Global health partnerships in practice: taking stock of the GAVI Alliance's new investment in health systems strengthening

Estimating population-based coverage of reproductive, maternal, newborn, and child health (RMNCH) interventions from health management information systems: a comprehensive review

Background

Routinely collected health facility data usually captured and stored in Health Management Information Systems (HMIS) are potential sources of data for frequent and local disaggregated estimation of the coverage of reproductive, maternal, newborn, and child health interventions (RMNCH), but have been under-utilized due to concerns over data quality. We reviewed methods for estimation of national or subnational coverage of RMNCH interventions using HMIS data exclusively or in conjunction with survey data from low- and middle-income countries (LMICs).

Methods

We conducted a comprehensive review of studies indexed in PubMed and Scopus to identify potential papers based on predefined search terms. Two reviewers screened the papers using defined inclusion and exclusion criteria. Following sequences of title, abstract and full paper reviews, we retained 18 relevant papers.

Results

12 papers used only HMIS data and 6 used both HMIS and survey data. There is enormous lack of standards in the existing methods for estimating RMNCH intervention coverage; all appearing to be highly author dependent. The denominators for coverage measures were estimated using census, non-census and combined projection-based methods. No satisfactory methods were found for treatment-based coverage indicators for which the estimation of target population requires the population prevalence of underlying conditions. The estimates of numerators for the coverage measures were obtained from the count of users or visits and in some cases correction for completeness of reporting in the HMIS following an assessment of data quality.

Conclusions

Standard methods for correcting numerators from HMIS data for accurate estimation of coverage of RMNCH interventions are needed to expand the use of these data. More research and investments are required to improve denominators for health facility-derived statistics. Improvement in routine data quality and analytical methods would allow for timely estimation of RMNCH intervention coverage at the national and subnational levels.

Pro-equity immunization and health systems strengthening strategies in select Gavi-supported countries

BACKGROUND

Achieving universal immunization coverage and reaching every child with life-saving vaccines will require the implementation of pro-equity immunization strategies, especially in poorer countries. Gavi-supported countries continue to implement and report strategies that aim to address implementation challenges and improve equity. This paper summarizes the first mapping of these strategies from country reports.

METHODS

Thirteen Gavi-supported countries were purposively selected with emphasis on Gavi's priority countries. Following a scoping of different documents submitted to Gavi by countries, 47 Gavi Joint Appraisals (JAs) for the period 2016-2019 from the 13 selected countries were included in the mapping. We used a consolidated framework synthesized from 16 different equity and health systems frameworks, which incorporated UNICEF's coverage and equity assessment approach - an adaptation of the Tanahashi model. Using search terms, the mapping was conducted using a combination of manual search and the MAXQDA qualitative analysis tool. Pro-equity strategies meeting the inclusion criteria were identified and compiled in an Excel database, and then populated on a tableau visualization dashboard.

RESULTS

In total, 258 pro-equity strategies were implemented by the 13 sampled Gavi-supported countries between 2016 and 2019. The framework determinants of social norms, utilization, and management and coordination accounted for more than three-quarters of all pro-equity strategies implemented in these countries. The median number of strategies reported per country was 17. Afghanistan, Nigeria, and Uganda reported the highest number of strategies that we considered as pro-equity.

CONCLUSION

Findings from this mapping can be useful in addressing equity gaps, reaching partially immunized, and 'zero-dose' vaccinated children, and valuable resource for countries planning to implement pro-equity strategies, especially as immunization stakeholders reimagine immunization delivery in light of COVID-19, and as Gavi finalizes its fifth organizational strategy. Future efforts should seek to identify pro-equity strategies being implemented across additional countries, and to assess the extent to which these strategies have improved immunization coverage and equity.

