101620 GLOBAL PROGRAM REVIEW The GAVI Alliance Global Program Review The World Bank’s Partnership with the GAVI Alliance Main Report and Annexes Contents ABBREVIATIONS .................................................................................................................................. V ACKNOWLEDGMENTS ........................................................................................................................ XI PROGRAM AT A GLANCE: THE GAVI ALLIANCE ............................................................................ XII KEY BANK STAFF RESPONSIBLE DURING PERIOD UNDER REVIEW ........................................ XIV GLOSSARY ......................................................................................................................................... XV OVERVIEW........................................................................................................................................ XVII GAVI ALLIANCE MANAGEMENT RESPONSE .............................................................................. XXV WORLD BANK GROUP MANAGEMENT RESPONSE ................................................................... XXIX CHAIRPERSON’S SUMMARY ......................................................................................................... XXXI 1. THE WORLD BANK-GAVI PARTNERSHIP AND THE PURPOSE OF THE REVIEW ...................... 1 Evolution of GAVI ...................................................................................................................................................... 1 Funding and Results ................................................................................................................................................. 2 Purpose of the Review .............................................................................................................................................. 5 Data, Methodology, and Timeframe .......................................................................................................................... 7 2. THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI ........................................................... 9 Setting up an International Finance Facility for Immunisation ................................................................................... 9 Origin and Establishment of IFFIm ........................................................................................................................................ 9 Financing IFFIm ................................................................................................................................................................... 11 IFFIm’s Governance and Management ............................................................................................................................... 13 The World Bank’s Role and Responsibilities as Treasury Manager of IFFIm ..................................................................... 13 External Evaluation of IFFIm ............................................................................................................................................... 15 Advanced Market Commitment to Spur Vaccine Development .............................................................................. 16 Origin and Establishment of the AMC ................................................................................................................................. 16 AMC Funding and Operations ............................................................................................................................................. 18 The World Bank’s Role in AMC’s Financial Platform .......................................................................................................... 19 Conclusions and Lessons on the Bank’s Contributions to Innovative Finance on Behalf of GAVI ......................... 20 3. THE WORLD BANK AS DEVELOPMENT PARTNER TO GAVI ..................................................... 21 Opportunities for Stronger Development Effectiveness in Immunization ................................................................ 21 Opportunities to Help Ensure Adequate and Sustainable Funding for Immunization ............................................. 22 Opportunities to Address Inequities in Immunization Access ................................................................................. 24 Opportunities to Coordinate Support to Health and Immunization via Global Health Partnerships ........................ 26 The Bank’s Limited Engagement in Immunization .................................................................................................. 27 Limited Bank-GAVI Country-level Engagements................................................................................................................. 30 Direct Bank-GAVI Trust Fund Collaboration Has Ceased ................................................................................................... 32 Country Visits Also Find Opportunities for Stronger Bank Engagement in Immunization ................................................... 35 i CONTENTS 4. THE BANK AS A GOVERNANCE PARTNER .................................................................................. 37 Pre-governance Reform Period .............................................................................................................................. 37 Post-governance Reform Period ............................................................................................................................. 39 GAVI’s Evolving Strategy and Relationship with the Bank ...................................................................................... 41 Lessons for Future Engagement with GAVI and other Partnership Programs ........................................................ 44 5. CONCLUSIONS AND LESSONS ..................................................................................................... 47 Lessons for the Bank’s relationship with GAVI and other partnership programs. ................................................... 49 REFERENCES ...................................................................................................................................... 95 ENDNOTES........................................................................................................................................... 99 Boxes Box 1. The International Health Partnership ..........................................................................................27 Box 2. Major Findings from Survey of World Bank TTLs .......................................................................34 Box 3. The World Bank’s Participation in GAVI Board Committees .......................................................41 Box 4. GAVI’s Phases and Strategies ...................................................................................................42 Tables Table 1. Contribution Receipts from AMC Donors, as of March 31, 2013 .............................................19 Table 2. Immunization-related Projects by Sector Board .......................................................................28 Table 3. Polio Projects, US$ million .......................................................................................................30 Table 4. References to GAVI in Country Assistance Strategies and Project Appraisal Documents, Fiscal Years 2001–11. ...........................................................................................................................30 Table 5. References to the Global Fund in Country Assistance Strategies and Project Appraisal Documents, Fiscal Years 2003–10 ........................................................................................................31 Table 6. DGF Contributions to GAVI, 2001–07 (US$ millions)...............................................................32 Table 7. Cross-Cutting Issues from Country Visits ................................................................................35 Table 8. GAVI Board and GAVI Fund Board Compositions Before the Reform, 2005 ...........................38 Figures Figure 1. Contributions and Pledges to GAVI (2000 - Present) .............................................................. 2 Figure 2. GAVI’s Commitments to Countries (from inception until August 31, 2013) .............................. 3 Figure 3. . IFFIm Process ......................................................................................................................11 Figure 4. . IFFIm Donor Commitments and Funds Raised, 2006-2030 .................................................12 Figure 5. . Cash Received by GAVI by Source (1999-2009) .................................................................12 Figure 6. . AMC Process........................................................................................................................17 Figure 7. AMC Funding Structure (Illustrative Example) ........................................................................18 Figure 8. Immunization Operations by Sector Board and as Share of Total Projects, 2003-12 .............29 ii CONTENTS Figure 9. Regional Distribution of Immunization-related Operations ..................................................... 29 Figure 10. World Bank Immunization Operations by GAVI Eligibility ..................................................... 29 Figure 11. Type of Activities Funded by ImGAVI Trust Fund ................................................................ 33 Figure 12. GAVI Alliance Board Composition, 2013 .............................................................................. 39 Figure 13. HNP Department Expenditures for GAVI and Immunization-related Projects, 2002-2013 ... 45 Appendixes APPENDIX A. GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES ............................................ 51 APPENDIX B. REPLICABILITY OF INNOVATIVE FINANCIAL MECHANISMS ................................. 63 APPENDIX C. TIMELINE OF GAVI ALLIANCE AND RELATED EVENTS IN THE WORLD BANK AND ELSEWHERE............................................................................................................................... 65 APPENDIX D. MEMBERS OF THE GAVI ALLIANCE BOARD ........................................................... 71 APPENDIX E. FINDINGS FROM THE COUNTRY VISITS ................................................................... 73 APPENDIX F. RESULTS OF THE ELECTRONIC SURVEY OF WORLD BANK TASK TEAM LEADERS ............................................................................................................................................. 79 APPENDIX G. WORLD BANK IMMUNIZATION-RELATED OPERATIONS ....................................... 88 APPENDIX H. LIST OF PERSONS CONSULTED ............................................................................... 91 Evaluation Managers  Caroline Heider Director-General, Evaluation  Nick York Director, IEGCC  Geeta Batra Manager  Christopher Gerrard Task Manager (for Approach Paper)  Rasmus Heltberg Task Manager (final Report) iii Abbreviations AAA Accra Agenda for Action AEFI Adverse Effects from Immunization AFR Africa Region AIDS Acquired Immune Deficiency Syndrome AMC Advanced Market Commitment AusAID Australian Agency for International Development BCG Bacille Calmette-Guérin CEO Chief Executive Officer CEPA Cambridge Economic Policy Associates CSO Civil Society Organization DAC Development Assistance Committee (of the OECD) DFID United Kingdom Department for International Development DGF Development Grant Facility DTP Diphtheria, Tetanus, and Pertussis EAP East Asia and Pacific Region EPI Expanded Program on Immunization FFA Financial Framework Agreement FIF Financial Intermediary Fund (World Bank) G8 Group of Eight Highly-industrialized Nations GAVI Global Alliance for Vaccines and Immunisation GDP Gross Domestic Product GEF Global Environment Facility GFA GAVI Fund Affiliate GHAP Global HIV/AIDS Program GNI Gross National Income GPEI Global Polio Eradication Initiative GTZ Deutsche Gesellschaft für Technische Zusammenarbeit HDN Human Development Network HepB Hepatitis B Hib Haemophilus Influenza Type B HIV Human Immunodeficiency Virus HLSP Health and Life Sciences Partnership (Consultants) v ABBREVIATIONS HNP Health, Nutrition, and Population HPV Human Papillomavirus HSCC Health Sector Coordination Committee HSFP Health Systems Funding Platform HSS Health Systems Strengthening IBRD International Bank for Reconstruction and Development ICC Interagency Coordination Committee (country-level) IDA International Development Association IEG Independent Evaluation Group IFF International Finance Facility IFFIm International Finance Facility for Immunisation IHP+ International Health Partnership ImGAVI Immunization and GAVI (Trust Fund) INS Injection Safety Support IPV Inactivated Polio Vaccine IRC Independent Review Committee (GAVI) ISS Immunization Services Support JANS Joint Assessment of National Health Strategies JFA Joint Financing Agreement JICA Japan International Cooperation Agency KFW Kreditanstalt fuer Wiederaufbau, (German Development Bank) LCR Latin America and Caribbean Region MAP Multi-Country AIDS Program M&E Monitoring and Evaluation MCH Maternal and child health MDBs Multilateral Development Banks MDGs Millennium Development Goals Men A Meningococcal A Vaccine MNA Middle East and North Africa Region MNT Maternal and Neonatal Tetanus MOH Ministry of Health MOHP Ministry of Health and Population NDHS National Demographic and Health Survey NIP National Immunization Program NVS New and Underused Vaccine Support OECD Organization for Economic Cooperation and Development OIC Organization of the Islamic Conference vi ABBREVIATIONS OPV Oral Polio Vaccine PBS Promoting Basic Services POL Polio PREM Poverty Reduction and Economic Management SAR South Asia Region SDC Swiss Agency for Development and Cooperation SP Social Protection SWAp Sector-wide Approach TB Tuberculosis TMA Treasury Manager Agreement TTL Task Team Leader UK United Kingdom UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund US United States of America USAID U.S. Agency for International Development WHO World Health Organization vii Fiscal Year of the GAVI Alliance January 1 to December 31 GAVI Alliance Phases GAVI Phase Period Governance Phase Phase I 2000-2006 Pre-governance reform (2000-October 2008) Phase II 2007-2010 Post-governance reform Phase III 2011-2015 (October 2008-present) ix Acknowledgments This review has been prepared by a team led by Bernhard Liese under the supervision of first Chris Gerrard and later Rasmus Heltberg following the outline and methodology in the Approach Paper that was issued in October 2012. Other members of the core team were Calvin Siow, Moritz Piatti, and Anahit Aghumian. Further support was provided by Yasmin Angeles. Nick York, Director, Country, Corporate, and Global Evaluations provided overall guidance. Bernhard Liese, Calvin Siow, and Rasmus Heltberg were the principal authors. The Independent Evaluation Group (IEG) gratefully acknowledges all who made their time available for interviews and provided useful information and insights for this review. IEG especially wishes to acknowledge the cooperation of the Bank Group’s Health, Nutrition, and Population Sector and the GAVI Alliance Secretariat in providing all requested information and documents. IEG is also grateful to Bank staff in country offices who facilitated the country visits. Peer reviewers for this report were Mark Rosenberg, the Task Force for Global Health; Enis Baris, Sector Manager for Health, Nutrition, and Population in the Middle East and North Africa Region of the World Bank; and the late Ciro de Quadras, the Sabin Vaccine Institute. The Norwegian Agency for Development Cooperation contributed financial support to this review. xi Program at a Glance: The GAVI Alliance Start date January 2000. GAVI was formally launched at the World Economic Forum in Davos, Switzerland. Purpose GAVI’s mission is to save children’s lives and protect people’s health by increasing access to immunization in poor countries. GAVI’s support contributes to the Millennium Development Goal (MDG) of reducing the under-five child mortality rate by two-thirds. Major activities As a public-private partnership, GAVI pools donor resources to fund vaccine introduction, encourage development of new and underused vaccines, and improve vaccine delivery by strengthening health systems. GAVI offers the following types of support to eligible countries:  New and underused vaccines (10 different types of vaccines)  Health system strengthening  Immunization services to improve immunization performance  Civil society organizations (CSOs) GAVI is also involved in shaping vaccine market conditions to lower vaccine prices and ensure sufficient supply of vaccines for vaccine program sustainability in developing countries. World Bank Group The World Bank is a voting member of the GAVI Alliance Board and roles three Board committees, is the Treasury Manager for International Finance Facility for Immunisation (IFFIm), provides the financial platform for the Advanced Market Commitment (AMC), and is a development partner at the global and country levels. The Bank contributed financial resources to GAVI during its early years, and GAVI set up a trust fund (now closed) for Bank activities in health system strengthening and immunization. Donor contributions GAVI is funded by direct contributions and innovative financing mechanisms. As of 2013, 32 public- and private-sector donors have contributed United States (US) $8.3 billion to GAVI since its inception. IFFIm currently has nine donor countries pledging US$6.3 billion over 23 years, and IFFIm has raised US$4.5 billion from investors. The Matching Fund has 12 partners and has raised more than US$162 million as of April 2014. The six largest donors (United Kingdom, Bill & Melinda Gates Foundation, Norway, United States, France, and Italy) contribute more than two-thirds of these resources. Location The GAVI Secretariat offices are located in Geneva, Switzerland and Washington, DC, USA. Website www.gavialliance.org xii Governance and GAVI is an independent legal entity incorporated as a foundation management under Swiss law. GAVI is governed by the GAVI Alliance Board comprised of 28 seats, which includes 18 representatives of donor and recipient governments, the private sector (including philanthropists), the vaccine industry (from developed and developing countries), research and technical institutes, CSOs, and key multilateral organizations, in addition to nine independent or “unaffiliated” individuals and one non-voting seat for GAVI’s CEO. Permanent seats are held by the Gates Foundation, World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and the World Bank. Aside from the four permanent members, Board representatives serve on a time-limited basis. The GAVI Alliance Board is supported by committees that oversee specific activities and the development of key policies. The GAVI Secretariat, with offices in Geneva and Washington, D.C., is led by the Chief Executive Officer (CEO) and is responsible for day-to-day operations, including mobilizing resources, coordinating program approvals and disbursements, developing policy, implementing strategic initiatives, monitoring and