Return to Aug
2000 contents page
Bringing it all together
The first set of governments have
been through the process of seeking support from the Vaccine Fund.
Heres how it felt in some African countries
FOR anyone involved in applying to GAVI
for support from the Vaccine Fund for grants, the past few months
have been a hectic and exciting time. Tight schedules have been
made tighter by face-to-face meetings, often between people who
have never sat down together before, even though they all work in
immunization in a given country. Data from sometimes scattered sources
have been gathered together and reviewed to meet the requirements
(see How GAVI and the Vaccine Fund will support countries).
But, whether governments joined the first round of proposals for
support, or decided to wait for the second, the experience has been
a useful one, according to many of those involved. And all the players
have learnt lessons that will stand them in good stead for the future.
Special delivery: vaccine supplies leave
Maputo for flooded regions of Mozambique earlier this year
Several key messages emerged. First,
the process allowed countries a unique opportunity to assemble
their key immunization "players" and review their current
services. Second, the process sometimes served as a catalyst
for change, for example by triggering a specific commitment
by a health minister to improve the safety of immunization
equipment or vaccine quality control. And third, in certain
situations, it was better to wait and gather the information
for a good proposal in the second round than to rush to
submit an incomplete one for the first.
"The time to talk brings a lot of change.
It has been a useful process," says Dr Tarande Manzila,
medical officer for new vaccines in WHOs regional
office for Sub-Saharan Africa in Harare, Zimbabwe, who has
worked with a number of countries in the region in preparing
"It was a very good experience for
all of us to get involved and get to know where we are," says
Eva Kabwongera, UNICEF project officer for health in Kampala,
In Mozambique, says Miguel Aragon
Lopez of UNICEFs Maputo office, the process has been catalytic.
For example, seeing that GAVI would supply autodestruct syringes
with new and under-used vaccines, Mozambique which has been
using re-sterilisable syringes until now has decided to match
GAVI by using disposable ones for all the other vaccines it administers
within its programme, such as BCG, measles and tetanus. Also,
says Rose Macauley, technical adviser to the Mozambique immunization
programme at the Ministry of Health, the process has triggered
a rethink of the role of the national Immunization Coordination
Committee (ICC). Before, this committee focused only on polio
eradication. Now, the committees scope of work is to be
extended. In a year in which Mozambiques immunization services
are still reeling from the effects of catastrophic flooding, the
pace of recovery has been fast.
Good news, but, of course, not everything
in the region went perfectly. As with many large and highly devolved
partnerships, GAVIs partners activities in Africa
suffered from some muddles and overlaps in the initial stages.
Early in the year, governments and officials in certain countries
were confused by uncoordinated messages from individual partners.
No time to spare
Also, once the process was set
up, time pressure was a problem. Several officials said
they would have liked more time to get ready. The proposal
packs were sent out in mid-May for return by 30 June for
consideration in the first round. "Its a very short
time, and there are many things to do, not only GAVI," said
one. "But people have worked very hard."
And then there was the inevitable
risk of a dash for cash. Some health ministers reportedly
returned from the World Health Assembly in Geneva and demanded
that their immunization officials complete and submit a
proposal form in the first round, even when officials warned
that some of the information required to complete the proposal
was lacking. Although the system is not competitive, it
does rely on countries providing all the necessary information.
Countries whose proposals are incomplete will be encouraged
to resubmit them at a later date: redoubled efforts are
needed to ensure that all countries are adequately briefed
on the process, says Dr Manzila.
Minutes count: it can take special effort
to maintain normal immunization services when floods strike
To ensure the best use of the proposal
process, the African regional offices of WHO and UNICEF held an
informal meeting in Abidjan, Côte dIvoire, in mid-April.
They clarified GAVIs mechanisms and examined some of the key
issues, such as how governments will plan to sustain support for
immunization services beyond the five years of support from GAVI
and the Vaccine Fund.
Then WHO officials worked with individual
countries to provide guidance on their proposals, focusing initially
on those best equipped to provide the information needed in the
short time available. Where there was enough time for discussion
at higher political levels, in-person visits were strikingly productive.
For example, in Tanzania, discussions with high-ranking officials
in the health ministry resulted in a renewed and specific commitment
by the government to sustaining immunization services.
