August 2000

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GRASSROOTS

Bringing it all together

The first set of governments have been through the process of seeking support from the Vaccine Fund. Here’s 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 WHO’s regional office for Sub-Saharan Africa in Harare, Zimbabwe, who has worked with a number of countries in the region in preparing their proposals.

"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, Uganda.

In Mozambique, says Miguel Aragon Lopez of UNICEF’s 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 committee’s scope of work is to be extended. In a year in which Mozambique’s 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, GAVI’s 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. "It’s 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 d’Ivoire, in mid-April. They clarified GAVI’s 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. Uganda’s 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 Fund’s 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 concept’s 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.

References

1. Global Alliance for Vaccines and Immunization and the Vaccine Fund: Guidelines on Country Proposals for Support. Available from the GAVI secretariat or at www.VaccineAlliance.org/download/guidelines.doc

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 What? GAVI and the Vaccine Fund will support countries initially to: 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. Who? 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. How? 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 services; and 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 districts. 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 in 2002. How long will the money last? The Vaccine Fund’s current resources have been budgeted to provide all eligible countries with five years of support. GAVI’s 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.

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