Organizational Readiness Tools for Global Health Intervention: A Review

The ability of non-governmental organizations, government agencies, and corporations to deliver and support the availability and use of interventions for improved global public health depends on their readiness to do so. Yet readiness has proven to be a rather fluid concept in global public health, perhaps due to its multidimensional nature and because scholars and practitioners have applied the concept at different levels such as the individual, organization, and community. This review concerns 30 publically available tools created for the purpose of organizational readiness assessment in order to carry out global public health objectives. Results suggest that these tools assess organizational capacity in the absence of measuring organizational motivation, thus overlooking a key aspect of organizational readiness. Moreover, the tools reviewed are mostly untested by their developers to establish whether the tools do, in fact, measure capacity. These results suggest opportunities for implementation science researchers.

Evaluating Global Health Partnerships: A Case Study of a Gavi HPV Vaccine Application Process in Uganda

BACKGROUND

Global health partnerships have grown rapidly in number and scope, yet there has been less emphasis on their evaluation. Gavi, the Vaccine Alliance, is one such public-private partnership; in Gavi-eligible countries partnerships are dynamic networks of immunization actors who work together to support all stages and aspects of Gavi support. This paper describes a conceptual framework - the partnership framework - and analytic approach for evaluating the perceptions of partnerships' added value as well as the results from an application to one case in Uganda.

METHODS

We used a mixed-methods case study design embedded in the Gavi Full Country Evaluations (FCE) to test the partnership framework on Uganda's human papillomavirus (HPV) vaccine application partnership. Data from document review, interviews, and social network surveys enabled the testing of the relationships between partnership framework domains (context, structure, practices, performance, and outcomes). Topic guides were based on the framework domains and network surveys identified working together relationships, professional trust, and perceptions of the effectiveness, efficiency, and legitimacy of the partnership's role in this process.

RESULTS

Data from seven in-depth interviews, 11 network surveys and document review were analyzed according to the partnership framework, confirming relationships between the framework domains. Trust was an important contributor to the perceived effectiveness of the process. The network was structured around the EPI program, who was considered the leader of this process. While the structure and composition of the network was largely viewed as supporting an effective and legitimate process, the absence of the Ministry of Education (MoE) may have had downstream consequences if this study's results had not been shared with the Ministry of Health (MoH) and acted upon. The partnership was not perceived to have increased the efficiency of the process, perhaps as a result of unclear or absent guidelines around roles and responsibilities.

CONCLUSION

The health and functioning of global health partnerships can be evaluated using the framework and approach presented here. Network theory and methods added value to the conceptual and analytic processes and we recommend applying this approach to other global health partnerships to ensure that they are meeting the complex challenges they were designed to address.

Local self governance in health - a study of it's functioning in Odisha, India

BACKGROUND

Local decision making is linked to several service quality improvement parameters. Rogi Kalyan Samitis (RKS) at peripheral decision making health units (DMHU) are composite bodies that are mandated to ensure accountability and transparency in governance, improve quality of services, and facilitate local responsiveness. There is scant literature on the nature of functioning of these institutions in Odisha. This study aimed to assess the perception of RKS members about their roles, involvement and practices with respect to local decision making and management of DMHUs; it further examined perceptual and functional differences between priority and non-priority district set-ups; and identified predictors of involvement of RKS members in local governance of health units.

METHODS

As members of RKS, health service providers, officials in administrative/managerial role, elected representatives, and officials from other departments (including independent members) constituted our study sample. A total of 112 respondents were interviewed across 6 districts, through a multi-stage stratified random sampling; we used a semi-structured interview schedule that comprised mainly of close-ended and some open-ended questions. Descriptive and inferential statistics were used to compare 3 priority (PD) and 3 non-priority districts (NPD), categorized on the basis of Infant Mortality Rate (IMR) estimates of 2011 as proxy of population health. Governance, human resource management, financial management and quality improvement functions were studied in detail. Opinion about various individual and organizational factors in local self-governance and predictors of involvement were identified.

