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Becker S.,Family and Reproductive Health | Hansen P.M.,GAVI Alliance | Kumar D.,Indian Institute of Health Management Research | Kumar B.,Indian Institute of Health Management Research | Niayesh H.,Ministry of Public Health
Bulletin of the World Health Organization | Year: 2010

Objective: To examine historical estimates of infant and under-five mortality in Afghanistan, provide estimates for rural areas from current population-based data, and discuss the methodological challenges that undermine data quality and hinder retrospective estimations of mortality. Methods: Indirect methods of estimation were used to calculate infant and under-five mortality from a household survey conducted in 2006. Sex-specific differences in underreporting of births and deaths were examined and sensitivity analyses were conducted to assess the effect of underreporting on infant and under-five mortality. Findings: For 2004, rural unadjusted infant and under-five mortality rates were estimated to be 129 and 191 deaths per 1000 live births, respectively, with some evidence indicating underreporting of female deaths. If adjustment for underreporting is made (i.e. by assuming 50% of the unreported girls are dead), mortality estimates go up to 140 and 209, respectively. Conclusion: Commonly used estimates of infant and under-five mortality in Afghanistan are outdated; they do not reflect changes that have occurred in the past 15 years or recent intensive investments in health services development, such as the implementation of the Basic Package of Health Services. The sociocultural aspects of mortality and their effect on the reporting of births and deaths in Afghanistan need to be investigated further.


Lind A.,University of Washington | Bonhoure P.,European Commission | Mustafa L.,Ministry of Public Health | Hansen P.,GAVI Alliance
International Journal for Quality in Health Care | Year: 2011

Objective: To determine the quality of outpatient hospital care for children under 5 years in Afghanistan. Design: Case management observations were conducted on 10-12 children under five selected by systematic random sampling in 31 outpatient hospital clinics across the country, followed by interviews with caretakers and providers. Main Outcome Measures: Quality of care defined as adherence to the clinical standards described in the Integrated Management of Childhood Illness. Results: Overall quality of outpatient care for children was suboptimal based on patient examination and caretaker counseling (median score: 27.5 on a 100 point scale). Children receiving care from female providers had better care than those seen by male providers (OR: 6.6, 95% CI: 2.0-21.9, P = 0.002), and doctors provided better quality of care than other providers (OR: 2.7, 95% CI: 1.1-6.4, P = 0.02). The poor were more likely to receive better care in hospitals managed by non-governmental organizations than those managed by other mechanisms (OR: 15.2, 95% CI: 1.2-200.1, P = 0.04). Conclusions: Efforts to strengthen optimal care provision at peripheral health clinics must be complemented with investments at the referral and tertiary care facilities to ensure care continuity. The findings of improved care by female providers, doctors and NGO's for poor patients, warrant further empirical evidence on care determinants. Optimizing care quality at referral hospitals is one of the prerequisites to ensure service utilization and outcomes for the achievement of the Child health Millennium Development Goals for Afghanistan. © The Author 2011. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.


Stenberg K.,World Health Organization | Axelson H.,World Health Organization | Sheehan P.,Victoria University of Melbourne | Anderson I.,Independent Consultant | And 24 more authors.
The Lancet | Year: 2014

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.


Lee L.A.,Consultant | Franzel L.,PATH | Atwell J.,Johns Hopkins University | Datta S.D.,GAVI Alliance | And 14 more authors.
Vaccine | Year: 2013