evaluation, legal and financial management, and administration for the GAVI Alliance Board and Committees. IFFIm is a registered charity in the United Kingdom (UK) and independent from the GAVI Alliance. IFFIm is governed by the IFFIm Board comprised of five independent directors. Latest external Cambridge Economic Policy Associates (CEPA) LLP, 2010, GAVI evaluation Second Evaluation Report. xiii Key Bank Staff Responsible during Period under Review Position Person Period Global Program Task Team Amie Batson 1999–2008 Leader Rama Lakshminarayanan 2008–2011 Robert Oelrichs 2011–present Sector Director, Health, Christopher Lovelace 1999–2002 Nutrition, and Population Jacques Baudouy 2003–2007 Department (HDNHE) Cristian Baeza (Acting) 2007 Julian Schweitzer 2007–2010 Cristian Baeza 2010–2012 Nicole Klingen (Acting) 2012–2013 Tim Evans 2013–present Director, Multilateral Susan McAdams July 2007–March 2014 Trusteeship and Innovative Financing Department Vice President, Human Eduardo Doryan 1999–2001 Development Network (HDN) Jozef Ritzen 2001–2003 Jean-Louis Sarbib 2003–2006 Joy Phumaphi 2007–2010 Tamar Manuelyan Atinc 2010–2012 GAVI Alliance Chief Executive Officers Position Person Period Chief Executive Officer, GAVI Tore Godal 2000–2004 Alliance Julian Lob Levyt 2005–2010 Helen Evans (Acting) 2010–2011 Seth Berkley 2011–present xiv Glossary Advance An innovative financing mechanism that stimulates the development and market manufacture of affordable vaccines, tailored to the needs of developing commitment countries. Donor commitments give vaccine manufacturers the incentive (AMC) to invest in vaccine research and development and to expand manufacturing capacity. In exchange, companies sign legally-binding commitments to provide the vaccines to developing countries at a long- term, affordable price. A pilot AMC for pneumococcal vaccines was launched in 2010. Diphtheria, Three combined doses of diphtheria-tetanus-pertussis (DTP) vaccine are tetanus, and usually provided in the first six months of life. Coverage with three doses pertussis of DTP vaccine, known as DTP3, is an indicator used by WHO and GAVI vaccine (DTP) to measure the strength of an immunization program. Expanded Since its inception in 1974, the Expanded Program on Immunization (EPI) Program on has brought together partners under the auspices of WHO to increase Immunization immunization coverage from the then low levels of 5 percent to the (EPI) current levels, which are close to 80 percent. The traditional EPI vaccines are Bacille Calmette-Guérin (BCG) (against tuberculosis), DTP (against diphtheria, tetanus, and pertussis), oral polio vaccine (OPV), and measles. International The International Finance Facility (IFF) is designed to frontload aid to help Finance meet the MDGs. At the July 2005 Gleneagles Summit, a group of Group of Facility (IFF) Eight Highly-industrialized Nations (G8) and other countries decided to take forward innovative financing mechanisms including a pilot of the IFF, the IFFIm. Pentavalent A pentavalent vaccine is a vaccine that includes five antigens. GAVI funds vaccine pentavalent vaccines against diphtheria, tetanus, pertussis, hepatitis B, and Hib disease (DTP-Hep B-Hib vaccine). xv Overview Highlights GAVI is the third largest multilateral in the health sector. It has a single-purpose mandate, to increase access to immunization in poor countries. The World Bank is a founding partner to GAVI and remains a major partner, particularly at a financial level by supporting operations of two major innovative financial mechanisms on its behalf. By design, GAVI itself does not have a presence at the country level and relies heavily on its partners, WHO and UNICEF, for planning and implementing country activities. While the Bank’s financial engagement on behalf of GAVI has been transformative, this review identifies opportunities for stronger Bank engagement in immunization activities at the country level, in GAVI’s governance, and in broader immunization policy discussions. Financial engagement. The Bank’s most significant contribution is a key role in the establishment and management of two innovative financing mechanisms (IFFIm and AMC) that have contributed one-third of GAVI’s financial resources from 2000 to 2010. In both cases the Bank worked with partners to translate a conceptual innovation into a viable financial pilot mechanism. Operationalizing these instruments required the Bank to assume financial risk, develop new systems, and make a long-term commitment. The Bank assumed a direct balance sheet risk on behalf of AMC and used its excellent credit rating to place IFFIm “vaccine” bonds. The Bank’s financial relationship with GAVI and IFFIm has been highly competent and professional. It deserves widespread appreciation and recognition. Engagement at country level. The relationship with GAVI has been collegial and constructive in countries where there is engagement, but in many countries the Bank is not substantially involved in immunization. This review concludes that the status quo leaves organizational synergies untapped, and that stronger Bank involvement, drawing on its strengths in sustainable funding for immunization, addressing inequities in access to immunization, investments in health systems strengthening, and donor coordination in health could help achieve greater development results. Governance. The mandates and priorities of the Bank and GAVI were mutually relevant and compatible at GAVI’s inception but the engagement diminished during a period from around 2008 until recently. This disengagement by the Bank can be traced to differences in alignment between the Bank’s broader development objectives and GAVI’s focused approach on accelerating introduction of new and sometimes costly vaccines in low-income countries, and the changing influence of the founding partners and growing autonomy of the GAVI Secretariat after GAVI’s 2008 governance reform. The new World Bank Group strategy makes requires partnering with private, public, a strong case for an expanded World Bank multilateral, and civil society actors. The Group role in global and regional dialogue Independent Evaluation Group (IEG) and collective action. It argues that conducted this review because the GAVI addressing complex development challenges Alliance is one of the largest global xvii OVERVIEW partnership programs in which the Bank is The World Bank helped develop, involved, and because GAVI as the world’s implement, and manage two major leading financier of immunization is a major player in global health: GAVI has become innovative financial mechanisms—the the third largest multilateral in the health International Finance Facility for sector, behind only the Global Fund and the Immunisation (IFFIm) and the Advanced World Bank. Market Commitment (AMC)—on behalf of GAVI. IFFIm and AMC provide additional The Bank played a crucial role in facilitating resource flows to GAVI in support of and supporting the establishment of GAVI childhood immunization. IFFIm raises during a period when immunization funding funds on international capital markets by was in decline and gains made in childhood issuing bonds known as “vaccine bonds” immunization since the 1970’s were in against long-term, legally binding grant serious danger. The Bank is a founding agreements from sovereign donors. IFFIm member and partner of GAVI since 2000. uses these grant payments to pay the At the time, GAVI was seen as highly principal and interest on its bonds. IFFIm congruent with the goals and mandates of bonds have raised US$4.55 billion which the Bank at global and country level. The IFFIm has used to fund GAVI programs GAVI partnership was regarded as and refinance its debt. complementary to the Bank’s country programs and would help achieve the In its stewardship of IFFIm, the Bank has MDGs related to child health. This been a vital and effective financial partner to alignment was the basis for the Bank’s GAVI. It subsidized the systems extraordinary and highly successful efforts development costs and has fulfilled its roles to set up and manage two innovative and responsibilities as treasury manager financial vehicles that provide GAVI with exceptionally well, managed liquidity well, significant and predictable resource flows. and used its supranational status and conservative risk management approach to The review focuses on the performance of reassure investors’ confidence in IFFIm. the Bank in the three roles that the Bank This has allowed IFFIm to raise funds on plays in GAVI: development partner at favorable terms, including spreads that have global and country level (that is, joint donor been lower than the weighted average of in the health sector); financial partner; and donors’ borrowing costs. The mechanism corporate governance as founding partner exposes IFFIm to risks of credit and voting board member. It does not downgrades of its major donors; the risks evaluate GAVI or its financial mechanisms. materialized but were managed with flexibility by the Bank. The Bank also The Bank Has Made Significant successfully navigated a complex Contributions to Innovative governance arrangement. The Bank Development Finance on Behalf of deserves widespread recognition for these GAVI contributions. xviii OVERVIEW The Bank also provides useful and on its partners to provide the necessary competent financial management and policy dialogue, technical assistance, and administrative services to the AMC. Donors operational support to help countries reap commit funds to the AMC to subsidize the the full benefits of immunization. Partners purchase of pneumococcal vaccines at an are funded for specific activities identified in affordable price for developing countries. the GAVI Alliance Strategy and Business This offers vaccine manufacturers a long- Plan 2011-2015. term, guaranteed market price. The Bank has taken on the financial risk associated In contrast to GAVI's singular categorical with donor default; this limited risk is role, the World Bank has a broad and transparently disclosed on International comprehensive role in the health sector. Its Bank for Reconstruction and Development pursuit of health system strengthening can (IBRD’s) balance sheet and the Bank is lay the groundwork for successful delivery compensated for carrying it. of immunization. Between FY2003 and 2012, the Bank provided US$2.91 billion for Thus, for both IFFIm and AMC, the Bank child health through health-sector-specific provided excellent execution that and multisectoral programs to reach the successfully translated conceptual MDGs and assist people in developing innovations in development finance into countries to create healthy futures. viable financial pilot mechanisms. These interventions were justified at the time but However, the Bank’s lending, policy for cost and other reasons are unlikely to be dialogue, and analytical work on childhood replicable for the health sector (Annex B). immunization has been quite limited. Bank The AMC has drawn criticism for lending and analytical support for overpaying on pneumococcal vaccine immunization have declined in recent years. (Hargreaves and others 2011). IEG did not Immunization as a share of total approved see evidence that the controversies health projects dropped from 15 percent in surrounding the AMC have affected the 2006 to less than 5 percent in 2012. Most of Bank’s reputation. the 36 Bank projects with an immunization- related objective or component approved The Bank as Development Partner to between 2002 and 2012 were general health GAVI: Opportunities for Stronger system strengthening projects with Development Results immunization as one element, including direct financing of seven immunization While GAVI provides extensive financial strengthening projects for polio. The resources for vaccines and related support, reduced direct financing for immunization its financial assistance does not cover all by the Bank accompanies the increased aspects that might be necessary to ensure financing for immunization by GAVI, and universal and sustainable immunization in as such can be seen as a logical division of low-income countries. GAVI’s model relies labor resulting from the rise of GAVI as the xix OVERVIEW world’s pre-eminent financier of traditional EPI vaccines, as well as immunization. But Bank analytical and supporting GAVI’s renewed focus other work has also been reduced: IEG on vaccine sustainability in could identify only a few Bank studies countries. IEG’s country visits and related to immunization. The Bank interviews with experts suggest that participates in the country-level sustainable funding for the GAVI- coordination mechanism for immunization, supported vaccine program cannot the Interagency Coordination Committee be assured once countries graduate (ICC) chaired by the Ministry of Health from GAVI, but IEG did not find (MOH), in only a few countries. This has evidence of substantive Bank left some gaps. engagement in assessing the fiscal implications of new vaccine Bank health-sector staff, particularly at introduction. country level, and health-sector staff from  Finding ways to improve donor partner organizations consulted by IEG coordination in health in order to identified missed opportunities for stronger reduce transaction costs and avoid development results. There is also a strong creating overlapping reporting and wish among senior GAVI staff for stronger accounting requirements for client Bank engagement. IEG finds that the status countries. Several mechanisms for quo leaves potential organizational synergies donor coordination in health have untapped, creating room for greater been set up but have fallen short of development results via stronger Bank expectations. involvement in: The Bank did not make a conscious  Addressing the serious inequities in decision to reduce immunization-related access to immunization faced by activities; several contributing factors could many low-income countries. be identified. The GAVI Secretariat’s lack Reaching marginalized groups with of field presence (apart from periodic visits immunization poses organizational by its Geneva-based country responsible difficulties for national health officers, and the presence of its in-country systems. partners WHO and UNICEF) makes it  Helping to ensure adequate and difficult for the Bank to engage with the sustainable funding for GAVI Secretariat at the country level. immunization. Drawing on its Direct funding between the Bank and experience in health-sector GAVI has ceased: a GAVI-financed and financing, the Bank could provide a Bank-executed trust fund that provided useful counterweight to GAVI’s direct funding to the Bank’s work on current focus on rapid introduction immunization-related health systems of new vaccines which are strengthening was discontinued in 2011 at considerably more expensive than the Bank’s request due to a perceived xx OVERVIEW conflict of interest. The Bank did not The reform fundamentally changed the develop directives on how to engage with nature of the GAVI partnership. GAVI GAVI, and no formalized division of labor evolved from an informal alliance to a exists between the two organizations, in part formal, corporate identity. The new 2008 because the Bank could not accept the semi- GAVI Alliance Board diluted the voting contractual relationship arrangement influence of the founding partners. Two- envisioned in the GAVI Alliance Business thirds of the 28 board members are Plan 2011-15. constituency determined, including the pharmaceutical industry, and one-third The Bank’s Contributions to GAVI’s comprises independent individuals that are Governance neither stakeholders nor shareholders. The three founding UN partners—UNICEF, From GAVI’s initial years until around WHO, and the World Bank—representing 2008-10, the Bank was an active participant the traditional “Alliance” element of GAVI, in GAVI’s economic and financing are now represented by only three votes on strategies, was a member of GAVI’s a 28 vote corporate Board. Certain Financing Task Force, co-chair of the constituencies interviewed by IEG Immunization Financing and Sustainability expressed concern that GAVI has Task Team, and helped with the design and transitioned from an alliance of equal implementation of the co-financing policy. partners to a corporate organization. These active engagements were supported by a dedicated Bank team that conducted Differences in corporate priorities between studies on topics of relevance to GAVI. the Bank and GAVI sharpened after 2008 and seem to have greatly contributed to the GAVI became an independent legal entity diminishing interactions. GAVI’s emphasis in 2008, when the GAVI Board merged on making new vaccines available as quickly with the GAVI Fund Board into the present as possible, even if costly, was viewed GAVI Alliance Board. The Bank was skeptically by many Bank staff and others represented at the vice presidential-level in interviewed for this evaluation, who the governance reform process. For the expressed concerns over the implications Bank and the other multilateral partners, the for overall health-sector finance. People reorganization gave rise to issues regarding perceived that their concerns regarding the number and allocation of voting board sustainable financing of immunization were seats and brought up many questions not adequately addressed (GAVI has regarding their role in the new entity. The increased its attention to vaccine cost process was described by several reductions in recent years although this has stakeholders as contentious. The Bank did always been a part of its mission). People not have any explicit corporate guidelines to interviewed by IEG use terms such as guide its position on the issues. “withdrawal” and “cautious engagement” to describe the Bank’s position vis-à-vis GAVI xxi OVERVIEW from 2008 until recently. Bank staffers have World Bank Group strategy, the Bank could a perception that there has been limited benefit from managerial oversight of how time for discussion and critical questions at its major partnerships are governed. GAVI Board and committee meetings. Third, the governance reform process which Staff in both organizations would like to see transformed GAVI from an informal alliance closer Bank-GAVI cooperation. GAVI hosted by UNICEF into a new independent perceives that the Bank could add value, Swiss foundation, involved complex particularly in the financial sustainability of governance issues and legal concerns. The vaccine programs and health systems choice of creating a new independent strengthening, because of its institutional organization can also create an expansionary knowledge, relationships with ministries of institutional dynamic, as new organizations finance, and the perception that it can be a strive for budget and recognition. The lender of last resort and help countries international community may want to graduate from GAVI support to domestic carefully weigh the pros and cons of creating vaccine financing. More recently, the Bank new independent organizations versus is actively involved in developing GAVI’s housing partnerships in existing 2016-2020 strategy. organizations. Conclusions and Lessons for the A fourth lesson is that the Bank’s Bank’s Relationship with GAVI and competence and experience in concessional other Partnership Programs development finance can be highly useful in future