RESULTS

The socio-demographic profile and composition of respondents were comparable between PD and NPD. Majority of respondents were 'satisfied' with their current roles in the governance of local health institutions. About one-fourth opined that the amount of funds allocated to RKS under National Health Mission (NHM) was 'grossly insufficient'. Fifty percent of respondents said they requested for additional funds, last year, and 38.8 % informed that they requested additional funds for purchase of drugs. About 87 % respondents were satisfied with their role in the local governance of the health units (PD = 94.3 % vs. NPD = 80.7 %). Almost all (PD = 98 % vs. NPD = 80.7 %) opined that local decision making helped in improving the performance of health units. For most of the open-ended questions the responses were non-specific. Staggering differences were found between PD and NPD with respect to their involvement in district plan preparation (NPD = 78.9 % vs. PD = 58.5 %), training in plan preparation (NPD = 47.4 % vs. PD = 27.5 %), participation of officials from other departments (PD = 96.9 % vs. NPD = 45.5 %), and inclusion of activities of other sectors (PD = 70.8 % vs. NPD = 41.8 %). Whereas, no significant PD-NPD difference was found about their perceived 'involvement' in undertaking the 12 designated responsibilities. Composite scores on various individual and organizational factors were compared and found to be varying significantly. Through regression, we inferred work experience, qualification and non-monetary incentives as strong determinants of current level of involvement of RKS members in governance and management of health units.

CONCLUSION

Poor knowledge/expectation of RKS members was diluting the decision making process at DMHUs. There is an urgent need to improve their knowledge, understanding and expertise in areas of governance and management practices. A locally-monitored and time-bound capacity building plan could achieve this. Yearly resource allocation for drug procurement needs revision. Specific eligibility criteria based on work experience and qualification may be fixed for RKS membership. Further research may focus on identifying the underlying individual and systemic factors behind such large PD-NPD differences.

Perspective and investments in health system strengthening of Gavi, the Vaccine Alliance: a content analysis of health system strengthening-specific funding

BACKGROUND

This paper aimed to compare the health systems strengthening (HSS) framework of Gavi and WHO and to analyze resource allocation in HSS by Gavi.

METHODS

Among 76 countries which received HSS funding from Gavi from 2006 to 2013, summary reports of 44 countries and approved proposals of 10 countries were collected. After comparing the HSS framework of WHO and Gavi, each activity described in documents was categorized according to Gavi's framework and funding allocation was analyzed.

RESULTS

Compared with WHO's HSS framework, Gavi's has a distinctive function within the building block 'Drugs, Equipment, Supplies, Facilities' and a distinctive function of 'providing incentive and bonuses' under the building block 'Human Resource/Performance Management'. Gavi has steadily invested 10% of their total budget on HSS, but 47% were allocated in these categories, whereas 78% were for activities arguably not covered by WHO's HSS framework. In Africa, 70% of Gavi's budget fell under 'Drugs, Equipment, Supplies, Facilities' and 92.8% were for activities arguably not deemed as HSS by WHO.

CONCLUSIONS

Gavi's HSS support emphasized inputs with short-term measurable outcomes. Harmonization of the concept of HSS and collaboration between Gavi and multilateral international agencies, such as World Bank and WHO, are needed.

From Millennium Development Goals to post-2015 sustainable development: sexual and reproductive health and rights in an evolving aid environment

Using research from country case studies, this paper offers insights into the range of institutional and structural changes in development assistance between 2005 and 2011, and their impact on the inclusion of a sexual and reproductive health and rights agenda in national planning environments. At a global level during this period, donors supported more integrative modalities of aid - sector wide approaches, poverty reduction strategy papers, direct budgetary support - with greater use of economic frameworks in decision-making. The Millennium Development Goals brought heightened attention to maternal mortality, but at the expense of a broader sexual and reproductive health and rights agenda. Advocacy at the national planning level was not well linked to programme implementation; health officials were disadvantaged in economic arguments, and lacked financial and budgetary controls to ensure a connection between advocacy and action. With increasing competency in higher level planning processes, health officials are now refocusing the post-2015 development goals. If sexual and reproductive health and rights is to claim engagement across all its multiple elements, advocates need to link them to the key themes of sustainable development: inequalities in gender, education, growth and population, but also to urbanisation, migration, women in employment and climate change.

