Study Details

GAVI Health Systems Strengthening Support Evaluation: Key Findings and Recommendations


Martinez J  England R  Carlson C.  Lewis D.  Lucas H.  Maw H.  Pearson M.  Ortendahl O. 


October 2009



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GAVI, health systems strengthening

Study Type

External evaluation


To emphasise experience with GAVI Health System Strengthening (HSS) implementation to date in order to learn how the GAVI HSS business model has worked when applied to a variety of countries and national health systems.


In-depth case studies in 11 countries (six countries studied as part of the GAVI HSS Tracking Study DRC Ethiopia, Kyrgyzstan, Nepal, Vietnam and Zambia, plus five further countries Burundi, Cambodia, Liberia, Pakistan and Rwanda). For each country a document review was undertaken, and stakeholder interviews were held at national and sub-national levels.


GAVI HSS has been implemented for too short a time to allow detection of changes in outcomes/impacts. It will, however, be possible to link GAVI HSS-funded interventions to outputs that can serve as plausible proxies for outcomes although this will require significant revision of HSS monitoring and annual review process. Countries are using their GAVI HSS grants primarily for downstream activities (immunisation and Maternal and Child Health services delivery) rather than upstream sector wide change or reform. Predominantly, country programmes cover training, strengthening management and supervision, and procuring supplies and equipment. Very few countries have used GAVI HSS funds for enacting fundamental change in health systems. Whilst generating high demand from countries because it is country-driven, is delivered through a relatively straight forward and non-competitive application process, and is predictable GAVI HSS funding has weaknesses in three areas:

  • Insufficient technical support provided to HSS grants. GAVI HSS partnership model (where tasks are distributed amongst its technical partners (WHO, WB, UNICEF) is not resulting in high quality technical support. Support concentrates on proposal design and pre-review but is weak for start up and implementation. Support is also weak for ensuring that monitoring mechanisms are in place to produce adequate information for country program management and external assessment. Neither financial nor programmatic risks are being controlled adequately through the partnership model.
  • Proposal assessment. Currently, the GAVI Independent Review Committee (IRC) it is not identifying resulting problems adequately
  • Performance review process. Weak annual review and reporting are hindering results-oriented ambitions of the GAVI HSS model. The IRCs are not able to interrogate countries on their Annual Progress Reviews; are not able to validate the data these reports contain; and are not contributing to improving the monitoring and reporting capacity.

Conclusions /

GAVI cannot rely on other institutions to control its HSS-related risk. The GAVI Secretariat must play a more proactive role in this regard through, for example, greater engagement with countries through all stages of the HSS process. As a matter of urgency, increased in-house capacity for GAVI Secretariat to assess individual country support needs is required.

The IRC process requires redesign. As it is, it is too distant and removed from countries to provide a realistic evaluation of proposals, and is not able to provide sufficient useful support to improve program design. Deploying IRC at country level would be too expensive so GAVI might want to contract out this function to an intermediary.

It is also recommended that the performance review function of IRC be contracted out to an intermediary, comprised of HSS experts able to operate in-country and provide country-specific support.

GAVI HSS should also ensure that its rounds-based approach for assessing new proposals does not conflict with country budget cycles.

It should also require countries to adopt indicators that measure HSS outputs and not just immunisation and health outcomes/impact. Indicators should not be generic to all programmes but, rather, be programme-specific and realistically within country capacity to monitor.

GAVI should consider replacing the HSS Task Team with a small advisory team chaired by GAVI.

Whilst not surprising that countries are diverting GAVI HSS funds to downstream activities rather than upstream reform, HSS funding will not go very far in expanding interventions on the scale needed to make big impacts on worker motivation, management competency and predictable funding significant upstream changes are required for this.

Sponsored by DFID, Danida, Irish Aid