Health system strengthening support

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Over 50 countries are using GAVI's health system strengthening support to strengthen their health services at the district level and below

HSS Nepal UNICEF Anita Khemka

By the end of 2010, GAVI had committed US$ 568 million to health system strengthening support (HSS) for 53 countries.

Most countries are applying the funds to peripheral health service delivery, with 75% of the first 49 proposals received targeting district level and below.

GAVI's second evaluation emphasises the high level of country ownership in GAVI's HSS support, with a range of countries making significant headway in advancing both immunisation coverage and maternal and child health services:

HSS evaluation

In November 2009, GAVI published an evaluation of its health system strengthening (HSS) support, covering the experiences of 21 countries.


In Afghanistan, GAVI support to HSS has been used to boost access to immunisation and other health services through in-service training programmes for health workers, establishment of health centres and public information campaigns.

Between 2007 and 2009, Afghanistan reported a six percent increase in its national DTP3 coverage (three doses of the diphtheria, tetanus and pertussis vaccine) while the child mortality rate fell from 191 to 161 deaths per 1,000 live births. In the same period, the number of births assisted by a skilled birth attendant rose by 13%.


GAVI HSS support to Cambodia has focused on improving child and maternal health in 10 districts with low immunisation coverage and a lack of civil society organisations. In December 2005, when HSS support began, only one of the 10 districts had a DTP3 coverage above 80%. Three years later, this number had increased to nine.

GAVI funds training for health volunteers in Vietnam

10 years after her only training session, Nguyen Thi Xuan is set to attend a residential course funded by GAVI’s HSS support and designed to upgrade village health worker skills.


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HSS Vietnam health workers


With GAVI HSS funds, Vietnam aims to improve the health status of children through improve basic health services, including immunisation, in the country's 10 most disadvantaged provinces.

Activities have included materials and training courses for health workers, training of managers at provincial and district level and development of an immunisation module for the health management information system. After three years of HSS funding, DTP3 coverage in the 10 provinces had increased by 12.8% to reach 97.9% in 2009.

In Sierra Leone, the capacity of district level supervision of health care facilities is being rebuilt and in Nepal, training and certification of auxiliary midwives and volunteer health workers is extending community based integrated child health services from 85% to 100% of districts.

Supporting the introduction of life-saving vaccines is not enough if the vaccines cannot reach the children who need them

Countries in Africa account for 24% of the global disease burden but have only 3% of the world's health workers 

WHO world health report 2006: working together for health

From poorly trained health workers and under-equipped hospitals to a lack of data to track progress and no fridges to store vaccines, weak health systems represent a critical barrier to GAVI's mission to increase access to immunisation. 

Building blocks for strong health system

WHO identifies six building blocks that should form the foundations of a strong health system:

  • Health service delivery: a network of health facilities to provide access to primary and secondary care;
  • Health workers: in the right place, at the right time with training, experience and incentives;
  • Logistics and supply systems: including adequate cold chain in place to deliver vaccines;
  • Health financing: to raise sufficient funds for health and improve financial risk protection;
  • Health information and monitoring: to generate quality data and to measure what is being done and achieved;
  • Leadership and governance: to ensure that a strategic policy framework exists and there is proper accountability and oversight.

Barriers to immunisation

In 2004, a report by the Norwegian agency for development cooperation (Norad) identified several examples of how poor health systems undermine the performance of immunisation programmes in developing countries:

- unavailability of staff, transport and funds for immunisation activities at district level;

- few and under-trained health workers at district and service delivery level;

- failure to track available data on district immunisation coverage and vaccine stock levels;

- low staff morale, lack of career prospects and the international migration of health professionals;

- in post-conflict situations, immunisation is hit by the lack of health infrastructure and a shortage of skilled human resources.

Clear gap

While the quality of these six building blocks varies from country to country, there is a clear gap between low- and high-income countries. African countries account for 24% of the global disease burden but have only three percent of the world's health workers.

Health systems in developing countries suffer from chronic under-resourcing. The Task force on Innovative International Financing for Health Systems estimated health systems costs would account for between 62% and 74% of addressing basic health needs in low income countries.