The GAVI Alliance and the 'Gates approach' to health system strengthening

Lauded for getting specific health issues onto national and international agendas and for their potential to improve value for money and outcomes, public-private global health initiatives (GHIs) have come to dominate global health governance. Yet, they have also been criticised for their negative impact on country health systems. In response, disease-specific GHIs have, somewhat paradoxically, appropriated the aim of health system strengthening (HSS). This article critically analyses this development through an ethnographic case study of the GAVI Alliance, which funds vaccines in poor countries. Despite GAVI's self-proclaimed ‘single-minded’ focus on vaccines, HSS support is fronted as a key principle of GAVI's mission. Yet, its meaning remains unclear and contested understandings of the health systems agenda abound, reflecting competing public health ideologies and professional pressures within the global health field. Contrary to broader conceptualisations of HSS that emphasise social and political dimensions, GAVI's HSS support has become emblematic of the so-called ‘Gates approach’ to global health, focused on targeted technical solutions with clear, measurable outcomes. In spite of adopting rhetoric supportive of ‘holistic’ health systems, GHIs like GAVI have come to capture the global debate about HSS in favour of their disease-specific approach and ethos.

Can investments in health systems strategies lead to changes in immunization coverage?

National immunization programs in developing countries have made major strides to immunize the world's children, increasing full coverage to 83% of children. However, the World Health Organization estimates that 22 million children less than five years of age are left unvaccinated, and coverage levels have been plateauing for nearly a decade. This paper describes the evidence on factors contributing to low vaccination uptake, and describes the connection between these factors and the documented strategies and interventions that can lead to changes in immunization outcomes. The author suggests that investments in these areas may contribute more effectively to immunization coverage and also have positive spill-over benefits for health systems. The paper concludes that while some good quality evidence exists of what works and may contribute to immunization outcomes, the quality of evidence needs to improve and major gaps need to be addressed.

Performance-based financing with GAVI health system strengthening funding in rural Cambodia: a brief assessment of the impact

INTRODUCTION

Though Cambodia made impressive gains in immunization coverage between the years 2000 and 2005, it recognized several health system challenges to greater coverage of immunization and sustainability. The Global Alliance for Vaccines and Immunization (GAVI) opened a Health System Strengthening (HSS) funding window in 2006. To address the health system challenges, Cambodia has been receiving the GAVI HSS fund since October 2007. The major component of the support is performance-based financing (PBF) for maternal, neonatal and child health (MNCH) services.

OBJECTIVE

To examine the impact of the PBF scheme on MNCH services and administrative management in rural Cambodia.

METHODS

Quantitative and qualitative studies were conducted in Kroch Chhmar Operational District (OD), Cambodia. Quantitative analyses were conducted on the trends of the numbers of MNCH services. A brief analysis was conducted using qualitative data.

RESULTS

After the commencement of the PBF support, the volume of MNCH services was significantly boosted. In addition, strengthened financial and operational management was observed in the study area. However, the quality of the MNCH services was not ensured. Technical assistance, rather than the PBF scheme, was perceived by stakeholders to play a vital role in increasing the quality of the services.

DISCUSSION

To improve the quality of the health services provided, it is better to include indicators on the quality of care in the PBF scheme. Mutual co-operation between PBF models and technical assistance may ensure better service quality while boosting the quantity. A robust but feasible data validation mechanism should be in place, as a PBF could incentivize inaccurate reporting. The capacity for financial management should be strengthened in PBF recipient ODs. To address the broader aspects of MNCH, a balanced input of resources and strengthening of all six building blocks of a health system are necessary.

