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BMC Public Health
Published in: BMC Public Health 1/2015

Open Access 01-12-2015 | Research article

Charting the evolution of approaches employed by the Global Alliance for Vaccines and Immunizations (GAVI) to address inequities in access to immunization: a systematic qualitative review of GAVI policies, strategies and resource allocation mechanisms through an equity lens (1999–2014)

Author: Gian Gandhi

Published in: BMC Public Health | Issue 1/2015

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Abstract

Background

GAVI’s focus on reducing inequities in access to vaccines, immunization, and GAVI funds, − both between and within countries - has changed over time. This paper charts that evolution.

Methods

A systematic qualitative review was conducted by searching PubMed, Google Scholar and direct review of available GAVI Board papers, policies, and program guidelines. Documents were included if they described or evaluated GAVI policies, strategies, or programs and discussed equity of access to vaccines, utilization of immunization services, or GAVI funds in countries currently or previously eligible for GAVI support. Findings were grouped thematically, categorized into time periods covering GAVI’s phases of operations, and assessed depending on whether the approaches mediated equity of opportunity or equity of outcomes between or within countries.

Results

Serches yielded 2816 documents for assessment. After pre-screening and removal of duplicates, 552 documents underwent detailed evaluation and pertinent information was extracted from 188 unique documents. As a global funding mechanism, GAVI responded rationally to a semi-fixed funding constraint by focusing on between-country equity in allocation of resources. GAVI’s predominant focus and documented successes have been in addressing between-country inequities in access to vaccines comparing lower income (GAVI-eligible) countries with higher income (ineligible) countries. GAVI has had mixed results at addressing between-country inequities in utilization of immunization services, and has only more recently put greater emphasis and resources towards addressing within-country inequities in utilization to immunization services. Over time, GAVI has progressively added vaccines to its portfolio. This expansion should have addressed inter-country, inter-regional, inter-generational and gender inequities in disease burden, however, evidence is scant with respect to final outcomes.

Conclusion

In its next phase of operations, the Alliance can continue to demonstrate its strength as a highly effective multi-partner enterprise, capable of learning and innovating in a world that has changed much since its inception. By building on its successes, developing more coherent and consistent approaches to address inequities between and within countries and by monitoring progress and outcomes, GAVI is well-positioned to bring the benefits of vaccination to previously unreached and underserved communities towards provision of universal health coverage.
Appendix
Available only for authorised users
Footnotes
1
The term “GAVI countries” is generally employed to denote both GAVI eligible countries as well as countries in the process of graduating from GAVI support. The specific definitions of eligible and graduating countries are delineated in GAVI’s eligibility policy [135] and graduation procedures [236].
 
2
In the GAVI Alliance Evaluation Workplan 2015 report to GAVI’s Evaluation Advisory Committee, the GAVI Secretariat notes that it is currently conducting, or planning to commence End-of-Support Evaluations in at least two graduated countries, Albania and Bosnia & Herzegovina. The report mentions an Advance Market Commitment (AMC) Impact Evaluation and Health Systems Strengthening Grant Evaluations, both due to commence in 2015 [26].
 
3
One paper on this topic does exist although the discourse is at a very high level and since it was published in 2009, it does not comment on the evaluated impacts of Phase II and progress during Phase III [237]. Another piece of work was commissioned by the GAVI Secretariat for internal purposes, to provide a stock-take of how the GAVI Alliance defines, measures and seeks to address equity in Phase III. This working paper is not in the public domain and does not assess GAVI’s approach to addressing inequities has changed over time through its programs and policies, nor does it set out GAVI’s equity impacts on opportunity versus outcomes. [Vaccine Implementation Technical Assistance Consortium (VITAC), “The GAVI Alliance and equity: immunisation for all,” PATH, Geneva, 2013 Unpublished].
 
4
Separate to this qualitative assessment of literature, analyses of longitudinal immunization program performance data have been undertaken to assess more objectively, the possible impact of GAVI’s approaches on observed between- and within- country inequities in immunization. These analyses are described in a separate forthcoming paper.
 
5
In this review, the terms inequity and disparity are used interchangeably. These terms are defined here as differences that are unnecessary, avoidable, unfair and unjust across any dimension (e.g. wealth, ethnicity, geography, gender) [238, 239]. The term inequality, while related to inequity, is used in this paper specifically with reference to gender since unlike socioeconomic, ethnographic or other need-based differences, no amount of difference according to gender is necessary, fair or just.
 
6
It is acknowledged that in some large and often federated states, the roll out of new vaccines is phased over two or more years such that a NIP schedule in one region of a country may—for a time—be different than in another part of the country. It is also acknowledged that in a handful of countries that are characterized by markedly heterogeneous and biodiverse environments, risks of certain VPDs may be much more concentrated in some regions than others, and as such, vaccination schedules may differ slightly from one part of the country to another. However, these are exceptions rather than the rule, and as such are not explicitly considered in this review.
 