attempts to set up innovative The central lesson for the Bank’s development finance on behalf of partners. relationship with GAVI is the need to The World Bank Group strategy aims to discuss, update, and re-affirm the principal leverage private-sector resources, partnership arrangements to reflect the partnerships, and innovative finance. The changing realities in which both partners lessons from the Bank’s work on behalf of operate. The 2008 governance reform GAVI for future endeavors is that the Bank profoundly changed the governance should: carefully consider if the short-term structure, and with it the dynamics of the benefits of any innovative financial relationship. The Bank has not, to IEG’s mechanism justify the long-term knowledge, reviewed what if any consequences for the Bank and its partners; consequences the governance reform find ways to maintain simple governance should have for its own contributions to arrangements; and ensure appropriate Bank GAVI’s governance. recognition and reasonable protection against reputational risks from its work on A second lesson is to manage governance of behalf of partners. partnership programs more proactively and systematically, particularly during initial setup and reform. As also mentioned in the xxii OVERVIEW A fifth lesson is that clearer definition of roles and responsibilities at country and global level could enhance the impact of the Bank, GAVI, and other organizations’ support for immunization. It would be helpful for the Bank and GAVI to agree on priority countries, modes of engagement, and division of labor. The division of labor should be documented yet flexible so as to avoid excessively restrictive contractual approaches and permit the Bank to pursue its comparative advantages in policy dialogue and analytical work tailored to country contexts. Sixth, the Bank-GAVI experience is not unique: there are often missed opportunities for stronger results in the Bank’s engagements in partnership programs. IEG’s synthesis report of global program reviews in 2011 found strong operational linkages to the Bank’s country-level work in only four of 17 global programs reviewed (IEG 2011a). To remedy this, IEG has recommended a more explicit definition of roles and accountabilities in partnership programs. IEG has also recommended that the Bank put in place stronger coordination mechanisms between partnership programs and the relevant sectors and practices and empower its representatives on program boards to work for the Bank’s corporate interests (the Bank has yet to implement a proposal that staff serving on partnership boards be guided by terms of reference that set out Bank-wide institutional positions). These steps could help fulfill the World Bank Group strategy objective of closer alignment between global engagements and Bank Group goals. xxiii GAVI Alliance Management Response to World Bank Global Program Review of the World Bank–GAVI Relationship The World Bank is a founding partner and important member of the GAVI Alliance. We therefore welcome the opportunity to comment on this review, recognising that it is an evaluation of the World Bank’s partnership with the GAVI Alliance, rather than a report on the Alliance itself. We strongly endorse the report’s overall conclusion that the GAVI Alliance has much to gain from deeper World Bank engagement and we look forward to working together to achieve this. The proposed areas for increased engagement – fiscal space analysis to ensure financial sustainability and health systems strengthening – represent key priorities for the GAVI Alliance in the coming years (and are the focus of our 2016-20 strategy) and are areas in which the Bank’s unique capabilities, resources, and networks will play a crucial role. In this context, we welcome recent signals from World Bank leadership that they wish to strengthen their engagement in the Alliance, and particularly recent collaboration on results-based funding as well as support for immunisation in Pakistan. We look forward to a broader and deeper partnership to help ensure every child in the world’s poorest countries benefits from the power of immunisation. We would, however, like to clarify a number of important issues and also note that we identified a number of errors of fact and queried a number of findings in the draft report, some of which remained unchanged in the final version. Distinction between the GAVI Alliance and GAVI Secretariat The report is vague in its distinction between the GAVI Alliance and the GAVI Secretariat. The GAVI Alliance – by its very design – is an alliance between partners, donors, countries and industry, of which the World Bank is a founding partner and Board member. The GAVI Secretariat supports the Alliance but implementation is largely performed by partners and countries. It would be helpful to clarify where the report is referring to the GAVI Secretariat and where it refers to the Alliance, in order to understand its conclusions. xxv GAVI ALLIANCE MANAGEMENT RESPONSE For example, the report states that “GAVI itself does not have a presence at the country level and relies heavily on its partners, WHO and UNICEF, for planning and implementing country activities.” It later suggests this is a reason why the Bank has found it difficult to engage with “GAVI” at country level. By design, the GAVI Secretariat does not have a country presence and this is a core part of the GAVI Alliance model which the World Bank as a founding partner helped to create. However, the GAVI Alliance has a strong presence at country level where it is represented primarily by UNICEF and WHO, both of whom are Alliance partners and many of whose immunisation staff are funded by GAVI. In this example, we are unclear if the report’s finding is that the World Bank will always face challenges engaging with “GAVI” at country level given our Alliance model. GAVI Alliance Strategy The Independent Evaluation Group (IEG) report paints a shift in the GAVI Alliance’s strategy from focusing broadly on access to immunisation at its inception towards a focus on accelerating introduction of new vaccines and technologies after 2008. It cites this as one reason why the Bank decided to disengage from the Alliance. In fact, a major rationale for the creation of the GAVI Alliance was to accelerate introduction of new vaccines and this has always accounted for the majority of GAVI financial support. It was only in 2007, with the first disbursements of health system strengthening grants, that the Alliance began to work more comprehensively on broadening immunisation coverage and access across all GAVI countries. With the development of the Alliance’s 2016-2020 strategy, in which the World Bank has been an active partner, coverage and equity will become even greater priorities. As the report suggests, this should hopefully further reinforce strategic alignment between the GAVI Alliance and the World Bank. Causes of World Bank Disengagement from GAVI The report traces the Bank’s disengagement to 2008, linking it primarily to GAVI’s governance reform and disagreements over whether to prioritise new vaccine introduction or financial sustainability. Many of the tensions described in the report, however, existed long before GAVI’s governance reform. Indeed the greatest tensions were over introduction of pentavalent vaccine, which GAVI has supported since its early years and which Bank staff felt was too expensive to be sustainable. We note that 72 of 73 GAVI-eligible countries have now introduced pentavalent vaccine (with the final country planning to introduce this year) and that there has been a two-thirds reduction in the lowest price available thanks xxvi GAVI ALLIANCE MANAGEMENT RESPONSE largely to the Alliance’s market shaping efforts which are central to our strategy for sustainability. Moreover, the Bank remained actively engaged with the GAVI Alliance until 2010. For example, it chaired the Immunisation Financing and Sustainability Task Team until 2010, chaired the working group that developed GAVI’s eligibility policy in 2010 and chaired the working group on performance-based financing that was presented to the Board in December 2010. From our perspective, the Bank’s greatest disengagement followed its decision not to participate in GAVI’s 2011-15 business plan because the GAVI Board required that all funded partners be held accountable for specific deliverables in return for receiving funding. While sustainability has always been core to the GAVI model (which includes features such as long-term financial commitments to countries and requiring co- financing from countries based on their ability to pay), it will be an even greater priority during our next strategy period as a number of countries “graduate” from GAVI Alliance support. We look forward to deeper World Bank engagement on this issue, where the Bank’s unique capabilities within the Alliance and strong relationships with Ministries of Finance will be critical. Looking Forward Again, we strongly share the IEG’s finding that the World Bank and GAVI share common goals and would mutually benefit from increased engagement. We are committed to strengthening the relationship and feel that we have good momentum with the current leadership team. The ongoing dialogue on the 2016- 2020 GAVI Alliance strategy and operating model will facilitate additional definition around the roles and responsibilities of the GAVI Secretariat, the World Bank, and other GAVI Alliance partners at both the country and global levels. We look forward to the Bank’s continued involvement in this process. As part of these discussions, we particularly hope to secure the Bank’s increased engagement at country level to ensure sustainability of immunisation programs. The Bank’s deep relationship with Ministries of Finance in GAVI countries, combined with its expertise (e.g., in fiscal space analysis), will be crucial to the success of the Alliance as a whole in this area. As noted in the report, this is an “area of Bank comparative advantage that other partners do not systematically cover” – precisely the type of partnership at the core of the GAVI Alliance model. Similarly, collaboration between the Bank and GAVI on health systems strengthening represents a clear opportunity for collaboration. We would also note that both the Bank and the GAVI Alliance have prioritised strengthening data, and that this is another potential opportunity for further joint work. xxvii GAVI ALLIANCE MANAGEMENT RESPONSE As the report notes, the World Bank has made critical contributions to the GAVI Alliance in our first 14 years. We look forward to working with colleagues at the Bank to further deepen our engagement going forward. We fundamentally believe that by working more closely together, we can ensure more of the world’s children have access to the power of immunisation. xxviii World Bank Group Management Response Management broadly supports the findings of the Independent Evaluation Group’s (IEG) Global Program Review of the Bank’s performance as a development partner of the Global Alliance for Vaccines and Immunization (GAVI). The Review is timely, as the GAVI Alliance is finalizing a new strategy for 2016 to 2020 and the next GAVI replenishment is just around the corner in 2015. The Review also has the potential to inform an expanded partnership and renewed engagement between the Bank’s new Global Health Practice and GAVI which is currently underway. In that, the Bank and GAVI agreed to deepen and expand collaboration to integrate vaccine financing and delivery into health systems and to co-finance selected operations in countries, including through Results-Based-Financing (RBF). Further, the international health community in a recent meeting of their leaders, re-committed to the principles of the International Health Partnership (IHP+ for which both the Bank and GAVI are co-signatories), requiring donors to adhere to Paris/Accra principles of aid effectiveness. Management concurs with IEG in their assessment that GAVI has evolved as a successful, well-funded, and highly effective public-private partnership which has succeeded in accelerating the introduction of new vaccines for poor countries at a large scale, hence saving millions of lives. We particularly welcome IEG’s assessment regarding the constructive role the Bank was able to play in partnering with GAVI to come up with two of the most innovative and promising financing instruments for development: the International Financing Facility for Immunisation (IFFIm) has become an important funding source for GAVI and allows for additional funding flexibility, and the pilot Advanced Market Commitment (AMC) for pneumococcal vaccines, which received just recently a very positive evaluation, has resulted in an over 90 percent unit price reduction for pneumococcal vaccines tailored to the needs of the poorest countries. As GAVI has grown over the last decade from an informal alliance of partners into a robust Swiss foundation of several hundred staff with more formal governance arrangements and a multi-billion dollar budget, it is clear that the relationship with the Bank also has changed and evolved during that time. Management notes that IEG found that the Bank’s vaccine portfolio, both in terms of operations and specific analytical work on immunization, has been on a downward trend. This, however, might be both a reflection of a natural division of labor as the GAVI Secretariat has become larger and technically highly competent to carry out and commission analytical work themselves, and the result of rational choices of countries to substitute concessional credits with available grant funding for vaccines. But we xxix WORLD BANK GROUP MANAGEMENT RESPONSE agree with IEG that there is a need for the Bank to engage with GAVI along the entire value chain of vaccines, ranging from making the investment case for a vaccine introduction, to assuring cost-effectiveness of vaccine programs and long- term sustainability of investments within a country’s budget and fiscal space. Management also agrees with IEG’s assessment that the Bank has an important role to play in assuring that the vaccine sector is firmly embedded within an equitable and effective health system in low and middle income countries and that such systems effectively contribute to further the Bank’s dual objectives of ending poverty and boosting shared prosperity. Management would like to re-affirm that the Bank always was, and will remain, in the future a valued and productive partner within the GAVI Alliance. This is reflected not only in the successful collaboration and impressive results featured in the IEG review, but also as regards to the important role the Bank is playing in GAVI governance. The Human Development Network and the Concessional Finance and Global Partnerships Vice Presidency have collaborated very effectively over the years in sharing this responsibility, and such technical, fiduciary and strategic input through our work in Committees and the Board is highly valued by the GAVI Secretariat and the partners of the Alliance. Management concurs with IEG and notes that during the first decade of the existence of the GAVI Alliance many impressive quick wins have been made at an ever increasing scale. As the Alliance partnership matures, the challenges for GAVI will build. The Bank will have to play an important role as a key GAVI partner in assuring GAVI’s relevance in serving the most hard-to-reach populations, both in low- and middle-income countries with modern vaccines. At the same time, GAVI partners, including the Bank, need to focus on the financial and technical sustainability of an ever more expensive and complex immunization sector within countries’ health systems. Management concurs with the IEG Review that this will require innovative financing mechanisms, effective and seamless in-country collaboration within the IHP+ principles of aid harmonization, institutional leadership, and good governance. The Bank is fully prepared to meet this challenge as a member in good standing of the GAVI Alliance and considers the IEG report a useful tool for reflection and discussion to meet this goal. xxx Chairperson’s Summary: Sub-Committee of the Committee on Development Effectiveness The Sub-Committee of the Committee on Development Effectiveness (CODE) considered the Independent Evaluation Group’s (IEG) Global Program Review – The World Bank’s Partnership with the GAVI Alliance and the draft Management Comments. The Committee welcomed IEG’s timely Global Program Review and observed that its scope was in line with the Approach Paper endorsed in October 2012. Members broadly supported the report’s findings and lessons learned. Members recognized the Bank-GAVI partnership as an overall success story. They commended the World Bank Group’s key role as one of the founding partners of GAVI, and noted that through this public-private partnership, the World Bank Group helped address a systematic shortfall in the global health architecture related to vaccination. Members acknowledged GAVI’s transformative accomplishments in accelerating coverage of children’s immunization globally, as well as the World Bank Group’s track record in pioneering two of the most innovative financing mechanisms through the GAVI Alliance: the International Financing Facility on Immunization and the Advanced Market Commitment, both of which have been essential for scaling up the immunization enterprise and for giving signals to the private sector that have helped to overcome market failures. Members recognized the changing dynamics in the World Bank Group-GAVI partnership as a result of GAVI’s evolution from an informal alliance to a formal, independent organization, and the consequential governance adjustments. Most members agreed, however, that the Bank can and should have an important role in anchoring the vaccine sector in an equitable and effective health system that contributes to the World Bank Group’s new corporate goals. To that end, members underscored the importance for the Bank Group to enhance its engagement with GAVI along the entire value chain of vaccines, particularly at the country level, in order to assure GAVI’s relevance in delivering modern vaccines to underserved populations. In response to a query on whether IEG’s review captured all the relevant programs and components that have contributed to immunization but may not have been labeled as such in the World Bank Group’s portfolio, the committee was informed by management that the World Bank Group may have done more in strengthening xxxi CHAIRPERSON’S SUMMARY: SUB-COMMITTEE OF THE COMMITTEE ON DEVELOPMENT EFFECTIVENESS delivery systems for immunizations. Management added that the downward trend in the World Bank Group’s vaccine portfolio could be a reflection of division of responsibilities and informed choices by beneficiary countries of grant funding over concessional credits. Members encouraged management to strategize the World Bank Group’s continued catalytic role in GAVI, in particular vis-à-vis innovative and sustainable financing, governance and decision-making, and coordination with other donors. Juan José Bravo, Chairman, CODE Wilhelm Rissmann, Chairman, CODE Sub-Committee xxxii 1. The World Bank-GAVI Partnership and the Purpose of the Review 1.1 The new World Bank Group strategy makes a strong case for an expanded World Bank Group role in global and regional dialogue and collective action (World Bank 2013). It argues that addressing complex development challenges requires partnering with private, public, multilateral, and civil society actors. Global partnerships such as GAVI complement the Bank’s country-led business model by addressing critical global issues and helping countries achieve specific Millennium Development Goals (MDGs). 