The emergence of global attention to health systems strengthening

After a period of proliferation of disease-specific initiatives, over the past decade and especially since 2005 many organizations involved in global health have come to direct attention and resources to the issue of health systems strengthening. We explore how and why such attention emerged. A qualitative methodology, process-tracing, was used to construct a case history and analyse the factors shaping and inhibiting global political attention for health systems strengthening. We find that the critical factors behind the recent burst of attention include fears among global health actors that health systems problems threaten the achievement of the health-related Millennium Development Goals, concern about the adverse effects of global health initiatives on national health systems, and the realization among global health initiatives that weak health systems present bottlenecks to the achievement of their organizational objectives. While a variety of actors now embrace health systems strengthening, they do not constitute a cohesive policy community. Moreover, the concept of health systems strengthening remains vague and there is a weak evidence base for informing policies and programmes for strengthening health systems. There are several reasons to question the sustainability of the agenda. Among these are the global financial crisis, the history of pendulum swings in global health and the instrumental embrace of the issue by some actors.

Analysis of a unique global public-private partnership to promote oral health

Partnerships for health promotion are between two or more partners to work co-operatively towards a set of shared health outcomes; few public-private partnerships in oral health promotion have been established.

AIM

To undertake a detailed analysis of a unique global public-private partnership to promote oral health between a global company, Unilever and the Féderation Dentaire International (FDI), a membership organisation representing more than one million dentists worldwide.

METHODS

Qualitative and quantitative, including: collating and analysing a wide range of partnership documents (n =164); reviewing film and pictorial records; undertaking structured interviews (n=34) with people who had a critical role in establishing and delivering the aims of the partnership, and external experts; and site visits to selected global projects active at the time of the evaluation.

RESULTS

Over 1 million people have been reached directly through their engagement with 39 projects in 36 countries; an oral health message about the benefits of twice daily tooth brushing has appeared with the authority of the FDI logo on billions of packs of Unilever Oral Care's toothpastes worldwide; many individual members of National Dental Associations have participated in health promotion activities within their communities for the first time; some organisational challenges during the development and delivery of the partnership were recognised by both partners.

CONCLUSIONS

The first phase of this unique global partnership has been successful in making major progress towards achieving its goals; lessons learned have ensured that the next phase of the partnership has significant potential to contribute to improving oral health globally.

Do existing research summaries on health systems match immunisation managers' needs in middle- and low-income countries? Analysis of GAVI health systems strengthening support

BACKGROUND

The GAVI Alliance was created in 2000 to increase access to vaccines. More recently, GAVI has supported evidence-based health systems strengthening to overcome barriers to vaccination. Our objectives were: to explore countries' priorities for health systems strengthening; to describe published research summaries for each priority area in relation to their number, quality and relevance; and to describe the use of national data from surveys in identifying barriers to immunisation.

METHODS

From 44 health systems strengthening proposals submitted to GAVI in 2007 and 2008, we analysed the topics identified, the coverage of these topics by existing systematic reviews and the use of nation-wide surveys with vaccination data to justify the needs identified in the proposals.

RESULTS

Thirty topics were identified and grouped into three thematic areas: health workforce (10 topics); organisation and management (14); and supply, distribution and maintenance (6). We found 51 potentially relevant systematic reviews, although for the topic that appeared most frequently in the proposals ('Health information systems') no review was identified. Thematic and geographic relevance were generally categorised as "high" in 33 (65%) and 25 (49%) reviews, respectively, but few reviews were categorised as "highly relevant for policy" (7 reviews, 14%). With regard to methodological quality, 14 reviews (27%) were categorised as "high".The number of topics that were addressed by at least one high quality systematic review was: seven of the 10 topics in the 'health workforce' thematic area; six of the 14 topics in the area of 'organisation and management'; and none of the topics in the thematic area of 'supply, distribution and maintenance'. Only twelve of the 39 countries with available national surveys referred to them in their proposals.

CONCLUSION

Relevant, high quality research summaries were found for few of the topics identified by managers. Few proposals used national surveys evidence to identify barriers to vaccination. Researchers generating or adapting evidence about health systems need to be more responsive to managers' needs. Use of available evidence from local or national surveys should be strongly encouraged.

The Health Systems Funding Platform: Is this where we thought we were going?