7
GAVI Committee papers usually cover the same topics as are eventually reviewed by the GAVI Board only in more detail, or in a less complete state. As such, Committee papers were only included where they provided important additional information (relevant to the assessment) than could be found in a Board paper.
 
8
Following GAVI’s formation, three goals were specified: (1) Increase coverage – boost the number of children whose lives can be saved with the remarkably effective tool of vaccination. (2) Shorten the time span between registration of a vaccine product in the marketplace and its full-scale use in the developing world. (3) Accelerate the development and introduction of new vaccines [42].
 
9
Phase I ran from 2000–2005 [17], while the Phase II strategy covered the period 2007–2010 [58]. The year 2006 was a transition year of sorts, in which the new Phase II strategy was developed.
 
10
Two operating principles in GAVI’s Phase III strategy that describe GAVI’s principles vis-à-vis addressing inequities: “Focusing on innovation, efficiency, equity, performance and results”; and “Ensuring gender equity in all areas of engagement” [61, 144].
 
11
GAVI’s target in Phase III with respect to equity improvement is as follows: To improve equity in immunisation coverage from baseline levels as measured by the performance indicator—the percentage of GAVI countries where the DTP3 coverage in the lowest wealth quintile is ±20 percentage points of the coverage in highest wealth quintile [240].
 
12
The strategic objective in GAVI’s Phase III strategy that articulates GAVI’s aims with respect to equity is as follows: “Increase equity in access to services” [61, 144].
 
13
In Phase III, GAVI renamed the Workplan as ‘the Business Plan’ – The name change signified a more rigorous approach that attempted to link back TA activities through a coherent logical framework to the overarching strategy.
 
14
Four of the countries identified as having large disparities in immunization coverage overlapped with countries characterized by low coverage (i.e. DTP3 < 70 % nationally). In these countries, WHO and UNICEF have co-led TA efforts to simultaneously improve both overall national coverage rates and geographic inequities in subnational coverage.
 
15
In order to evaluate vaccine portfolios, the VIS IRC used the following seven priorities: i). Prioritise potential integration with EPI schedule (<12 months); ii). Prioritise potential integration with an extended EPI schedule (<18 months); iii). Focus on highly effective vaccines (>75 % effectiveness in GAVI countries); iv). Focus on diseases for which no adequate treatment is currently available; v). Focus on diseases for which no adequate prevention is currently available; vi). Prioritise vaccines that address inequity of the poor (relating to diseases disproportionally affecting the poor, or to vaccines specifically beneficial to the poor); vii). Prioritise vaccines that address gender inequity (relating to diseases disproportionally affecting one sex, or to vaccines specifically beneficial to one sex).
 
16
While GAVI-funded MenA vaccine campaigns commenced in a handful of countries at the end of phase II (along with support for the MenA vaccine stockpile) following the approval of a MenA vaccine investment case [86, 87], the majority of these vaccines were planned for roll out in phase III as and when appropriate conjugated vaccines became available.
 
17
While it is not well-known, at the time of GAVI’s first three Board meetings, the list of eligible countries was initially proposed (in the Board materials) as being defined based on those countries with an annual GNP/per capita equal to or less than US $1,000 and a total national population of less than 150 million people [49, 107]. This ruled out three large countries: China, India and Indonesia. However, the strict population criterion was removed, and replaced with a different approach to large countries as discussed in the section entitled 'Large countries and budget cap policies' of this paper.
 
18
In 1999, at the time of the first Board meeting, there were initially 71 eligible countries [68 countries with per capita GNP ≤ US $1,000 and a population less than 150 million, three countries with uncertain per capita GNP but anticipated to be below or close to $1,000 (Cuba, Democratic Peoples’ Republic of Korea, and Ukraine)]. In addition, there were three further more countries with per capita GNP ≤ US $1,000 and a population above 150 million (China, India and Indonesia) whom, as noted in the footnote above and in the section of this paper entitled 'Large countries and budget cap policies' would be considered partially eligible through the remainder of phase I [116]. In 2002, following the country’s formation (and recognition by the United Nations), Timor-Leste was added to the list of eligible countries taking the total number of GAVI countries to 75 through the remainder of Phase I.
 
19
In 2003, the World Bank adopted the 1993 System of National Accounts (SNA) and as such changed its terminology from GNP per capita to Gross National Income (GNI) per capita. This alteration however, did not have an impact on the country statistics themselves or the ranking that informed GAVI’s country eligibility [241].
 
20
An update of the eligibility criteria reference data was considered midway through Phase I, but it was decided to hold the eligibility policy constant to ensure predictability [242, 243].
 