Introduction: From August to December 2011, a multidisciplinary group with expertise in mathematical modeling was constituted by the GAVI Alliance and the Bill & Melinda Gates Foundation to estimate the impact of vaccination in 73 countries supported by the GAVI Alliance. Methods: The number of deaths averted in persons projected to be vaccinated during 2011-2020 was estimated for ten antigens: hepatitis B, yellow fever, Haemophilus influenzae type B (Hib), Streptococcus pneumoniae, rotavirus, Neisseria meningitidis serogroup A, Japanese encephalitis, human papillomavirus, measles, and rubella. Impact was calculated as the difference in the number of deaths expected over the lifetime of vaccinated cohorts compared to the number of deaths expected in those cohorts with no vaccination. Numbers of persons vaccinated were based on 2011 GAVI Strategic Demand Forecasts with projected dates of vaccine introductions, vaccination coverage, and target population size in each country. Results: By 2020, nearly all GAVI-supported countries with endemic disease are projected to have introduced hepatitis B, Hib, pneumococcal, rotavirus, rubella, yellow fever, N. meningitidis serogroup A, and Japanese encephalitis-containing vaccines; 55 (75 percent) countries are projected to have introduced human papillomavirus vaccine. Projected use of these vaccines during 2011-2020 is expected to avert an estimated 9.9 million deaths. Routine and supplementary immunization activities with measles vaccine are expected to avert an additional 13.4 million deaths. Estimated numbers of deaths averted per 1000 persons vaccinated were highest for first-dose measles (16.5), human papillomavirus (15.1), and hepatitis B (8.3) vaccination. Approximately 52 percent of the expected deaths averted will be in Africa, 27 percent in Southeast Asia, and 13 percent in the Eastern Mediterranean. Conclusion: Vaccination of persons during 2011-2020 in 73 GAVI-eligible countries is expected to have substantial public health impact, particularly in Africa and Southeast Asia, two regions with high mortality. The actual impact of vaccination in these countries may be higher than our estimates because several widely used antigens were not included in the analysis. The quality of our estimates is limited by lack of data on underlying disease burden and vaccine effectiveness against fatal disease outcomes in developing countries. We plan to update the estimates annually to reflect updated demand forecasts, to refine model assumptions based on results of new information, and to extend the analysis to include morbidity and economic benefits. © 2013 .


Shakarishvili G.,The Global Fund | Lansang M.A.,The Global Fund | Mitta V.,Boston University | Bornemisza O.,The Global Fund | And 4 more authors.
Health Policy and Planning | Year: 2011

Significant scale-up of donors' investments in health systems strengthening (HSS), and the increased application of harmonization mechanisms for jointly channelling donor resources in countries, necessitate the development of a common framework for tracking donors' HSS expenditures. Such a framework would make it possible to comparatively analyse donors' contributions to strengthening specific aspects of countries' health systems in multi-donor-supported HSS environments. Four pre-requisite factors are required for developing such a framework: (i) harmonization of conceptual and operational understanding of what constitutes HSS; (ii) development of a common set of criteria to define health expenditures as contributors to HSS; (iii) development of a common HSS classification system; and (iv) harmonization of HSS programmatic and financial data to allow for inter-agency comparative analyses. Building on the analysis of these aspects, the paper proposes a framework for tracking donors' investments in HSS, as a departure point for further discussions aimed at developing a commonly agreed approach. Comparative analysis of financial allocations by the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance for HSS, as an illustrative example of applying the proposed framework in practice, is also presented. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2010; all rights reserved.


McCarney S.,Solar Electrical Light Fund | Robertson J.,GAVI Alliance | Arnaud J.,Voltaire | Lorenson K.,PATH | Lloyd J.,PATH
Vaccine | Year: 2013

Large areas of many developing countries have no grid electricity. This is a serious challenge that threatens the continuity of the vaccine cold chain. The main alternatives to electrically powered refrigerators available for many years-kerosene- and gas-driven refrigerators-are plagued by problems with gas supply interruptions, low efficiency, poor temperature control, and frequent maintenance needs. There are currently no kerosene- or gas-driven refrigerators that qualify under the minimum standards established by the World Health Organization (WHO) Performance, Quality, and Safety (PQS) system. Solar refrigeration was a promising development in the early 1980s, providing an alternative to absorption technology to meet cold chain needs in remote areas. Devices generally had strong laboratory performance data; however, experience in the field over the years has been mixed. Traditional solar refrigerators relied on relatively expensive battery systems, which have demonstrated short lives compared to the refrigerator. There are now alternatives to the battery-based systems and a clear understanding that solar refrigerator systems need to be designed, installed, and maintained by technicians with the necessary knowledge and training. Thus, the technology is now poised to be the refrigeration method of choice for the cold chain in areas with no electricity or extremely unreliable electricity (less than 4. h per average day) and sufficient sunlight. This paper highlights some lessons learned with solar-powered refrigeration, and discusses some critical factors for successful introduction of solar units into immunization programs in the future including: •Sustainable financing mechanisms and incentives for health workers and technicians are in place to support long-term maintenance, repair, and replacement parts.•System design is carried out by qualified solar refrigerator professionals taking into account the conditions at installation sites.•Installation and repair are conducted by well-trained technicians.•Temperature performance is continuously monitored and protocols are in place to act on data that indicate problems. © 2013 The Authors.