BACKGROUND

In March 2009, the Task Force for Innovative International Financing for Health Systems recommended "a health systems funding platform for the Global Fund, GAVI Alliance, the World Bank and others to coordinate, mobilize, streamline and channel the flow of existing and new international resources to support national health strategies." Momentum to establish the Health Systems Funding Platform was swift, with the World Bank convening a Technical Workshop on Health Systems Strengthening (HSS), and serial meetings organized to progress the agenda. Despite its potential significance, there has been little comment in peer-reviewed literature, though some disquiet in the international development community around the scope of the Platform and the capacity of the partners, which appears disproportionate to the available information.

METHODS

This case study uses documentary analysis, participant observation and 24 in-depth interviews to examine the processes of development and key issues raised by the Platform.

RESULTS

The findings show a fluid and volatile process, with debate over whether ongoing engagement in HSS by Global Fund and GAVI represents a dilution of organizational focus, risking ongoing support, or a paradigm shift that facilitates the achievement of targeted objectives, builds systems capacity, and will attract additional resources. Uncertainty in the development of the Platform reflects the flexibility of the recently formed global health initiatives, and the instability of donor commitments, particularly in the current financial climate. But implicit in the conflict is tension between key global stakeholders over defining and ownership of the health systems agenda.

CONCLUSIONS

The tensions appear to have been resolved through a focus on national planning, applying International Health Partnership principles, though the global financial crisis and key personnel changes may yet alter outcomes. Despite its dynamic evolution, the Platform may offer an incremental path towards increasing integration around health systems, that has not been previously possible.

Drivers of inequality in Millennium Development Goal progress: a statistical analysis

BACKGROUND

Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs), which may limit the ability of households to address child mortality and increase risks of infectious diseases.

METHODS AND FINDINGS

We calculated each country's distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15-49 y), and NCD burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries' initial disease burdens, we analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in child mortality progress (R(2)-infant mortality = 0.57, R(2)-under 5 mortality = 0.54). HIV/AIDS and NCD burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R(2) = 0.57), with NCDs having an effect independent of HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries.

CONCLUSIONS

Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between NCDs, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households--whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis).

The response to flexibility: country intervention choices in the first four rounds of the GAVI Health Systems Strengthening applications

Since December 2005 the GAVI Alliance (GAVI) Health Systems Strengthening (HSS) window has offered predictable funding to developing countries, based on a combined population and economic formula. This is intended to assist them to address system constraints to improved immunization coverage and health care delivery, needed to meet the Millennium Development Goals. The application process invites countries to prioritize specific system constraints not adequately addressed by other donors, and allows them to allocate their eligible funds accordingly. This article presents an analysis of the first four rounds of countries' funding applications. These requested funding for a variety of health system initiatives that reflected country-specific requirements, and were not limited to improving immunization coverage. Analyses identified a dominance of operational-level health service provision activities, and an absence of interventions related to demand and financing. While the proposed activities are only now being implemented, the results of this study provide evidence that the open application process employed by the HSS window has led to a shift in analysis and planning-from the programmatic to the systemic-in the countries whose applications have been approved. However, the proposed responses to identified constraints are dominated by short-term operational responses, rather than more complex, longer term approaches to health system strengthening.

An approach to health system strengthening in the Union of Myanmar

OBJECTIVES

In 2007 and 2008, Myanmar developed a health system strengthening (HSS) strategy and proposal through funding support from the Global Alliance for Vaccines and Immunization (GAVI). The aim of this paper is to identify critical success factors in the development of the HSS strategy in Myanmar.

METHODS

The main source of information for this review includes international and national literature, and participant observation by the authors in the health systems analysis and HSS strategy development in Myanmar between 2007 and 2009.

RESULTS

Critical success factors in the development of the HSS strategy included evidence-based development of the strategy through a sector analysis, and a long-term approach to strategy development with wide stakeholder participation. This contributed to important strategy breakthroughs in the areas of health planning, health financing, human resource management and civil society partnerships.