1.2 GAVI’s mission is to increase access to immunization in poor countries. The Bank is a founding member and has made several substantial contributions to GAVI. GAVI is one of the Bank’s largest partnership programs in financial terms, and possibly its most complex. The Bank has three major roles in GAVI: development partner, as another donor active in health and immunization; financial partner, helping to establish and manage two major innovative financial vehicles on behalf of GAVI; and corporate governance partner, as voting member on the GAVI Alliance Board. Evolution of GAVI 1.3 GAVI was launched in 2000 as a partnership of public and private organizations with a mission “to save children’s lives and protect people’s health by increasing access to immunization in poor countries.”(Cambridge Economic Policy Associates (2010). GAVI pools donor resources to fund vaccine introduction programs, supports the development of new and underused vaccines, and improves vaccine delivery by strengthening health systems. GAVI’s current strategy emphasizes rapid introduction of new vaccines and has renewed its focus on vaccine market shaping (reducing vaccine costs). 1.4 GAVI’s founding structure was designed as an informal alliance of partners with a shared mission, a dual governance structure with GAVI on the programmatic side and the Vaccine Fund (later called the GAVI Fund) on the financial side, and a small secretariat based at the United Nations Children’s Fund (UNICEF) office in Geneva. The World Bank, the World Health Organization (WHO), UNICEF, and 1 CHAPTER 1 THE WORLD BANK GAVI PARTNERSHIP AND THE PURPOSE OF THE REVIEW Gates Foundation are founding members of GAVI and still hold permanent seats on the GAVI Alliance Board. 1.5 Over time, GAVI has become more formal with a single governance structure and a more independent secretariat in response to its increased programs, resources, and responsibilities. As discussed in chapter 4, GAVI was restructured in 2008 and transformed from an informal partnership hosted by UNICEF and operating under international law into an independent foundation anchored under Swiss national law (but with a headquarters agreement with the Swiss government that affords it certain privileges and immunities) and located in Geneva. Administrative services were subsequently moved from UNICEF to a new GAVI corporate secretariat. Funding and Results 1.6 GAVI receives funds from both direct contributions from donor governments, the Bill and Melinda Gates Foundation and other private donors, and from innovative financing mechanisms, namely the International Finance Facility for Immunisation (IFFIm) and the pilot Advance Market Commitment (AMC) for pneumococcal vaccines (see glossary) (Figure 1). The Bank has made substantial contributions to these two mechanisms, as discussed in Chapter 2. GAVI also has a Matching Fund that matches corporate donations. Figure 1. Contributions and Pledges to GAVI (2000 - Present) Source: GAVI Alliance Website. 2 CHAPTER 1 THE WORLD BANK GAVI PARTNERSHIP AND THE PURPOSE OF THE REVIEW 1.7 Since its inception, GAVI has committed US$8.4 billion for vaccine support and immunization-related, health-sector development and disbursed over US$6 billion to 76 countries, making GAVI the third largest multilateral funder in health, after the Global Fund and the World Bank.1 From a country perspective, GAVI is considered a donor with a categorical (single-purpose) mandate, without strong field presence, instead relying heavily on partners, such as UNICEF and WHO, to support country activities. Most support is for the vaccines themselves, with some funding also going to health systems strengthening, immunization services, and other programs (Figure 2). Annual commitments by GAVI have increased from US$26 million in 2001 to US$700 million in 2011. To be GAVI-eligible, countries must have per-capita Gross National Income (GNI) below US$1,570 (adjusted annually for inflation); as of April 2014, 53 countries were eligible for GAVI support.2 These countries can apply for any of GAVI’s support programs. Figure 2. GAVI’s Commitments to Countries (from inception until August 31, 2013) Source: GAVI Alliance Website. 1.8 GAVI’s funding and capacity building have been credited with contributing to substantial increases in vaccination rates in low-income countries. Over the 2000- 2013 period, GAVI support has contributed to the immunization of an estimated additional 440 million children and the global immunization coverage rates have increased from 70 to 83 percent, which has been essential in the continuous decline in the global under-five mortality rate.3 External evaluations in 2007 and 2010 of GAVI highlight that, in addition to improving access to vaccines, GAVI has 3 CHAPTER 1 THE WORLD BANK GAVI PARTNERSHIP AND THE PURPOSE OF THE REVIEW contributed to strengthening health systems, improving vaccine storage and delivery, getting immunization onto national and international health agendas, and stimulating vaccine research and development.4 1.9 External evaluations conclude that GAVI’s rising profile and advocacy have raised the issue of immunization at the international level. The Decade of Vaccines (2011-2020) envisions “a world in which all individuals and communities enjoy lives free from vaccine-preventable diseases” by extending “the full benefit of immunization to all people, regardless of where they are born, who they are, or where they live.”5 In May 2012, the Sixty-fifth World Health Assembly adopted the Global Vaccine Action Plan which calls on stakeholders, including the World Bank, to take actions in order to achieve the vision for the Decade of Vaccines. The Global Vaccine Action Plan proposes six strategic immunization objectives:  all countries commit to immunization as a priority;  individuals and communities understand the value of vaccines and demand immunization as their right and responsibility;  the benefits of immunization are equitably extended to all people;  strong immunization systems are an integral part of a well-functioning health system;  immunization programs have sustainable access to predictable funding, quality supply, and innovative technologies; and  country, regional, and global research and development innovations maximize the benefits of immunization. 1.10 Actions called upon to which the World Bank could contribute include: coordinate synergies between immunization and other health services; promote sustainable national funding; pursue innovative financing and procurement mechanisms; improve technical assistance to strengthen immunization and health systems; and promote equity and affordability for low- and middle-income countries.6 1.11 Thus, the international development community has called upon the World Bank to contribute its expertise toward shared immunization goals. Doing so would appear to be in line with the World Bank Group strategy and its emphasis on partnership and would build on the Bank’s first-rate contribution to set up innovative finance for immunization. Yet this review finds that the reality is rather the opposite: the Bank has diminished its activities in immunization, at least for some time. 1.12 Several external evaluations and assessments have reviewed GAVI’s performance. The latest full evaluation, the Second Evaluation Report completed in 4 CHAPTER 1 THE WORLD BANK GAVI PARTNERSHIP AND THE PURPOSE OF THE REVIEW 2010, focuses primarily on GAVI’s strategic period from 2006 to 2009. The evaluation praises GAVI for: attracting increased funding for immunization, the development of innovative financial instruments, the accelerated introduction of vaccines in low- income countries, and the country ownership approach. GAVI’s support is described as cost-effective and life-saving. The evaluation also discusses weaknesses of GAVI’s strategy and performance framework, particularly how GAVI’s activities have been insufficiently aligned with its strategy.7 The report notes the need for better prioritization of secretariat and partner resources, GAVI’s failure to prioritize monitoring and evaluation (M&E), and the poor accountability between GAVI and its implementing partners. The report also highlights GAVI’s weak performances in reducing vaccine prices and its issues with the Health Systems Strengthening (HSS) delivery model. Furthermore, the report notes that GAVI’s choice of vaccines and basic funding model has adverse implications for country financial sustainability.8 1.13 In recent years, some development partners have assessed GAVI in terms of value added, aid effectiveness, and alignment and relevance to their development objectives. The United Kingdom Department for International Development (DFID) Multilateral Aid Review 2011 assessed 43 organizations on relative value for money spent. GAVI is rated as “very good value for money” for delivering cost-effective health interventions, being innovative and transparent, and taking a country-led approach. The review also notes that GAVI needs to focus on further reducing vaccine prices. Sweden’s 2011 assessment rates GAVI as highly relevant to Swedish development assistance policy, stating that it has a very high level of internal and external effectiveness with an efficient and responsive secretariat. Australia’s Multilateral Assessment of GAVI from 2012 rates GAVI highly on delivering results, transparency and accountability, partnership behavior, cost and value consciousness, strategic management and performance, contribution to the multilateral system, and alignment with Australia’s interest. Purpose of the Review 1.14 The Independent Evaluation Group (IEG) undertook this review because global partnerships are strategically important to the World Bank Group, and the GAVI Alliance is one of the largest global partnership programs in which the Bank is involved. GAVI is a major player in global health; it is one of a growing number of large partnerships that finance country-level investments to help countries achieve specific MDGs that have inclusive governance structures, and that subscribe to the 2005 Paris Declaration on Aid Effectiveness (other such programs include the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Climate Investment Funds; and the Global Program for Education). 5 CHAPTER 1 THE WORLD BANK GAVI PARTNERSHIP AND THE PURPOSE OF THE REVIEW 1.15 This review focuses on the Bank-GAVI relationship and assesses the performance of the Bank in the three major roles that the Bank plays in GAVI:  Financial partner: what has been the Bank’s performance in financing GAVI, chiefly in helping to establish and manage the treasury and other functions of its innovative financial vehicles, the International Finance Facility for Immunisation (IFFIm) and the pilot Advanced Market Commitment (AMC) for vaccines?  Development partner at global and country levels: what is the relevance of the World Bank to GAVI and of GAVI to the Bank? How has the Bank engaged with GAVI at the country level? What has been the experience of the Bank and GAVI in relation to the changing international aid architecture for health?  Corporate governance partner and founding member of the GAVI Alliance: how has the Bank fulfilled its roles as a founding member and full voting board member of GAVI since inception, and how has it managed the potential conflicts of interest among the Bank’s multiple roles in the Alliance? What has been the impact of GAVI’s 2008 governance reform on its partnership with the Bank? 1.16 The review aims to provide strategic inputs into the Bank’s partnership with GAVI, draw broad lessons for the Bank’s involvement with other global health partnerships, and, along with IEG’s other work on partnership programs, inform the Bank as to how well its regional and global engagements align with the World Bank Group twin goals. Such alignment is a key component of the new Bank Group strategy, which notes that “global engagements represent an important opportunity for the World Bank Group to make an impact on development, but this rapidly growing role also places additional demands on the Bank Group that it must ensure are aligned with the goals.”9 Improved alignment and stronger engagement between the Bank and GAVI was also emphasized in the Bank’s 2007 Health-Sector Strategy.10 This review also seeks to add value to the World Bank and GAVI beyond what is contained in the two evaluations of GAVI (neither of which specifically address the Bank’s role and performance), and the evaluation of IFFIm. The review builds on IEG’s experience in reviewing the Bank’s involvement with a growing number of Partnership Programs.11 The review does not assess the effectiveness of GAVI, its financing mechanisms, and its corporate governance. 1.17 This review is structured as follows: Chapter 2 reviews the Bank’s performance in financing GAVI. Chapter 3 assesses the Bank’s role as global and country-level development partner. Chapter 4 discusses how the Bank has contributed to GAVI’s corporate governance. Chapter 5 draws conclusions and lessons. Annexes contain supportive evidence. 6 CHAPTER 1 THE WORLD BANK GAVI PARTNERSHIP AND THE PURPOSE OF THE REVIEW Data, Methodology, and Timeframe 1.18 The review covers the period from 2000 to mid-2013, but with a focus more on the recent phases from GAVI’s Phase II (2007) to the present Phase III. Developments in the relationship between the World Bank and GAVI since mid- 2013 are also noted in this review. 1.19 The review applies IEG’s standard global program review methodologies which IEG developed over several years and applied in its reviews of 23 global partnership programs with World Bank participation. Following the evaluation framework outlined in the Approach Paper, the following primary data and information were gathered, analyzed, and triangulated using IEG best practice evaluation methodologies:  Document review of the GAVI and World Bank strategies and operations in the health sector, including the role of the health sector in the Bank’s country assistance strategies;  Portfolio review of the Bank’s immunization-related, health-sector operations;  Document review of GAVI, IFFIm, and AMC Evaluation reports;  Electronic survey of Bank staff managing immunization activities;  Structured interviews, mostly face-to-face and using a common question outline, of key staff and management in GAVI, World Bank, UNICEF, WHO, and other partners. In the Bank and GAVI, these interviews covered nearly all of the managers and key staff responsible for or involved in the relationship (see list of interviewees in Annex G);  Interviews with select GAVI board members;  Missions to Ethiopia, Indonesia, Nepal, and Tajikistan; discussions in Ghana. Interviews with staff from the Bank, and partner agencies, and countries’ Ministries of Health and Finance;  Review of the academic literature on the AMC; Review of the Bank’s immunization portfolio. 7 2. The World Bank as a Financial Partner to GAVI 2.1 This chapter assesses the World Bank’s contributions to GAVI’s finances. The Bank’s most significant contribution to GAVI is helping to establish and manage two innovative financing mechanisms, the International Finance Facility for Immunisation (IFFIm) and the Advanced Market Commitment (AMC) for pneumococcal vaccines. They have contributed one-third of GAVI’s financial resources from 2000 to 2010 and both represent pilot models of globally innovative development finance. 2.2 The Bank’s financial relationship with GAVI and IFFIm has been highly competent and professional and deserves widespread recognition. Operationalizing the IFFIm and AMC instruments required the Bank to assume financial risk, develop new systems, and make a long-term commitment. The Bank assumed a direct balance sheet risk on behalf of AMC and used its excellent credit rating to place IFFIm bonds. The Bank reviewed these commitments at the Board level and worked consistently to launch and implement two complex and somewhat risky innovative financial vehicles. The Bank subsidized the system development costs of IFFIm. 2.3 The key lesson of this chapter is that the Bank has a unique capability to assist the international development community with setting up and running innovative finance for development, even if the two specific GAVI-related pilots are unlikely to be replicated. Setting up an International Finance Facility for Immunisation ORIGIN AND ESTABLISHMENT OF IFFIM 2.4 The United Kingdom (UK) and Goldman Sachs proposed the concept of an International Finance Facility (IFF) as a new vehicle for development finance, and the Bank was critical in translating and implementing this concept. Health spending was seen as needing to be scaled up, and the IFF concept was conceived as an innovative way to cover the funding gap required to meet the MDGs. The basic concept—that aid pledges can be used to issue bonds that raise funds for development—was initially proposed for piloting by Gordon Brown, then UK Chancellor of the Exchequer, in 2001 and further developed with input from Goldman Sachs and set out in a UK Treasury paper in 2003. 2.5 An IFF for Immunisation (IFFIm) was raised at the World Health Assembly in 2004 and discussed at the Group of Eight Highly-industrialized Nations (G8) meeting in 2005. The World Bank became involved in the detailed design work on IFFIm at the end of 2005. IFFIm was launched in 2006 to pilot the innovative 9 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI financing mechanism with GAVI as the implementing partner and the World Bank as the Treasury Manager.1 IFFIm was incorporated as a UK charitable company in June 2006. 2.6 IFFIm is thus a pilot application of a general conceptual innovation in which aid pledges by sovereign donors can be used to leverage private capital. Immunization was chosen to test the IFF concepts because it has features consistent with the requirements of the IFF concept: it is a cost-effective intervention that offers positive externalities and contributes to economic and social development. IFFIm raises funds on international capital markets by issuing bonds, colloquially referred to as “vaccine bonds.” IFFIm’s assets against which it issues bonds are long-term, legally binding grant agreements from sovereign donors. IFFIm uses these grant payments to pay the principal and interest on its bonds. 2.7 IFFIm addresses not only the constraints of high vaccine prices and irregular supplies by frontloading resources, it also provides predictable resource flows that it hopes will increase market volumes, attract new investment in vaccine research and production, and improve market stability. 2.8 The World Bank provides treasury management services to IFFIm. The donor countries wanted to keep IFFIm’s running costs low by utilizing existing organizations. IFFIm operates without staff and outsources its functions to the GAVI Secretariat and the World Bank. Key donors wanted IFFIm to have highly conservative financial and risk management policies; AAA credit ratings; and for the treasury manager to have supranational status.2 A competitive tender was undertaken for the treasury management services, and the World Bank emerged as the only qualified bidder (the donor requirements restricted the number of available bidders). As a result, the IFFIm Board had to directly negotiate with the World Bank for the treasury management services. 