GAVI saves children, but exact numbers are disputed because of data quality issues
The evaluation performed by independent consultants concludes that during Phase 1(2000-2005), GAVI significantly increased access to immunization, and expanded use of new vaccines through its support to immunization programs in recipient countries. In GAVI countries, in aggregate the DTP3 coverage rate increased from 64% to 71%, HepB3 coverage rate increased from 16% to 46%, and Hib3 coverage rate increased from 1% to 7%. Based on data from WHO/Unicef estimates of coverage rates and projections, the consultants conclude that the additional children immunized resulted in preventing 1.48 million future deaths from HepB (which leads to chronic liver disease), 141,000 future deaths from whooping cough (pertussis), and 112,000 premature deaths from Hib (serious bacterial lung and meningitis infections) among the cohort of children born in 2001-2005.
Nonetheless, despite good performance the report concludes that there is room for improvement in the design of GAVI's performance based funding scheme and to provide better support to underperforming countries. Also, in-country mechanisms to monitor funds were not effective and improvement was recommended. The new Transparency and Accountability Policy indicates that GAVI is moving forward in reducing fiduciary risks in Phase 2.
The report also highlights GAVI's ability in the first five years to build an effective partnership, foster innovative approaches and place immunization high on the public agenda.
The report does not only display success stories. GAVI's impact on influencing vaccine pricing and supply has been more mixed. GAVI had limited success in influencing vaccine pricing, and had no clear strategy in the start-up phase for influencing vaccine markets in order to obtain more favourable pricing while maintaining vaccine security. Given GAVI's choice based on country preferences for vaccine presentations that were easier to administer (combination vaccines) but for which there was only one supplier, its assumption that market forces would bring down vaccine prices in five years was unrealistic, the consultants claim. It is only now that prices are starting to drop as more suppliers have entered the market. High costs for the newer vaccines raise concerns around sustainability and will be a key issue as GAVI moves forward.
At the same time as this report is being presented other independent researchers from the Institute for Health Metrics and Evaluation (IHME) are raising concerns about the quality of data that is used to measure immunisation coverage rates. In an article in The Lancet last week, researchers claim that the data which is reported from countries to WHO/UNICEF and GAVI is too high. Based on statistical modelling the authors claim that the global vaccination initiatives have immunised only half as many children as officially reported and that several GAVI supported countries have over-reported immunized children and coverage rates.
The discussion at the Norad seminar suggested that there may be several reasons for the discrepancy between administrative reports and household surveys, including the use of different denominators, possible over-reporting in administrative data and possible under- reporting in household surveys that for a large part are based on maternal recall. Participants suggested that more attention to and investments in national health information systems as well as the use of independent data validation mechanisms would be part of the solution and focus for the future.
More will follow in the coming months as more studies get available and countries and international partners further examine issues both related to data quality and to performance-based approaches. The focus on data and performance is welcome.