21
At the time, this funding was referred to as the New and Under-used Vaccines sub-account from the Global Fund for Children’s Vaccines (The Fund).
 
22
At the time, this funding was referred to as the Immunization Services sub-account of The Fund.
 
23
At the time of the update, 26 GAVI-eligible countries, representing 55 % of GAVI’s birth cohort, were above the US $1,000 GNI per capita threshold according to the latest GNI data (published by the World Bank for the financial year 2008). In addition, there were 23 countries not eligible for GAVI support whose incomes were below that of the wealthiest eligible GAVI country [145].
 
24
It is recognized that the terms “poor countries” and “poor people” are pejorative and no longer commonly used. However, they are used here only because it the parlance used in GAVI policy documents, Committee and Board papers during the time.
 
25
In June 2010, following slow progress to develop and implement a mechanism to improve coverage in countries with low coverage, the GAVI Board decided to temporarily suspend the November 2009 decision of the Board to raise the DTP3 filter to 70 % thereby re-establishing the filter threshold at 50 % for 2010 round of new vaccine support applications – and until GAVI’s new performance-based funding had been designed and launched.
 
26
The GOI also selected high-performing districts as it was felt these would be better placed to monitor and manage AEFIs and vaccine wastage.
 
27
The HSS evaluation provides the following additional information: “The approach to equity is mixed. In some countries certain districts or provinces have been targeted based on a range of criteria, including current immunisation performance, availability of infrastructure/transport/human resources as well as socio-economic indicators: Vietnam, Bhutan, Burundi, DRC, Honduras (focused on 104 municipalities), Nicaragua (which focused on specific municipalities), Zambia (12 districts), Yemen (64 districts), Cambodia (10 ODs), Nepal (varies by component), Sri Lanka and Ghana all fall into such category. However, there is often little focus on ensuring that those most in need within those geographical areas are targeted. This is an important distinction in countries where, for instance, socio-economic status plays a higher role in accessing health care than geographical location. In other countries a national approach is adopted in some cases more because all areas are seen as equally poor (Liberia, Sierra Leone) or others where it was seen as the best way to move forward (as in Rwanda, where new districts might not have had at the time of design sufficient planning experience to enable a more differentiated district approach)” [22].
 
28
The ten countries are Afghanistan, Bolivia, Democratic Republic of Congo, Ethiopia, Indonesia, Mozambique, Pakistan, Ghana, Burundi, and Georgia (although Bolivia, Georgia and Mozambique had not received CSO funding support by the time of the independent evaluation.
 
29
Specifically, in June 2001 the GAVI Board adopted the following definition of financial sustainability: “Although self-sufficiency is the ultimate goal, in the nearer term sustainable financing is the ability of a country to mobilize and efficiently use domestic and supplementary external resources on a reliable basis to achieve current and future target levels of immunization performance in terms of access, utilization, quality, safety and equity”. (Emphasis added) [146].
 
30
GAVI’s original co-financing policy country groupings used the following criteria: GNI per capita (i.e. countries with a GNI p.c. ≤ US $1,000 versus countries with a GNI p.c. >US $1,000), UN development status (i.e. least developed countries (LDCs) versus non-LDCs), and fragility (i.e. defined by the World Bank as a ‘Fragile State’) [203].
 
31
It is recognized that the term “fragile states” is considered pejorative and no longer commonly used. It is used here only because it reflected the parlance used in GAVI policy and strategy documents and Board papers, particularly during Phase II.
 
32
The Bank uses two criteria to classify countries as LICUS: (i) low-income; and (ii) poor performance on Country Policy and Institutional Assessment (CPIA). Lists of the countries classified by the World Bank as LICUS for the financial years 2006–2009 can be found online [244].
 
33
Other objectives of GAVI’s pilot prioritization mechanism are as follows: Maximize overall health impact (i.e. reduction of disease burden); Maximize value for money (i.e. cost-effectiveness); Reinforce the financial sustainability of immunization programs; Focus GAVI’s support on countries with the greatest need/least ability to pay; Ensure country readiness for use of GAVI-supported vaccines [226].
 
34
Roughly one third of GAVI countries had DTP3 coverage below 50 %, and roughly one sixth of GAVI countries had coverage below 40 % in 1999.
 
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Metadata
Title
Charting the evolution of approaches employed by the Global Alliance for Vaccines and Immunizations (GAVI) to address inequities in access to immunization: a systematic qualitative review of GAVI policies, strategies and resource allocation mechanisms through an equity lens (1999–2014)
Author
Gian Gandhi
Publication date
01-12-2015
Publisher
BioMed Central
Published in
BMC Public Health / Issue 1/2015
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-015-2521-8

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