2.9 Obligations and responsibilities were very clear at the outset.3 The founding legal agreements were signed in September 2006 by all parties involved in IFFIm. The Finance Framework Agreement (FFA) governs the GAVI-GFA-IFFIm-World Bank-donor relationships (Figure 3). 10 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI Figure 3. . IFFIm Process Source: Constructed by IEG from information from the GAVI Alliance Annual Financial Report 2010. FINANCING IFFIM 2.10 The governments of the UK, France, Italy, Norway, Australia, Spain, the Netherlands, Sweden, and South Africa have committed funds totaling over US$6.3 billion to IFFIm over a period of 23 years. IFFIm bonds have raised approximately US$4.55 billion since the program’s inception, and IFFIm has used the proceeds to fund GAVI programs and refinance its debt (Figure 3). The upfront costs of establishing IFFIm and gaining access to the financial markets have been paid, yet as noted in the external evaluation, the full potential of the IFFIm mechanism has not been utilized because its assets are not sufficiently large and are highly concentrated on a few donors.4 New donors had been expected to join IFFIm, but this has yet to be realized.5 Future funding from IFFIm is in decline (unless it is replenished) just as GAVI is embarking on an ambitious spending program. 11 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI Evaluation of the International Finance Facility for Immunisation (IFFIm) Figure 4. . IFFIm Donor Commitments and Funds Raised, 2006-2030 6. Use of IFFIm Funding and Health Impact 1. Overall Impact of IFFIm on GAVI Finances IFFIm has had a huge impact on GAVI’s spending power. Since 2006 IFFIm has accounted for some 64.0% of GAVI spend and has accounted for 49.2% of total GAVI spend since its inception. GAVI’s income year by year is shown in Figure 38. IFFIm has enabled GAVI to move from being something of a niche player – spending less than $200m a year – towards what GAVI senior management consider its ideal “cruising altitude” of over $1bn per annum. Figure 38 Source: Source: GAVI Alliance Website. Source: GAVI Secretariat Figure 5. . Cash Received by GAVI by Source (1999-2009) However, investment - based on current IFFIm pledges – will start to decline from 2012 Source: Person and others, 2011, pp 136. Note:just BMGF as Bill andis GAVI is the embarking Melinda on a very ambitious expansion programme. Figure 39 below - Gates Foundation. based on data presented at the November 2010 Kigali Board meeting sets out current commitments to GAVI against projected spending. Commitments will, no doubt, increase over time as donors make new commitments - especially those who tend to do so only on an annual basis. Nevertheless, this does re-emphasise concerns about sustainability - for GAVI specifically but also for the IFFIm model. 12 278789 - Evaluation of the International Finance Facility for Immunisation 136 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI 2.11 From IFFIm’s inception in 2006 to June 2013, IFFIm has provided US$2.4 billion to GAVI, funding 47 percent of GAVI programs in that period.6 Funds from IFFIm allowed GAVI to ramp up its commitments and disbursements: GAVI’s average annual commitments more than doubled from US$196 million during 2004- 2006 to US$474 million during 2007-2009.7 IFFIm has proven to be a very effective financial mechanism to frontload funding for GAVI. 2.12 The Bank’s role as treasury manager is critical for IFFIm’s position as a supranational and has allowed IFFIm to raise funds in the AAA bond markets on very favorable terms, including spreads that have been lower than the weighted average of donor’s borrowing costs. The World Bank’s reputation, participation, and credibility have benefited IFFIm which is perceived as a “World Bank surrogate” by investors. For example, IFFIm suffered only minor negative returns during the recent recession starting in 2008 and was able to issue bonds in the Japanese foreign currency denominated bond market (Uridashi market).8 IFFIM’S GOVERNANCE AND MANAGEMENT 2.13 IFFIm is a multilateral development institution incorporated as a private company and registered as a charity in England and Wales. IFFIm works with the GAVI Alliance and the World Bank treasury department to achieve its objectives. As a registered charity in the UK, IFFIm is accountable to the UK Charities Commission and prepares an annual trustees report and financial statements for the Charity Commissioners. The complicated IFFIm governance arrangements were chosen to satisfy the Eurostat regulators in order to allow for off-budget financing by donors.9 THE WORLD BANK’S ROLE AND RESPONSIBILITIES AS TREASURY MANAGER OF IFFIM 2.14 The Treasury Management Agreement (TMA) sets out the legal relationship between the IFFIm Board and the World Bank in relation to policy and treasury management functions.10 The Bank provides IFFIm with a comprehensive set of financial services: development and execution of market-based financing strategies and funding operations, liquidity and investment management, risk monitoring and asset-liability management, tracking of donor grants and payments, and accounting and reporting.11 The Bank is compensated for these services on a cost-recovery basis; earned fees from the IFFIm TMA are US$16.6 million since 2006. 2.15 The Bank maintains a single, commingled investment portfolio for IFFIm, as well as assets held in trust for other Bank Group institutions. The Bank also manages the risk on derivative contracts, executes a swap program, and is counterparty on all of IFFIm’s currency and interest swap contracts.12 “IFFIm’s liquid assets are invested in high-grade, fixed-income instruments with interest rate sensitivity matching that of the liabilities funding IFFIm’s projected investment portfolio.”13 If the Bank determines that the funds it manages are insufficient to meet all of IFFIm’s financial 13 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI obligations, it is empowered by the FFA, which governs the GAVI-IFFIm-World Bank donor relationships, not to comply with a GAVI request for disbursement.14 2.16 There have been differences in the interpretation of the TMA, particularly concerning the authority of the Bank in executing an approved strategy, including all individual transactions. There have also been some differences in opinions on the Bank’s conservative investment management strategy.15 The relationship between IFFIm Board and the World Bank has evolved over time; improved communication and engagement between the World Bank, IFFIm Board, and GAVI have ameliorated most, but not all, of the differences between the entities. Further clarity may be needed on the World Bank’s services to the IFFIm Board. Overall, the relationship between the Bank and GAVI has been cordial and professional, despite the complicated governance structure of IFFIm. 2.17 The World Bank was essential in the setup of IFFIm. The Bank was one of only a few Multilateral Development Banks (MDBs) capable of performing the roles and functions required for IFFIm, understanding the complexity of IFFIm, and subsidizing the systems development costs. Furthermore, liquidity management by the Bank’s Treasury Department has generated more revenues than costs to IFFIm.16 However, there are indications that the Bank’s essential contributions—setting up and running a new complex innovative financing mechanism and intermediating long-term financial hedges—may not have been sufficiently recognized by GAVI and other partners. 2.18 The credit downgrade of IFFIm is a major development that the Bank has navigated well. IFFIm’s financial strategy required excellent credit ratings in order to qualify for low yields. Under the original FFA, any new GAVI programs to be funded by IFFIm could not be approved by IFFIm if it is not rated “AAA” by two of the three major agencies. In 2012, IFFIm revised the minimum rating to “AA”. The main risk to IFFIm’s credit rating is the credit ratings of its key donors, specifically the credit ratings of the UK and France whose commitments jointly represent more than 70 percent of IFFIm assets. The three credit rating agencies have linked IFFIm’s rating to those two countries’ ratings. In November 2013, Standard and Poor’s Ratings Service lowered the long-term issuer credit rating for France and IFFIm to “AA.”17 Moody’s and Fitch downgraded France’s credit rating in November 2012 and July 2013, respectively. In early 2013, Moody’s Investor Service and Fitch Ratings downgraded the UK to AA+ rating; subsequently, IFFIm’s credit rating was also downgraded by the two credit rating agencies. Presently, IFFIm is not rated “AAA” (or its equivalent) by any of the three major international rating agencies.18 2.19 Under the agreed terms, IFFIm’s credit downgrades allow the World Bank the right “to call for collateral to protect against its exposure on IFFIm’s derivative positions.”19 The Bank decided not to exercise this right. Instead, the Bank added 14 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI “an additional buffer to the existing gearing ratio limit to manage the exposure for the World Bank under the derivative transactions entered into between IFFIm and the World Bank.”20 This prevented further negative effects on IFFIm’s credit rating. 2.20 IEG finds the Bank showed appropriate flexibility in making an exception to its practices of calling collateral, instead mitigating the risk through changes to the gearing ratio. It would be appropriate to determine if there is a potential for the World Bank’s reputation to be harmed if IFFIm continues to be viewed and presented as a “World Bank surrogate.” EXTERNAL EVALUATION OF IFFIM 2.21 The GAVI Secretariat, on behalf of the IFFIm Board, commissioned the consulting company Health and Life Sciences Partnership (HLSP) to carry out an evaluation of IFFIm. The Evaluation of the International Finance Facility for Immunisation Report, published in June 2011, concludes that IFFIm is now a proven concept but is not, on its own, a sustainable model and is unlikely to be replicable for other health-sector initiatives.21 Long-term, predictable donor funding would be preferable, as such IFFIm can be considered an efficient “second best solution” to providing international development financing by offering features such as predictability which traditional aid does not provide. 2.22 The Bank’s performance of treasury functions received high marks by the evaluators. In its stewardship of IFFIm, the Bank has clearly been a vital and effective financial partner to GAVI. It has fulfilled its roles and responsibilities as treasury manager exceptionally well, managed liquidity well, and used its supranational status and conservative risk management approach to the advantage of IFFIm. The World Bank has added credibility to IFFIm through its conservative policies and investment management which reassures investors’ confidence in IFFIm as a World Bank-managed vehicle. Discussing various risks, the evaluators consider the highest risk to IFFIm to be the loss of the World Bank as its treasury manager, something which would make it cease to be perceived as a “World Bank surrogate” by investors and therefore face sharply higher borrowing and refinancing costs. The evaluation also makes the point that the “the importance of the World Bank’s participation is overlooked.”22 The report remarks that the “World Bank’s reputation, credibility, and strong AAA ratings were absolutely critical to IFFIm being able to qualify as a supranational; zero percent risk weighting, AAA credit ratings, and investor confidence all depended in part on the World Bank’s participation.”23 Without the World Bank’s participation, IFFIm’s entire structure would have been different and the feasibility of IFFIM would need to be re- evaluated. 2.23 IEG considers the evaluation to be of high quality and concurs with the main conclusions. IEG agrees that IFFIm has proven to be a very effective, predictable, 15 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI and flexible financial mechanism to frontload funding for GAVI, but that it is unlikely to be replicated in the current format in the health sector. In part, this is because the total (including non-World Bank) legal, administrative, financial management, and governance costs are rather high and because of the drawbacks of frontloading, namely that, unless it is replenished, IFFIm will be going into repayment mode at a time when GAVI’s spending and financing needs are peaking. Advanced Market Commitment to Spur Vaccine Development ORIGIN AND ESTABLISHMENT OF THE AMC 2.24 The AMC for pneumococcal vaccines was launched as a pilot program in June 2009. The concept of an AMC for vaccines was conceived in 2005.24 In an AMC, donors commit funds to guarantee the price of medicines once they have been developed. The AMC provides an innovative financing mechanism for accelerating access to life-saving medicines in low-income countries and reduce the time gap between access to new vaccines in industrialized countries and low-income countries by incentivizing pharmaceutical manufacturers to develop and manufacture medicines for diseases more prevalent in low-income countries. Thus, the AMC is another instance where the Bank helped turn a conceptual idea into a viable pilot for innovative development finance. 2.25 With support from the World Bank, the Government of Italy presented a proposal for a pilot AMC for vaccines (the “Tremonti report”) to the Group of 8 (G8) Finance Ministers in December 2005. The World Bank and GAVI were asked to co- lead the design of a pilot AMC, and an advisory group was formed to provide insight and support. In 2006, an Independent Disease Expert Committee recommended pneumococcal disease as the candidate to pilot the AMC concept.25 2.26 A study conducted by GAVI and World Bank staff recommended that the optimal arrangement for an AMC would be for GAVI to host the AMC Secretariat and provide the programmatic functions, with the Bank providing financial and fiduciary functions.26 The World Bank and GAVI signed the AMC Legal Agreements in June 2009, which were subsequently revised in March 2011 to incorporate lessons learned from the first year of implementation. GAVI funds the vaccine purchase, UNICEF procures the vaccines from manufacturers, and the Bank provides the financial platform for the AMC, which includes taking on the financial risk of donor default on its own balance sheet (Figure 6).27 16 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI Figure 6. . AMC Process Source Constructed by IEG from information from the GAVI Alliance Annual Financial Report 2010. 2.27 The AMC pilot for pneumococcal vaccines was formally launched in June 2009 with US$1.5 billion legally binding commitments from Italy, the United Kingdom, Canada, the Russian Federation, Norway, and the Gates Foundation for the purchase of 2 billion doses of pneumococcal conjugate vaccines. In addition to the donor commitments, GAVI has also budgeted US$1.3 billion for the period 2010- 2015 to help fund vaccine costs.28 2.28 The overarching goal of the pilot AMC is to reduce morbidity and mortality from pneumococcal diseases in low-income countries. GAVI hopes to achieve this goal by (i) accelerating the development of vaccines that meet developing country needs; (ii) bringing forward the availability of pneumococcal vaccines by scaling up production capacity; (iii) accelerating vaccine uptake through predictable vaccine pricing; and (iv) testing the AMC concept for potential future applications. 17 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI Figure 7. AMC Funding Structure (Illustrative Example) Source: GAVI Alliance, 2011, “The Pilot Advance Market Commitment for Pneumococcal Vaccines (AMC): Lessons Learned on Disease and Design Choices and Processes,” pp. 12. AMC FUNDING AND OPERATIONS 2.29 Donors commit funds to the AMC to subsidize the purchase of pneumococcal vaccines at an affordable price for developing countries, thereby offering vaccine manufacturers a long-term, guaranteed market price. The AMC functions as an offer agreement for the manufacturers of pneumococcal vaccine to supply a proportion of the targeted demand of 200 million doses annually for 10 years at a maximum price (tail price) of US$3.50. This is more than a 90 percent reduction from industrialized country prices in 2009.29 The agreement also provides each manufacturer an additional payment equal to US$7.00 minus the tail price per dose, for approximately 20 percent of the doses they provide (Error! Reference source not found.). This additional top–up price is to help manufacturers recover the incremental cost of building up additional production capacity. 2.30 It is expected that the AMC will encourage multiple manufacturers to set up production and that competition will lower prices over time. There are presently two AMC-approved manufacturers (GlaxoSmithKline and Pfizer) while two Indian manufacturers are registered for the AMC and working to develop a vaccine. As of April 2014, 51 eligible countries have been approved to receive pneumococcal 18 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI vaccine support and over 25 countries have introduced pneumococcal vaccines.30 The unprecedented country demand and rapid introduction of pneumococcal vaccines have led to temporary shortages of supply and postponement of vaccine introduction in some countries.31 THE WORLD BANK’S ROLE IN AMC’S FINANCIAL PLATFORM 2.31 The World Bank provides fairly standard financial management and administrative services with respect to donor contributions and AMC commitments and disbursements. Donors make grant payments to the World Bank in accordance with specific schedules or through a demand-based payment agreement; fixed- payment donors have pledged US$765 million and on-demand donors have pledged US$735 million (Table 1). The Bank holds the donor contributions in trust for GAVI and informs GAVI about the amounts being held and available for disbursement on a quarterly basis. Table 1. Contribution Receipts from AMC Donors, as of March 31, 2013 Contribution Amount Paid-in Amount Remaining Balance Fixed Schedule Donors Italy 635,000,000 263,334,056 371,665,944 Russia 80,000,000 32,000,000 48,000,000 Gates Foundation 50,000,000 40,000,000 10,000,000 On Demand Donors UK 485,000,000 93,333,874 391,666,126 Canada 200,000,000 173,297,577 26,702,423 Norway 50,000,000 50,000,000 - Total 1,500,000,000 651,965,507 848,034,493 Source: GAVI Alliance, 2013, Pneumococcal AMC Annual Report, pp.24 2.32 The Bank also takes on an exceptional financial risk associated with donor default on its own balance sheet. The Bank has committed to pay AMC funds to GAVI regardless of whether or not donors actually pay on schedule or default. The purpose of this additional commitment is to enhance the predictability of AMC funding, even if the funds have not been received on schedule from donors.32 This financial risk is transparently disclosed on International Bank for Reconstruction and Development (IBRD’s) balance sheet and IBRD is compensated by a 30 basis point premium on outstanding grant payments not yet paid by AMC donors.33 2.33 The Bank deserves recognition for having translated the AMC concept into a pilot financial mechanism; even if it is unlikely to be replicated in the health sector (its many critics contend that it is not a cost-effective way to subsidize vaccine development, see Annex B). The AMC has achieved its objectives of increasing the supply and accelerating the uptake of pneumococcal vaccines in low-income 19 CHAPTER 2 THE WORLD BANK AS A FINANCIAL PARTNER TO GAVI countries, and it has inspired somewhat similar innovative financing mechanisms for development in other sectors, such as AgResults Initiative, Low Carbon AMC, Emission Reduction Underwriting Mechanism, and Sustainable Energy Sources.34 The Bank is involved in some of these new mechanisms. Conclusions and Lessons on the Bank’s Contributions to Innovative Finance on Behalf of GAVI 2.34 The Bank’s most significant contribution to GAVI is helping to develop, establish, and effectively manage two major innovative financing mechanisms which have helped GAVI become a major organization in global public health and expand immunization in low-income countries. The Bank has proven twice that it can turn conceptual ideas into viable financial pilot models and raise substantial funds for its partner, GAVI in this case. The Bank has devoted significant time and resources to this task, and has assumed financial risks (for the AMC) and potential reputational risks (for both AMC and IFFIm). The Bank’s relationship with GAVI in the financial management of IFFIm and AMC has been collegial and effective. 