In some cases, consultants for the
GAVI partners advised countries to wait for the second round to
submit their proposals. Uganda was one of several such countries.
"At first, we thought, why?" says Kabwongera. "But in the end
we agreed that with more time it [our proposal] will be much better."
Assembling scattered data
Most of the required information for
the proposal exists, says Kabwongera, but it was scattered and
needed to be assembled. Ugandas immunization services have suffered
in recent years, possibly due to the introduction of policies
such as the decentralization of health delivery services, and
reforms of the civil service that resulted in some immunization
workers being laid off. Some have now been reinstated, however,
and, says Kabwongera, strategies have been developed to revitalize
the immunization programme.
Predictably, there is a range of views
on how and whether GAVI and the Vaccine Fund should refine or develop
the conditions for support. Perhaps the newest feature of the
mechanism for funding countries is the "share" concept, which
represents the Vaccine Funds contribution to the cost of fully immunizing
one child (see How GAVI and the Vaccine Fund will support
countries). Nominally, this has been set at $20 per child.
Some commentators (2) argue that the real cost
varies from country to country, and that shares should therefore
be scaled to take account of population size and other factors.
Others welcome the share concepts flexibility, contrasting
it with the red tape that traditionally surrounds donor support.
"The only conditionality is a commitment to really vaccinate the
children," says Miguel Aragon Lopez in Mozambique.
Which, after all, is what this entire
effort is about.
1. Global Alliance for
Vaccines and Immunization and the Vaccine Fund: Guidelines on Country
Proposals for Support. Available from the GAVI secretariat or at
2. African Perspectives
on GAVI. Annex 7.2, Report of the Third Meeting of the GAVI Board,
Oslo, June 14-16 2000. Presented by Lomamy Shodu, Zimbabwe Ministry
of Health. www.VaccineAlliance.org/download/oslofullrept.doc
How GAVI and the Vaccine Fund will support countries
GAVI and the Vaccine Fund will support countries initially
- Strengthen their immunization services
for existing vaccines such as diphtheria, tetanus and
pertussis (DTP3), polio and measles; and
- Introduce under-used vaccines such
as hepatitis B and Hib.
All low-income countries with GNP per capita of US$1000
or less are eligible for support. In China, India and Indonesia,
special arrangements are envisaged.
To receive support, a country must have:
- A functioning mechanism for coordinating
the activities of all immunization players, usually an
Interagency Coordination Committee;
- A recent assessment of immunization
- A multi-year plan for immunization.
Which type of support is most suitable
for which countries?
- Support for immunization services
is to be given to countries where coverage for DTP3 is
below 80% of the target population. The aim will be to
strengthen health systems to improve the service in all
- Support for the introduction of new
and under-used vaccines will be provided to countries
where DTP3 coverage is above 50%. Where it is lower, countries
are encouraged to focus on improving their overall immunization
system before introducing new antigens.
How will the money be disbursed?
- For the improvement of immunization
services in countries with DTP3 coverage below 80%, GAVI
and the Vaccine Fund have developed a radical new approach. Rather
than tie up funds for specific restricted uses, as with
traditional donor support, the approach allows governments
and ICCs to decide how best to use the funds, requiring
in return a strict set of performance monitors.
Funding will be based on the concept of a "share" of US$20
for each fully immunized child. Total funds will be divided
into two equal amounts. The first half of the money will
be invested up-front on the basis of the number of children
that the government intends to immunize in the next two
years, over and above the percentage currently immunized.
The second half will be awarded in the form of "rewards"
for each additional child actually immunized.
- For the introduction of new and under-used
vaccines the Vaccine Fund will supply vaccines and safe
injection equipment. Governments are advised to plan to
transfer the costs of these items to their own budgets,
or to seek external support for their purchase, before the
end of the funding period. These plans will be reviewed
How long will the money last?
The Vaccine Funds current resources have been budgeted
to provide all eligible countries with five years of support.
GAVIs partners recognize the need for sustained support,
and are taking steps to extend the Vaccine Fund beyond five
years. However, they will also help governments to plan how
to sustain their improved performance and seek other support.
When is the next deadline?
Proposals for the next round should be
received by the GAVI secretariat by 15 October 2000.
Return to August 2000