Fang A.,GAVI Alliance | Hansen P.M.,GAVI Alliance | Pyle D.,John Snow International | Dia O.,John Snow International | Schwalbe N.,GAVI Alliance
PLoS ONE | Year: 2010

This paper presents the findings of a study to assess the effectiveness and sustainability of a GAVI (Global Alliance of Vaccines and Immunization) sponsored, time-limited Injection Safety (INS) support. The support came in two forms: 1) in kind, in the form of AD syringes and safety boxes, and 2) in cash, for those countries that already had a secure, multi-year source of AD syringes and safety boxes, but proposed to use INS support to strengthen their injection safety activities. In total, GAVI gave INS support for a three-year period to 58 countries: 46 with commodities and 12 with cash support. To identify variables that might be associated with financial sustainability, frequencies and cross-tabulations were run against various programmatic and socio-economic variables in the 58 countries. All but two of the 46 commodity-recipient countries were able to replace and sustain the use of AD syringes and safety boxes after the end of their GAVI INS support despite the fact that standard disposable syringes are less costly than ADs (10-15 percent differential). In addition, all 12 cash-recipient countries continued to use AD syringes and safety boxes in their immunization programs in the years following GAVI INS assistance. At the same time, countries were often not prepared for the increased waste management requirements associated with the use of the syringes, suggesting the importance of anticipating challenges with the introduction of new technologies. The sustained use of AD syringes in countries receiving injection safety support from GAVI, in a majority of cases through government financing, following the completion of three years of time-limited support, represents an early indication of how GHPs can contribute to improved health outcomes in immunization safety in the world's poorest countries in a sustainable way. © 2010 Levin et al.


Saxenian H.,Consultant to Results for Development Institute | Hecht R.,Results for Development Institute | Kaddar M.,World Health Organization | Schmitt S.,World Health Organization | And 2 more authors.
Health Policy and Planning | Year: 2015

Over the 5-year period ending in 2018, 16 countries with a combined birth cohort of over 6 million infants requiring life-saving immunizations are scheduled to transition (graduate) from outside financial and technical support for a number of their essential vaccines. This support has been provided over the past decade by the GAVI Alliance. Will these 16 countries be able to continue to sustain these vaccination efforts? To address this issue, GAVI and its partners are supporting transition planning, entailing country assessments of readiness to graduate and intensive dialogue with national officials to ensure a smooth transition process. This approach was piloted in Bhutan, Republic of Congo, Georgia, Moldova and Mongolia in 2012. The pilot showed that graduating countries are highly heterogeneous in their capacity to assume responsibility for their immunization programmes. Although all possess certain strengths, each country displayed weaknesses in some of the following areas: budgeting for vaccine purchase, national procurement practices, performance of national regulatory agencies, and technical capacity for vaccine planning and advocacy. The 2012 pilot experience further demonstrated the value of transition planning processes and tools. As a result, GAVI has decided to continue with transition planning in 2013 and beyond. As the graduation process advances, GAVI and graduating countries should continue to contribute to global collective thinking about how developing countries can successfully end their dependence on donor aid and achieve self-sufficiency. © The Author 2014; all rights reserved.


Galichet B.,World Health Organization | Goeman L.,Project SISKES PLUS | Hill P.S.,University of Queensland | Essengue M.S.,GAVI Alliance | And 4 more authors.
Tropical Medicine and International Health | Year: 2010

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. © 2009 Blackwell Publishing Ltd.


Saxenian H.,Results for Development Institute | Cornejo S.,GAVI Alliance | Thorien K.,Results for Development Institute | Hecht R.,Results for Development Institute | Schwalbe N.,GAVI Alliance
Health Affairs | Year: 2011

Immunization is one of the "best buys" in global health. However, for the poorest countries, even modest expenditures may be out of reach. The GAVI Alliance is a public-private partnership created to help the poorest countries introduce new vaccines. Since 2008 GAVI has required that countries cover a share of the cost of vaccines introduced with GAVI support. To determine how much countries can contribute to the cost of vaccines-without displacing spending on other essential programs-we analyzed their fiscal capacity to contribute to the purchase of vaccines over the coming decade. For low-income countries, external financing will be required to purchase vaccines supported by GAVI, so cofinancing needs to be modest. Relatively better-off "intermediate" countries could support initially modest but gradually increasing cofinancing levels. The countries soon to graduate from GAVI can generally afford to follow a rapid path to self-sufficiency. Co-financing for these countries needs to ramp up so that national budgets fully cover the costs of the new generation of vaccines once GAVI support ends. © 2011 Project HOPE-The People-to-People Health Foundation, Inc.

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