2.35 Leveraging resources and partnerships with the private sector and pursuing innovative finance are major aspects of the new World Bank Group strategy. The Bank’s work on behalf of GAVI is an example of just this. Even if the two specific GAVI-related pilots are unlikely to be replicated in their current form, there are lessons for the Bank and its partners for any future attempts to set up innovative development finance:  Find ways to keep total costs down: financial mechanisms can be costly to set up and operate.  Keep governance arrangements simple and maintain a clear division of labor: some aspects of the arrangements are complex and burdensome.  Ensure appropriate Bank recognition and reasonable protection against reputational risks associated with its work on innovative finance on behalf of partners: although IEG saw no evidence that controversies surrounding the AMC impacted the Bank’s reputation, a real risk existed.  Innovative finance does not necessarily equate with new, additional resources for development. Private investors expect to be repaid. In the case of IFFIm, the financial mechanism borrowed from future aid to finance and accelerate the introduction of vaccines today.  Balance the long-term financial risks and obligations of these arrangements against their short-term benefits: both mechanisms have long-term financial consequences for the Bank and its partners that need to be carefully considered. 20 3. The World Bank as Development Partner to GAVI 3.1 The new World Bank Group strategy highlights the need for stronger alignment between the Bank Group’s global engagements and the twin goals of eliminating extreme poverty and boosting shared prosperity.1 This is not a new issue for the Bank Group. Successive Bank strategy documents and IEG evaluations have stressed the need for effective operational linkages between partnership programs and Bank country operations.2 The key issue is how well the Bank Group aligns its global and regional engagements with its country-based model. How effectively does the Bank capture potential synergies and linkages between global and regional engagements to enhance development effectiveness at country level? 3.2 This chapter assesses the performance of the World Bank as a development partner to GAVI at the country level. The chapter discusses the relevance of the Bank to GAVI and vice versa and reviews the World Bank’s engagement in immunization activities and related donor coordination at the country level. 3.3 The key finding is that the Bank has reduced its analytical, financial, and policy dialogue engagement in immunization for a period beginning in 2008 until recently, even though its expertise potentially could have improved development outcomes. Although the relationship with GAVI has been constructive in countries where there is engagement, in many countries the Bank is no longer involved in immunization in any substantive manner. IEG country visits and interviews with sector staff from inside and outside the Bank suggest that the Bank has opportunities to bring its expertise on health systems, health financing, and health equity to bear on countries’ immunization subsectors in a manner that would be highly complementary to GAVI’s support. For the Bank, its collaboration with GAVI, or lack thereof, exemplifies a case of opportunities for stronger linkages between a major global partnership and its country programs. Opportunities for Stronger Development Effectiveness in Immunization 3.4 GAVI provides extensive vaccine and related support but this support does not cover all aspects of a country’s immunization needs, in part because the GAVI Secretariat by design has no country-level presence and relies heavily on its partners in the country.3 Policy dialogue, technical assistance, and operational support that might help countries reap the full benefits of immunization and ensure sustainable financing of vaccines have been left to partners (often UNICEF and WHO). Reliable data on immunization coverage that can help advance policy dialogue on health equity is not always available, as seen for example in Ethiopia; the GAVI Secretariat and its partners have no mechanism to identify and remedy such deficiencies. 21 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK Partners operate with their own mandates and priorities that, naturally, do not necessarily align with those of GAVI or seek to fill gaps in GAVI’s country support.4 The result is a risk to the development effectiveness of all partners. GAVI is not unique: other major global programs such as the GEF and the Global Fund also operate without country offices and have set up their own mechanisms to coordinate dialogue and investments in-country (Box A.2 in Annex A). 3.5 There is a strong perception among senior GAVI staff interviewed for this review that re-engagement with the World Bank would be beneficial. UNICEF and WHO are GAVI country-level partners. Among other things, UNICEF procures vaccines, provides some operational assistance (for example with vaccine distribution), advocates for children’s issues, and offers some limited assistance for health systems development. WHO is the technical agency in the field. However, WHO and UNICEF do not always have routine policy dialogue with ministries of finance. GAVI perceives that the Bank could add value, particularly in financial sustainability and health systems strengthening, because of its institutional knowledge, relationships with ministries of finance, and the perception that it can be a lender of last resort. 3.6 IEG concurs, finding that the status quo (until at least recently) leaves potential organizational synergies untapped. As argued in the following, there is room for greater development results via stronger Bank involvement in:  Helping to ensure adequate and sustainable funding for immunization.  Addressing the serious inequities in access to immunization faced by many low- income countries.  Improving donor coordination in health in order to reduce transaction costs and avoid creating overlapping reporting and accounting requirements for client countries. Opportunities to Help Ensure Adequate and Sustainable Funding for Immunization 3.7 GAVI’s Co-financing Policy–which the Bank helped to develop and which came into effect in December 2008–is a vital part of GAVI’s sustainability strategy, requiring countries to co-finance the cost of most GAVI-supported vaccines.5 The policy’s objective is to prepare countries for financial sustainability when GAVI support for new vaccines ends and to encourage country ownership of vaccine financing. The degree of co-finance depends on countries’ income levels, and countries with GNI per capita above US$1,570 are no longer eligible to receive GAVI support. Between January 2011 and August 2013, co-financing payments from beneficiary countries totaled US$125 million, representing 8 percent of GAVI’s total vaccine support to the co-financing countries.6 22 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK 3.8 Although co-financing has supported country ownership of immunization decisions, evidence is sparse that the policy has contributed to creating a stable and predictable financial framework for immunization, particularly for low-income countries. There is a substantial risk that graduating countries may fail to sustain the financial investment in immunization and the performance of immunization programs after GAVI’s support ends. In 2012, two graduating countries, Angola and the Republic of Congo, failed to fulfill their co-financing commitments to GAVI (a situation known as “default”). In both countries the problem was weak budgetary and planning capacity rather than the availability of fiscal space.7 3.9 GAVI is concerned to ensure that graduating countries can sustain their immunization programs after graduation, particularly as GAVI’s external evaluations have prominently highlighted issues around the financial sustainability of vaccines, concluding “that GAVI’s choice of vaccines has not in practice been based on realistic considerations of the potential of low-income countries to take on the financing of these vaccines after GAVI support comes to an end.”8 IEG country visits also confirmed that sustainable funding for the GAVI-supported vaccine program could be questionable after graduation, for example in Ghana, Nepal, and Tajikistan. Some graduating countries (currently 20 countries with Gross National Income (GNI) per capita above US$ 1,570 as of April 2014) may not be able to continue financing the vaccines using domestic resources and would stop to provide them. Such “defaults”—as GAVI terms them—jeopardize the public health benefits of GAVI programs since vaccines obviously have to be provided on an ongoing basis. There may also be implications for GAVI’s resource mobilization efforts. 3.10 In Tajikistan, for example, immunization is under-financed by the government, highly dependent on donors, and lacking political support. The government covers 12.5 percent of immunization costs and relies heavily on international donor contributions. The world’s largest polio outbreak in 2010 raised serious concerns about the weakness of routine immunization services and reliability of reported coverage, highlighting the country’s shortcomings in vaccine management and equity issues. The Bank has conducted some relevant analytical work on immunization through a health expenditure tracking study and provided moderate financing for immunization up to 2008. In recent years, immunization has been a marginal priority for the Bank. Development partners are presently unsure of Tajikistan’s ability to finance immunization and the Bank has considered immunization largely as GAVI’s responsibility. But there has been no dialogue and little engagement between GAVI and the government on strategy, financing, and sustainability of immunization. IEG was informed that policy dialogue on the role of immunization in the national development agenda and how to finance immunization has not occurred. 23 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK 3.11 GAVI is increasing its attention to sustainable funding for immunization and has made it clear that it would like to see the Bank re-engage on fiscal sustainability of vaccines, including via policy dialogue at the country level. GAVI would like the Bank to help countries avoid defaults and ensure the sustainability of country immunization programs. As far as IEG could discern, critical discussions about the financial consequences of introducing new vaccines and the aggregate health-sector finance issues rarely made it onto the GAVI Board agenda in the past, even though as noted, the Bank had concerns. Sustainability issues are increasingly being discussed as part of the strategy development for the next phase of GAVI. 3.12 The World Bank’s experience in dealing with health-sector financing might have provided a critical assessment of GAVI’s current focus on the rapid introduction of new but more expensive vaccines (in comparison to the traditional, so-called Expanded Program on Immunization (EPI) vaccines). Increases in the overall health-sector budget (or re-allocation within the sector) may be required to sustain the new vaccines. Additional economic and fiscal analyses of vaccine choice, combined with policy dialogue, would have been warranted. Yet during the last five years, the Bank’s engagement with GAVI on policy issues related to vaccine sustainability and the consequences of GAVI’s programs and vaccine choices on countries’ health sectors has been limited and occasional. For example, a Bank managing director arranged a side meeting with a small number of African Ministers of Finance to discuss sustainable financing for immunization during the 2012 Annual Meeting in Tokyo; GAVI indicated that they would like a follow-up to the meeting. 3.13 The World Bank’s experience in dealing with questions of affordability and fiscal sustainability at the country level, including in conducting public expenditure reviews, would have been of great benefit to GAVI and graduating countries. IEG was able to identify only a few studies on financial sustainability of vaccines conducted by the Bank; IEG’s forthcoming evaluation of health-sector financing also identifies limited Bank work on public expenditure tracking and fiscal space analysis. GAVI has done some studies, paradoxically commissioning retired Bank staff as consultants. 3.14 IEG feels that the timing is favorable for a dialogue about these issues as the GAVI Secretariat is developing a strategy on how to better support graduating countries. Opportunities to Address Inequities in Immunization Access 3.15 There are serious inequities in access to immunization. For example, the gap in Diptheria, Tetanus, and Pertussis (DTP) coverage between the top and the bottom wealth quintile is 37 percentage points in Indonesia, 23 in Ethiopia, and 21 in Nepal 24 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK according to National Demographic and Health Survey (NDHS) data. Indonesia, for example, considers immunization to be a health priority, yet immunization coverage rates have remained stagnant around 75 percent for a decade. There is no regular direct communication at the country level between the GAVI and Bank staff. Other donors expressed regret about this, since enhanced collaboration would be mutually beneficial. 3.16 The gaps are larger in low-income countries with low immunization rates. These equity issues have been consistently raised by Civil Society Organizations (CSOs), think tanks, and some bilateral donors.9 Consider Ethiopia: immunization is highly inequitable between the highest and lowest income quintiles and between regions. The Bank has supported immunization in ways that are broadly complementary to GAVI’s program but does not engage directly with GAVI. Bank support helps finance health worker salaries under Promoting Basic Services (PBS, a multidonor operation, now in its third phase). This support is clearly enabling for the immunization program. PBS I and II also financed some medical procurement. A recently approved Program-for-Results operation uses immunization coverage as one of its disbursement-linked indicators. Apart from this the Bank has little direct engagement in immunization. 3.17 The equity discussion is often framed as a tradeoff between the introduction of newer costly vaccines and equitable and affordable access to childhood immunization (“is it appropriate to push newer costly vaccines when a large percentage of the population is uncovered by the old ones?”). But such framing as a simple tradeoff may be too narrow. Reaching marginalized groups with immunizations poses serious organizational difficulties for many countries. The problem is not about the availability of vaccines but rather about access to vaccination services, a problem related to weak service delivery combined with the impacts of inequality, social exclusion, and stratification. Slum dwellers, pastoral and nomadic groups, and minorities experiencing social exclusion are often hard to reach by health systems. 3.18 GAVI’s forthcoming strategic plan 2016-2020 intends to address these issues by deepening GAVI’s focus on improving coverage and equity of access to immunization. The Bank could provide analytical, policy dialogue, and other support in addressing these issues, depending on country context. Doing so would be consistent with the World Bank Group goal of shared prosperity and the Bank Group strategy’s aim to strengthen the alignment of its global engagements with its goals. The Bank’s engagement with GAVI should be in the context of equal partners rather than a contractual relationship, grounded in independent analysis and consistent with the Bank’s country-driven model. The Bank should be able to deepen its dialogue on immunization where relevant and demanded, especially when requested by clients countries, but it is unlikely that the Bank can commit to 25 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK contractual obligations to advocate on behalf of GAVI in its policy dialogue and analytical work in specific countries; this would counter its mandate of providing independent evidence-based advice to client governments. Opportunities to Coordinate Support to Health and Immunization via Global Health Partnerships 3.19 The proliferation of global health partnerships and vertical funds (of which GAVI is one) has heightened concerns about aid effectiveness and led to renewed attempts to improve donor coordination in health. Several global health mechanisms for donor coordination have been set up: (a) the International Health Partnership (IHP+), which was launched in September 2007 to accelerate progress in achieving all the health-related MDGs in accordance with the principles of the Paris Declaration and the Accra Agenda for Action (AAA); (b) Joint Assessment of National Strategies (JANS), launched in July 2009; and (c) the Health Systems Funding Platform (HSFP), launched in early 2010. A full assessment of these frameworks falls outside the scope of this evaluation, but the Task Team Leader (TTL) survey and country visits suggest that a good share of Bank-GAVI interaction has taken place in the context of one of these frameworks. The HSFP was for some time the most directly relevant for the Bank-GAVI relationship.10 3.20 The HSFP was instrumental for harmonizing financial management in the health sector. It was used to assess strengths and weaknesses of financial management and implement a joint program to strengthen financial management systems and move toward joint fiduciary arrangements. Under the HSFP, the first Guidelines for Joint Financial Management Assessments were produced, which were used in Ethiopia and Sierra Leone. Nepal, a pilot country for HSFP, has demonstrated that aid coordination can be successfully implemented when a development partner (the Bank in the case of Nepal) takes a leadership role spearheading the effort. HSFP has recently been subsumed into IHP+; the objectives of HSFP are captured in IHP+ and its activities have become redundant. GAVI has throughout been a consistent partner of the Bank in implementing financial management harmonization. 