Human resources and infrastructure needs comprised the vast majority of the identified required investment. Without the people and equipment to deliver vaccines, no immunisation programme will be sustainable over the long term.

With the help of HSS support, countries can tackle weaknesses they have identified in their health systems which impede immunisation

Recognising that immunisation coverage is often constrained by health systems issues, GAVI took the first steps to widen its funding support to health system strengthening (HSS) in early 2005.

Part of GAVI's strategy

The second of GAVI's four strategic goals for 2011-2015 captures health service as a key principle of GAVI's mission. The health systems goal targets strengthening the capacity of integrated health systems to deliver immunisation.

Although most of GAVI’s support to countries is for the purchase of vaccines, 15-25% of funding support is to be directed to achieving this strategic goal.

As well as HSS support, GAVI provides two other types of support targeting delivery systems:

- immunisation services support (ISS);

- civil society organisation support (CSO).

Countries are encouraged to use GAVI HSS funding to target 'bottlenecks' or barriers in the health system that stand in the way of increased access to immunisation and other child and maternal health services.

Country ownership

In line with GAVI's principle of country ownership, countries can design programmes to address what they see as their real needs.

Commitments vary from one to five years in duration - 3.6 years on average - and are provided for the duration of the national health plan. Funding levels are determined by the size of the country's population and the national income per capita.

Although not exclusive, GAVI identified three themes to guide applicant countries:

  1. health workforce mobilisation, distribution and motivation at district level and below;
  2. drugs, equipment and infrastructure supply, distribution and maintenance;
  3. organisation, monitoring and management of health services at district levels and below.

GAVI also established some principles based on good practice for effective aid (see next tab).

The Platform and GAVI

In 2011, the Board decided to channel all GAVI’s cash support via a single funding window, to be delivered through the Health Systems Funding Platform. Support will be performance-based, feed directly into national strategies, and be linked to improvements in immunisation coverage and equity of access.

In the first year, countries will receive a fixed amount of funding from GAVI to invest in their national health systems. In subsequent years, they will receive both fixed and performance-related annual payments, provided they meet set targets for immunisation coverage and equity.

This approach will be gradually rolled out to countries as their existing GAVI cash support lapses. GAVI will tailor the support to country circumstances, and develop alternative funding mechanisms to support countries
that are fragile, underperforming or very large.

GAVI’s health system strengthening is based on the principles of the International Health Partnership (IHP+) in line with the Paris Declaration on Aid Effectiveness 


GAVI Alliance health system strengthening (HSS) support is intended to address weaknesses identified by implementing countries. They are encouraged to use recent immunisation programme and health sector analyses, National Health Sector Plans and similar inputs to identify weaknesses and gaps in current funding.


HSS should be consistent with the existing objectives, strategies and planning cycles of government health sector policy, aligned with government management systems and financial procedures, and reflected in national budgets wherever possible.


HSS should add value to (not compete with) current or planned efforts to strengthen the health systems by national governments, civil society and health sector partners.


HSS support is, in principle, available for the life of National Health Sector Plans (or equivalent).


HSS funds must be additional to the government's existing budget and not displace previously allocated health sector resources.

Inclusive and collaborative

All key stakeholders (beyond immunisation) should be involved in HSS. Government entities, partners, civil society, and the private sector should all be informed and involved, as appropriate, in the planning, implementation and evaluation stages.


HSS should not result in the creation of stand-alone, independently managed projects. Ideally, it should be an agent for catalytic change where possible - for example, testing pilot projects that could subsequently be scaled up by government.


GAVI encourages health service innovation. HSS can be used to test new strategies or approaches or to adapt learning and best practice from elsewhere.


Implementing countries must link strategies for tackling barriers to specific indicators that show how the use of HSS funds will improve immunisation and other forms of child and maternal health care. The results should be evident at local level. Progress towards agreed goals will be monitored by GAVI Alliance partners including WHO, UNICEF, the World Bank and the Health Metrics Network (HMN).


Implementing countries must take into consideration how the recurring financial and technical requirements of health service improvement of HSS support can be sustained beyond the period of GAVI support.

In addition to these principles, the HSS initiative is intended to:

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