reports, minutes from meetings
• Rapid assessment of facilities
• Vaccine stores, cold chain, fixed site facilities
• Twenty five fixed facilities visited in four
  countries

4
Objectives and scope

• To describe and evaluate the application process
• To report how systems support funding was being
  used, or plans for it
• To ascertain the anticipated impact of the
  implementation of new vaccines and GAVI funds

5
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6
Discussion findings

• Does GAVI fit in with country priorities?
• How did the application process go?
• What was the coordination process?
• What is the capacity of country systems to
  implement GAVI?
• How is the initiative being monitored?
• Are new vaccines sustainable?

7
Does GAVI fit in with country priorities?

• Countries generally very positive
• Renewed focus on immunization
• Introduction of Hep B vaccine and auto-destruct
  syringes and disposal boxes
• Flexible funding for systems
• Some contention over combination vaccines
• Ghanas acceptance of pentavalent vaccine
• Felt pressure to accept monovalent HepB
• Appropriateness of Hib vaccine

8
How did the application process go?

• All countries experienced pressure to make rapid
  decisions in six months leading to the
  application
• Some felt they were held to unreasonably tight
  deadlines
• GAVI response to applications was prompt and
  constructive
• Pressure on application process contrasted
  sharply with time lags in receiving vaccines

9
What was the coordination process?

• Considerable variation in the effectiveness of
  the Inter-Agency Coordination Committees
• Dominated by immunization interests, rather than
  broader health systems (SWAps)
• In some countries international agencies played
  lead role, not MoH
• Significant external technical assistance

10
What is the capacity of country systems to
implement GAVI?

• Under-investment in health systems
• Staff shortages
• Cold chain weaknesses
• Weak sterilisation, safe disposal of sharps
• Poor outreach, supervision and support
• GAVI systems support cannot redress this
• Small percentage of total health expenditure

11
How is the initiative being monitored?

• Problems with information systems
• Recording and reporting often unreliable at
  district level
• Uncertainty about coverage estimates
• Lack of confidence in target population size
• Performance related rewards
• Dangers of over-reporting immunizations,
  under-estimations of population size

12
Are new vaccines sustainable?

• Countries MoHs not concerned about
  sustainability welcome GAVIs five year time
  frame
• Donors are concerned in the case of Ghana,
  annual cost of routine EPI will almost triple

13
Recommendations

• GAVI needs to take steps to ensure
• Introduction of new products does not unduly
  distort countries immunization priorities
• Quantitative performance monitoring is
  complemented by the addition of other indicators
• Sufficient systems support is available for
  implementation of routine EPI, managing
  information systems, safe disposal
• Other players are involved in the above, to
  ensure coordination with existing national
  processes, to widen the constituency of support
• sustainability, by working at a pace which allows
  change to be consolidated (and costs to be met)