3.21 Nepal was a pilot country for HSFP and it is the only country so far where the HSFP has been implemented. Nepal has demonstrated that close donor coordination can be achieved and that the SWAp provides a suitable mechanism to this effect, using a “Joint Financing Agreement” (JFA) to pool funding from several donors, including the Bank and GAVI. Five non-pooling partners, such as WHO and U.S. Agency for International Development (USAID), have also signed the JFA which provides a common reporting system. The HSPF has considerably lowered transaction costs for both, the government and the partners and has provided stable financing for immunization in politically difficult times. 26 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK Box 1. The International Health Partnership IHP+ represents a group of partners working together to accelerate progress in achieving all the health-related MDGs in accordance with the principles of the 2005 Paris Declaration on Aid Effectiveness, 2008 Accra Agenda for Action, and the 2011 Busan Partnership Agreement. IHP+ currently has 59 members, including developing and developed country governments, development partners, and CSOs, involved in improving health and adhering to the commitments in the IHP+ Global Compact. IHP+ is intended to achieve better health results by mobilizing donor countries and other development partners around a single country-led, national health strategy, by improving coordination among actors, by strengthening health systems, by building momentum at the national level for improving existing country-led health plans, and by financial management harmonization and alignment. IHP+ is not a formal partnership program with a governing body or legally binding agreement between the partners in relation to governance. Its activities are coordinated by an interagency core team with WHO and Bank participation. Source: IEG, 2012, Global Program Review of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the World Bank’s Engagement with the Global Fund, pp.3 The Bank’s Limited Engagement in Immunization 3.22 As argued above, Bank engagement, technical expertise, and participation in donor coordination could potentially enhance the development effectiveness of immunization and complement GAVI’s financial support for vaccines. Yet the reality on the ground is not a vibrant Bank program, but rather one of limited engagement in immunization, both in lending and other areas. 3.23 The World Bank has provided approximately US$ 2.91 billion for “child health” between FY2003 and FY2012 through health-sector specific and multisectoral programs to reach the MDGs and assist people in developing countries to create healthy futures. The World Bank shares with the global health community the collective goals of universal childhood immunization and strengthening health systems.11 3.24 In the decade from 2003 to 2012, the Bank approved 390 projects with substantial engagement in health, of which 36 projects had an immunization-related objective or component (Table 2). Most projects with immunization objectives or components (18 of the 36) are HSS projects that contain immunization as an element of the general system support. In terms of internal organization, these immunization operations were largely mapped to the Health, Nutrition, and Population (HNP) sector board and span both investment credits and development policy operations. Direct financing of immunization was largely restricted to seven polio projects. In addition, five conditional cash transfer projects mapped to Social Protection reflected immunization objectives. And six projects mapped to the Poverty 27 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK Reduction and Economic Management (PREM) sector board used immunization targets as prior actions or conditionality for general budget support. Table 2. Immunization-related Projects by Sector Board Sector Board Polio Other - Share of total Non Total operations immunization- immunization related projects projects HNP 7 18 13.4% 164 189 SP - 5 8.1% 57 62 PREM - 6 4.1% 133 139 Total 7 29 9.1% 354 390 Source: World Bank data. Note: HNP=Health, Nutrition, and Population; SP=Social Protection; PREM=Poverty reduction and Economic Management. 3.25 The number of broadly immunization-related projects has been very limited in the Bank’s health-related lending, comprising 9 percent of all projects and 13 percent of projects mapped to HNP. Lending increased slightly in 2008 and decreased gradually since then. Immunization as a share of total approved health projects dropped from 15 percent in 2006 to less than 5 percent in 2012 ( Figure 8). Whereas the number of HNP projects declined over that time span, immunization disappeared entirely from projects managed by other sector boards. Over this time period, the Africa Region (AFR) had the largest number of immunization-related operations followed by Latin America and the Caribbean Region (LCR) and South Asia Region (SAR). There were very few immunization operations in the Middle East and North Africa Region (MNA), and most immunization operations in SAR focused on polio (Figure 9). A considerable number of Bank operations focused on middle-income countries that were not GAVI eligible, especially in Latin America and the East Asia and Pacific Region (EAP) (Figure 9). 28 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK Figure 8. Immunization Operations by Sector Board and as Share of Total Projects, 2003-12 5 25% Number of immunization projects 4 20% 3 15% HNP SP 2 10% PREM Share of total proj 1 5% 0 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: World Bank data. Figure 9. Regional Distribution of Immunization- Figure 10. World Bank Immunization Operations by related Operations GAVI Eligibility 14 12 19% 10 36% 3% 8 6 4 31% 2 11% 0 AFR EAP LCR MNA SAR AFR EAP LCR MNA SAR GAVI eligible Not eligible Source: World Bank data. 3.26 The Bank’s engagement in polio has been substantial and timely, committing US$779 million for vaccines and program support to key problem countries of the Global Polio Eradication Initiative (GPEI) (Table 3). In Nigeria and Pakistan, this was financed largely through buy-down options by the Gates Foundation. This funding was supportive but outside the direct GAVI mandate, as GAVI has so far been helping countries to expand routine childhood immunization, including 29 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK limited provision of oral polio vaccine (OPV). Recently, however, the GAVI Board approved support for the introduction of Inactivated Polio Vaccine (IPV) to bring GPEI to a successful conclusion. This vaccine will be added to routine childhood immunization for 73 GAVI-eligible and graduating countries, constituting a significant change to GAVI’s mandate. This may decrease the need for Bank funding for polio. Table 3. Polio Projects, US$ million Commitments US$ million Afghanistan 8 India 326 Pakistan 225 Nigeria 190 Congo, D.R. 30 Total 779 Source: World Bank data. Actual disbursements are slightly lower. LIMITED BANK-GAVI COUNTRY-LEVEL ENGAGEMENTS 3.27 The Bank has gradually refocused its attention and priority away from immunization in policy dialogue and investment since the creation of GAVI. Project documents, country assistance strategies a survey of TTLs (Box 2), searches for analytical work, and IEG’s country visits all indicate a limited Bank focus on immunization in recent years (apart from polio). The Bank has been far less involved with GAVI-supported activities at the country level than it has with the Global Fund, despite the fact that immunization is at the core of any public health program. Table 4. References to GAVI in Country Assistance Strategies and Project Appraisal Documents, Fiscal Years 2001–11. Sub- East and Europe Latin Middle South Total Saharan the and America East and Asia Africa Pacific Central and the North Asia Caribbean Africa Country Assistance Strategies 6 0 1 0 1 1 9 Project Appraisal Documents 18 1 2 1 3 5 30 Number of Different Countries 13 1 3 1 2 3 23 a Source: World Bank data a. Does not include countries in one regional project in Africa. (With the inclusion of regional projects, Africa would be 15 and the total would be 25.) 30 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK Table 5. References to the Global Fund in Country Assistance Strategies and Project Appraisal Documents, Fiscal Years 2003–10 Sub- East and Europe Latin Middle South Total Saharan the and America East and Asia Africa Pacific Central and the North Asia Caribbean Africa Country Assistance Strategies 23 2 13 6 0 1 45 Project Appraisal Documents 62 8 11 14 0 6 101 Number of Different Countries 31 6 13 8 0 5 63 a Source: World Bank data a. Does not include countries involved in 6 regional projects in Africa, 1 regional project in central Asia, and 2 regional projects in Latin America 3.28 IEG is not aware of any conscious Bank decision to withdraw from immunization lending and other support. Declining lending for immunization could be viewed as a natural consequence of the advent of relatively generous GAVI funding and a rational division of labor; however, this does not explain the decline in other types of Bank support for immunization and related HSS needs. 3.29 While no single causal reason can be identified, several factors could have limited the Bank’s engagement with GAVI-supported activities, including:  Lack of a GAVI counterpart in-country. Bank health-sector staff do not have an in-country GAVI counterpart to engage with. GAVI has country responsible officers to assist countries with immunization and development issues but they are based in Geneva.  Limited Bank participation in sub-sector coordination. The key coordinating mechanism for immunization services at the country level is the Interagency Coordination Committees (ICC), usually chaired by the Ministry of Health (MOH). Its membership includes development partners and organizations involved in immunization activities. According to interviews with Bank and GAVI staff, country health officials, and development partners, the number of countries in which the Bank actively participates in the ICC has substantially decreased to only a few countries presently. Anecdotal evidence suggests that Bank staffers have shifted their focus and time away from attending ICC meetings to other priorities in the health sector.  Absence of written guidelines and directives for Bank staff on how to engage with GAVI.  A perception that GAVI takes care of immunization and that the Bank can focus on other priorities in the health sector. 31 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK  Closing of the Bank-executed trust fund for immunization-related work (see next section). DIRECT BANK-GAVI TRUST FUND COLLABORATION HAS CEASED 3.30 There had been direct funding between the Bank and GAVI, flowing in both directions, but this has now ceased. Initially from 2001 to 2007, the Bank contributed US$8 million through its Development Grant Facility (DGF) to set up the GAVI Secretariat; it also helped implement certain GAVI activities (Table 6). From 2002 to 2006, the Dutch government provided an additional US$8.9 million in financial support through a Bank-executed trust fund for activities related to GAVI. Table 6. DGF Contributions to GAVI, 2001–07 (US$ millions) Year 2001 2002 2003 2004 2005 2006 2007 Amount 1.5 0.5 1.5 1.5 1.5 1.0 0.5 Source: World Bank data. 3.31 Subsequently, the resource flows changed as GAVI provided US$10 million in direct funding to the Bank’s country work on HSS through the Immunization and GAVI (ImGAVI) Trust Fund which was set up in 2007 but discontinued in 2011. The US$10 million ImGAVI Trust Fund was set up with funding from GAVI and housed at the Bank to finance Bank work on strengthening the capacity of client countries’ health systems to deliver immunization and other health services in a sustainable manner; accelerate the uptake and use of underused and new vaccines and associated technologies; improve vaccine supply security; and increase the predictability and sustainability of long-term financing for national immunization programs. The Administration Agreement stipulates that the Bank should provide an annual report on the activities financed by ImGAVI. IEG, however, was unable to locate any such progress reports and it appears that GAVI did not request them. 3.32 Judging from the grant reporting and monitoring documents—available for 30 of the total 46 ImGAVI activities—activities included technical assistance, studies and workshops on strengthening the capacity of countries’ health workforce and identification of critical gaps in child health services. The ImGAVI Trust Fund was used to strengthen health systems broadly; activities were not necessarily immunization-specific, but many activities related to child health. Most of the grants supported HSS (67 percent) often related to immunization sector finance and human resource management, which are areas of Bank comparative advantage. Twenty percent of ImGAVI activities supported immunization while 13 percent of activities were neither related to immunization nor to HSS, such as a pilot community nutrition project or hospital management strengthening (Figure 11). 3.33 IEG finds that the projects funded by the ImGAVI Trust Fund were used for meaningful country activities to strengthen health systems to deliver immunization 32 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK and maternal and child health services. But the activities did not fulfill many of the broader, rather ambitious objectives which the initial trust fund work plan set out to achieve. These objectives were: to support efforts to create a healthy vaccine market, undertake relevant analysis and policy dialogue on underused and new vaccines, and increase the predictability of national financing for immunization through analysis and dialogue with governments. It also seems that the initial 2007 work plan was not updated on a yearly basis as had been envisioned at the outset. 3.34 In 2011, the Bank’s HNP department in consultation with legal counsel concluded that being a recipient of direct GAVI funding through the ImGAVI Trust Fund while being a voting member of the GAVI Alliance Board comprised a conflict of interest; subsequently, the Bank decided to stop accepting funds from GAVI and closed the Trust Fund.12 However, WHO and UNICEF continue to be recipients of GAVI funding and are managing the potential conflicts of interest. Both organizations provide technical assistance and critical services for GAVI in line with their institutional mandates and capabilities.13 In IEG’s view, potential conflicts of interest could have been handled in other ways than by closing the ImGAVI Trust Fund. There is little doubt that this decision has contributed to an uneasy relationship between the two organizations. In IEG’s experience, based on review of many partnership programs with shared governance, institutional conflicts of interest are common and unavoidable in partnership programs where key partners routinely perform multiple roles (in GAVI, the Bank is a voting board member, financial partner, development partner engaged in immunization and HSS at country and global level, and, at different points in time, trust fund donor and recipient). The solution is not to shy away from multiple and potentially conflicted roles; rather, conflicts of interest should be transparently disclosed, and if possible resolved at the governance level. Figure 11. Type of Activities Funded by ImGAVI Trust Fund Source: World Bank data. Note: Grant monitoring and reporting documents (GRMs) available for 30 out of 46 ImGAVI Trust Fund activities. 33 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK Box 2. Major Findings from Survey of World Bank TTLs An electronic survey was administered in April-May 2013 to 112 Task Team Leaders (TTLs) of Bank-supported health projects during the period 2006-2012, in which there was an immunization component, ImGAVI Trust Fund activities, and either “child health” or “health systems performance” was listed as a theme. The response rate was rather low, as is often the case: 24 TTLs responded to the survey. Results should therefore be considered indicative and lacking of statistical precision. The TTLs who responded to the survey covered projects in 47 countries, and 80 percent of the respondents indicated that GAVI was active in the countries during the time period they were working in the countries. Among the respondents, 16 TTLs worked on investment projects, and 13 worked on policy dialogue. The Bank TTLs who responded to the survey considered the World Bank to be a high or substantial partner of GAVI to a much greater extent at the global level than at the country level. The majority of TTL respondents said that GAVI’s presence has not had any consequences for the World Bank lending to the overall health sector, but some thought that the World Bank lending for childhood immunization was lower than it would otherwise have been. GAVI is viewed positively by survey respondents for its focus on low-income countries and grant assistance. Survey respondents viewed GAVI’s most important comparative advantages as (a) mobilizing donor resources for childhood immunization in the short term; (b) building country-owned strategies for immunization; and (c) promoting country-owned strategies for immunization. In contrast, GAVI’s least important comparative advantages were seen as (a) promoting a results focus to development assistance; (b) sustaining financial resources for childhood immunization over the long term; and (c) lowering the transactions costs of development assistance from the point of view of beneficiaries. Most of the TTLs indicated there has been some degree of engagement between the two organizations in the countries in which they were working, but that it was often confined to information sharing or consultative more than direct, active collaboration. Bank TTLs reported direct involvement (such as helping with country grant applications to GAVI, support introduction of new vaccines, support for immunization activities under a Sector- wide Approach (SWAp)) with GAVI in only four countries: Benin, Bolivia, Pakistan, and Tanzania. While some felt that the engagement should have been closer, others found it appropriate. The survey results suggest (as does other evidence) that the country-level engagement between the two organizations has primarily occurred within the donor coordination framework (i.e. the Health Systems Funding Platform, IHP+, and SWAp), and through studies and sector work financed by the ImGAVI Trust Fund. These frameworks have made it easier for the World Bank to engage with GAVI at the country level. The World Bank participated in the Interagency Coordination Committee (ICC) in only a few countries. This extent of engagement between the two organizations is consistent with the findings from the country missions in Ethiopia, Nepal, and Tajikistan. 