CONCLUSION

Implementation of the HSS strategy in Myanmar should position the MOH and partners well to implement challenging system reforms in the areas of health planning, financing and human resource management in the coming years, as well as support more coordinated efforts for relief and recovery effort following the Nargis natural disaster in 2008. These innovations in Myanmar, with evidence of similar breakthroughs in other countries of the Asian region including North Korea, Cambodia, Nepal and Sri Lanka, provides promising evidence of the potential of the HSS approach as an emerging health development paradigm, particularly in relation to responding to the issue of "within country" inequities in access to health care.

Linking programmes and systems: lessons from the GAVI Health Systems Strengthening window

OBJECTIVES

To analyse the first four rounds of country applications to the GAVI Alliance Health Systems Strengthening (GAVI-HSS) funding window; to provide valuable insight into how countries prioritize, articulate and propose solutions for health system constraints through the GAVI-HSS application process and to examine the extent to which this process embodies alignment and harmonization, Principles of the Paris Declaration.

METHODS

The study applied multiple criteria to analyse 48 funding applications from 40 countries, submitted in the first four rounds, focusing on the country analysis of health systems constraints, coordination mechanisms, alignment with national and sector planning processes, inclusiveness of the planning processes and stakeholder engagement.

RESULTS

The applications showed diversity in the health systems constraints identified and the activities proposed. Requirements of GAVI for sector oversight and coordination, and the management of the application process through the Ministry of Health's Planning Department, resulted in strong alignment with government policy and planning processes and good levels of stakeholder inclusion and local technical support (TS).

CONCLUSION

Health Systems Strengthening initiatives for global health partnerships (GHPs) can provide a link between the programmatic and the systemic, influencing policy alignment and harmonization of processes. The applications strengthened in-country coordination and planning, with countries using existing health sector assessments to identify system constraints, and to propose. Analyses also produced evidence of broad stakeholder inclusiveness, a good degree of proposal alignment with national health plans and policy documents, and engagement of a largely domestic TS network. While the effectiveness of the proposed interventions cannot be determined from this data, the findings provide support for the GAVI-HSS initiative as implementation continues and evaluation begins.

Country-level governance of global health initiatives: an evaluation of immunization coordination mechanisms in five countries of Asia

BACKGROUND

In recent years there have been innovations in immunization financing and new technologies, and the scaling up of investment by the Global Alliance for Vaccines and Immunization (GAVI) in the Asia region. The main mechanism for coordination of this global health initiative (GHI) investment is country-level 'Inter-Agency Coordination Committees' (ICCs).

AIM

The aim of the evaluation was to determine the utility and future perspectives of stakeholders regarding the role of ICCs in improving immunization services in the Asian Region.

METHODS

A literature review, documentary analysis and semi-structured interviews (n = 65) were undertaken in five countries (India, Bangladesh, Nepal, Sri Lanka and Indonesia), with senior level members of Ministries of Health and the GAVI partnership.

RESULTS

The evaluation has identified that there have been significant changes recently in the strategic environment for immunization, including developments in new vaccines, increasing GAVI investment, trends towards health system integration and decentralization, and institutional development of the non-government sector. This evaluation found that ICCs are functioning well in relation to information sharing and GAVI application processes. However, they are performing less well in the areas of evaluation, strategic gap analysis and coordination of immunization technical co-operation.

CONCLUSIONS

There are high levels of institutional and contextual complexity at country level that require a more focused global response by GAVI to the governance challenges of institutions and partners implementing GHIs at the country level. ICCs should be maintained and strengthened in the more pluralistic context of an 'immunization coordination system' that is represented by the wider health sector, regulatory authorities, and civil society and private sector interests. Managing through systems, rather than being over-reliant on committees, will broaden participation in implementation and, in doing so, expand the reach of immunization and maternal and child health care services in developing countries.

An assessment of interactions between global health initiatives and country health systems

Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity, value for money, and outcomes in global public health, then these opportunities should not be missed.