34 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK COUNTRY VISITS ALSO FIND OPPORTUNITIES FOR STRONGER BANK ENGAGEMENT IN IMMUNIZATION 3.35 Findings from IEG visits to Ethiopia, Indonesia, Nepal, and Tajikistan, along with discussions in Ghana, support the analysis and findings in this chapter pointing to missed opportunities for stronger Bank engagement in immunization. The countries visited were a purposeful sample based on the following (not mutually exclusive) criteria: (a) countries that were pilot countries for the HSFP, (b) countries to which the ImGAVI Trust Fund provided technical assistance, and (c) countries where both GAVI and the World Bank have been active in the health sector since GAVI was founded in the year 2000, and where prior desk reviews indicated some engagement between GAVI and the World Bank. 3.36 The country visits focused on the Bank’s roles in GAVI and its engagement at the country level. To supplement the breadth of information obtained from desk reviews and interviews with TTLs at the Bank, the country visits provide in-depth information in answering evaluation questions on sustainability, as well as questions on the Bank’s performance as a development partner in the context of the Bank’s 2007 Health Sector Strategy. As mentioned, this stated that the Bank “looks forward to close collaboration in the implementation of country-led system strengthening efforts and knowledge generation with global financing partners including . . . GAVI,” and that “particularly on health systems, [the Bank] will substantially increase its strategic engagement with WHO, the Global Fund, and GAVI, particularly in low-income countries.”14 3.37 DTP3 coverage - a proxy for childhood immunization coverage - has increased substantially in all countries. Yet equitable access to immunization continues to be a problem, particularly in low-income countries such as Ethiopia and Nepal. Limited co-financing for GAVI-provided vaccines was assured by all visited countries, but preliminary discussions also indicated that the countries still expect long-term donor support for the new more costly vaccines. Cross-cutting issues from the country visits are summarized in Table 7 and mission findings are described in Appendix E. Table 7. Cross-Cutting Issues from Country Visits Nepal Ethiopia Tajikistan Indonesia Ghana DTP3 Coverage 2000 2012 2000 2012 2000 2012 2000 2012 2000 2012 Rate 74% 90% 27% 61% 83% 94% 75% 64% 88% 92% GNI US$ 700 US$ 410 US$ 860 US$ 3,420 US$ 1,550 Co-financing status Low-income Low-income Low-income Graduating Intermediate (2012) Government co- Yes Yes Yes Yes Yes financing GAVI vaccines Assessment on Unclear (since the Unclear (since the No assurance Likely Unclear (since country’s prospect to country is not country is not (budget line the country is not 35 CHAPTER 3 THE WORLD BANK AS A GOVERNANCE BANK Nepal Ethiopia Tajikistan Indonesia Ghana fully finance graduating in the graduating in the requested by MOH graduating in the immunization medium term) medium term) but not approved) medium term) programs with the additional vaccines Equitable access to 75% 96% 25% 48% 82% 91% 44% 81% 82% 96% vaccines/ DTP3 by (Q1) (Q5) (Q1) (Q5) (Q1) (Q4) (Q1) (Q5) (Q3) (Q4) wealth quintiles Country Coordinating The Bank does The Bank has limited The Bank no longer The Bank stopped The Bank does Mechanism not participate in participation in the participates in the participating in the not participate in the ICC. ICC ICC. ICC since 2010. the ICC. Bank’s Involvement The Bank is a key The Bank’s Program The Bank’s Limited Limited in HSS for driver in the for Results operation involvement has immunization Health Systems for HSS has declined in recent Funding Platform immunization targets years among the disbursement linked indicators GAVI’s involvement GAVI is a partner GAVI has contributed Limited (US$1 Limited (US$12 Substantive (US$ in HSS in the HSFP (US$ to the MDG million) million) 9.6 million) 17 million performance fund for disbursed/ US$23 HSS (US$ 80 million million disbursed/ US$ 152 commitments) commitments) Bank policy dialogue Yes Limited No No No on immunization ImGAVI support No Yes (US$409,000) Yes (US$276,000) No Yes (US$453,000) Source: DTP3 Coverage Rates – WHO/UNICEF estimates from GAVI Alliance Country Hub Website (as of December 2013); IEG Country Visits 2013. 36 4. The Bank as a Governance Partner 4.1 This chapter reviews the World Bank’s roles in the governance of GAVI as an example of how the Bank practices its corporate oversight and governance role in a major partnership program. The Bank, along with UNICEF, WHO, and the Gates Foundation, are founding partners who were instrumental in the setup and launch of GAVI, and they still hold permanent seats with voting powers on the GAVI Board.1 The Bank has worked to align the institutional interests between GAVI and the Bank; brought its expertise to the partnership; participated in the committee that oversaw GAVI’s governance reform in 2008; and managed potential conflicts of interest. The chapter does not assess the overall effectiveness of the GAVI corporate structures such as the GAVI Board and Secretariat. 4.2 The chapter finds that the Bank-GAVI relationship on governance issues has diminished since 2008 and that staff in both organizations would like to see closer Bank-GAVI cooperation. There have been unresolved tensions related, for example, to perceived discrepancies in corporate priorities, concerns over the fiscal implications of new vaccines, diluted influence of the Bank and other founding partners, and a perception among some Bank staff that the Bank was at times treated more like a contractor than a complementary partner. Pre-governance Reform Period 4.3 From GAVI’s initial years until 2008-10, the World Bank was an active participant in GAVI’s economic and financing strategies and was a member of GAVI’s Financing Task Force (2000-2006) and co-chair of the Immunization Financing and Sustainability Task Team (until 2010). The Bank helped with the design and implementation of the co-financing policy. These roles were supported by a dedicated Bank team housed in the HNP anchor unit. This team conducted studies on financial sustainability, strategy implementation, immunization-related HSS, and other topics of relevance to GAVI. 4.4 The Bank was also initially a small financial contributor to GAVI using the DGF. Since DGF funds are not designated, they were used to support the administrative costs of the GAVI Secretariat while it was hosted at UNICEF. As mentioned in Chapter 2, the Bank has been the Treasury Manager of the IFFIm since 2006. 4.5 At its inception, GAVI was designed as an informal alliance of partners with a shared mission and a small Secretariat hosted at UNICEF’s office in Geneva. At GAVI’s inception, the governance structure was divided between the GAVI Alliance on the programmatic side and the Vaccine Fund (later the GAVI Fund) on the financial side (Table 8). The GAVI Fund was set up as a U.S. 501(c)(3) (nonprofit) 37 CHAPTER 4 THE WORLD BANK AS A GOVERNANCE PARTNER organization based in Washington, D.C., to allow tax-exempt donations from U.S.- based donors and provide a legal personality to GAVI. There were differences in the culture of the two Boards, with the “GAVI Alliance Board being consensus-driven and cognizant of the political positions of Board members, while the Fund Board embodied a culture that focused primarily on the final results.”2 Furthermore, there were differences “in their approaches to financial sustainability, the extent GAVI should support vaccine research, and strategic timeframes.”3 4.6 Under the reorganization, the old GAVI Board merged with the GAVI Fund Board in October 2008 into what is now called the GAVI Alliance Board; the hosting agreement with UNICEF was terminated, and GAVI became a legal entity in the form of a Swiss Foundation located in Geneva.4 The nature of the partnership was fundamentally altered.5 Table 8. GAVI Board and GAVI Fund Board Compositions Before the Reform, 2005 GAVI Board GAVI Fund Board Permanent Seats (5): Permanent Seats: 14 Independent Board Members  Board Chair (rotates between UNICEF and WHO) Note: All Board members served as individuals, not as  Gates Foundation  UNICEF representatives of another entity  World Bank  WHO Rotational Seats (13):  Organization for Economic Cooperation and Development (OECD) country governments (3)  Developing country governments (4)  OECD country pharmaceutical industry  Research and Technical Health Institutes  Nongovernmental Organizations  Developing country pharmaceutical industry  Vaccine Fund Board member IFFIm donors Source: Abt Associates, 2008, Evaluation of GAVI Phase I Performance, pp. 84-85. 4.7 As an internal GAVI matter, it falls outside the scope of this review to assess the necessity of the reform, but the Bank’s participation in it is of interest. It appears the governance reform process was hasty, complex, and contentious: although preparation of the reforms had been ongoing for some time, partners felt that they were given only short time to select the new board structure from among six different options.6 Some issues around the change in GAVI’s legal status and new governance arrangements proved very consequential and controversial. For the Bank and the other multilateral partners, the reorganization gave rise to issues regarding the number and allocation of voting board seats, concerns regarding dilution of influence, their role in the new entity, and some legal concerns 38 CHAPTER 4 THE WORLD BANK AS A GOVERNANCE PARTNER surrounding their participation as board members in a Foundation governed by Swiss law rather than international law which normally governs the multilaterals. The question for the Bank is how effectively its contributions to GAVI’s governance reform served its development objectives, whether the Bank team received adequate support and guidance, and whether its participation in the process invited reputational risks. IEG is not able to draw clear conclusions on these questions, in part because the Bank’s written records are rather silent on the reform process, suggesting a need to better document the Bank’s contributions to global program’s governance. Moreover, as emphasized before by IEG, the Bank lacks corporate guidelines to inform its contributions to governance of global partnership programs.7 Post-governance Reform Period 4.8 The new 2008 GAVI Board hybrid structure is uncommon and has had the effect of diluting the voting influence of the founding partners. Two-thirds of the 28 board members are constituency-determined and one-third are independent individuals (neither stakeholders nor shareholders—an uncommon feature in global development partnership organizations). The three founding multilateral partners representing the traditional “Alliance” element of GAVI – UNICEF, WHO, and the World Bank — are now represented by three out of 28 votes, whereas representatives of the private pharmaceutical sector have two votes (Figure 12). Figure 12. GAVI Alliance Board Composition, 2013 Source: GAVI Alliance Website. 4.9 Although the governance reforms might well have been necessary and contributed to GAVI’s subsequent growth, the reorganization gave rise to concerns among the founding partners, including the Bank. As also noted in an evaluation of 39 CHAPTER 4 THE WORLD BANK AS A GOVERNANCE PARTNER GAVI, some partners became less involved in policy development and felt a reduced sense of ownership in the Alliance, as it evolved from an informal partnership hosted at UNICEF to a more formal and independent corporate identity. IEG interviews also highlighted that the change in legal personality (from informal partnership based on international law to a foundation governed by Swiss law) and related corporate governance arrangements resulted in considerable discussions and concerns among the legal departments of WHO, UNICEF, and the Bank; these organizations are used to being represented on boards in partnerships governed by international law with the associated privileges and immunities, while Board membership governed by national law entails a different set of risks and obligations.8 Moreover, Bank staff are bound by the Bank’s articles of agreement to have sole and entire duty to the Bank. And they can only sit on partnership programs’ boards in their Bank capacity, not in their individual capacity. In contrast, domestic law generally assigns board members a personalized fiduciary duty toward the legal entity they help govern. Hence the legal concerns about GAVI’s reorganization: In the view of the legal department, it is ultimately a better fit for the Bank to be part of an informal partnership governed by international law than a corporate partnership governed by domestic law. 4.10 But it is unusual for the Bank to be a voting member in a partnership such as GAVI where it is not a financial contributor. In practice, the Bank is only a voting member of the governing bodies of those Financial Intermediary Fund (FIF)- supported programs in which it has also been a financial contributor, by means of annual grants from the DGF.9 At the inception of GAVI, there was a DGF grant, but at the time of the reorganization this grant had long closed. 4.11 GAVI has de facto shifted from an informal partnership to a corporate model. The GAVI Secretariat changed and grew in size after the reorganization. Staff increased from about 20 in 2005 to over 200 today. The Secretariat has become an effective independent organization, operating like a corporation. It has advanced marketing and advocacy capabilities but limited presence at the country level. Partners report a strong perception that the initial collaborative partnership dimension has faded and that the model has become more Secretariat-driven. 4.12 Tensions between the partners’ corporate priorities arose in the years since 2008. GAVI and the World Bank continue to share a mission “to save children’s lives and protect people’s health by increasing access to immunization in poor countries.”10 However, GAVI has expressed its mandate with increased emphasis and attention to a categorical objective, namely to accelerate immunization. In contrast, the multilateral development organizations all have broader mandates in comprehensive and balanced health-sector development. Many Bank staff interviewed for this evaluation expressed concern over the cost implications of GAVI’s singular focus on new vaccine expansion for country’s health systems, and 40 CHAPTER 4 THE WORLD BANK AS A GOVERNANCE PARTNER GAVI has more recently renewed its emphasis on vaccine cost reductions (“market shaping”). 4.13 Membership and participation in GAVI’s governing bodies (Box 3) offers the Bank many opportunities to contribute to GAVI’s governance but has not been sufficient to resolve the issues described in this review. Interviews with Bank and GAVI staff members recalled greater interaction between the two organizations during GAVI’s early period, and that engagement at the corporate level waned after the governance reform in 2008. It is conceivable that GAVI required less support from the Bank as it matured, but various tensions described below also contributed. Box 3. The World Bank’s Participation in GAVI Board Committees The World Bank is a member of the GAVI Alliance Board and manages the financial platform for the AMC and is the treasury manager for the IFFIm, two innovative financing instruments central to GAVI’s funding. In addition, the Bank is presently a member of the following GAVI Board committees:  The Executive Committee makes time-sensitive decisions that allow the GAVI Alliance to function between Board meetings.  The Program and Policy Committee is the main advisory body to the Board on all GAVI program areas.  The Audit and Finance Committee assists the Board in fulfilling its oversight responsibilities in respect to the accounting, financing, budgeting, and financial practices by reviewing financial information to be reported to GAVI donors and others, evaluating GAVI’s systems of internal controls, and overseeing the audit process. Source: GAVI Alliance Website GAVI’s Evolving Strategy and Relationship with the Bank 4.14 GAVI was initially established with the primary objective to save children’s lives and protect people’s health by increasing access to immunization in poor countries, thereby achieving the MDG for child health, making it closely aligned with the Bank’s goals. But after 2008, GAVI’s strategy was increasingly focused on the technology aspects of its mandate that is, accelerating the introduction of new (but also more costly) vaccines in developing countries. In this period, GAVI was perceived by observers to have lessened its focus on the other strategic goals (see Box4). This change in emphasis of GAVI’s corporate goals has been supported by several of GAVI’s major stakeholders, in particular the Gates Foundation, the pharmaceutical industry, and WHO; it has diminished but not eliminated the alignment of corporate priorities between the Bank and GAVI. 4.15 For example, GAVI added the Human Papillomavirus (HPV) Vaccine, which protects female adolescents from cervical cancer to its vaccine portfolio. And in June 41 CHAPTER 4 THE WORLD BANK AS A GOVERNANCE PARTNER 2013, GAVI decided to support polio eradication by introducing the IPV as well as to consider vaccines for malaria and cholera programs.11 These vaccines are administered to all age groups, marking a departure from GAVI’s focus on childhood immunization. The potentially large recurrent cost implications for the recipient countries were not discussed at the Board meeting where this decision was made. Box 4. GAVI’s Phases and Strategies Phase I (2000-06): GAVI concentrated on two primary areas:  Supply of new and underused vaccines;  Strengthening vaccine delivery systems Phase II (2007-10): GAVI had four strategic goals:  Contribute to strengthening the capacity of the health system to deliver immunization and other health services in a sustainable manner;  Accelerate the uptake and use of underused and new vaccines and associated technologies and improve vaccine supply security;  Increase the predictability and sustainability of long-term financing for national immunization programs; and  Increase and assess the added value of GAVI as a public-private global health partnership through improved efficiency, increased advocacy, and continued innovation. Phase III (2011-15): GAVI’s has four goals:  Accelerate the uptake and use of underused and new vaccines;  Contribute to strengthening the capacity of integrated health systems to deliver immunization;  Increase the predictability of global financing and improve the sustainability of national financing for immunization;  Shape vaccine markets. Source: GAVI Alliance Website 4.16 The alignment of the mandates and priorities of the Bank and GAVI has diminished over time but not disappeared. As a multilateral development organization, the Bank has broad and comprehensive roles in the health sector, as contrasted to GAVI’s singular categorical role. The Bank became a partner and founding member of GAVI in 2000, at a time when immunization funding was in decline and gains made in childhood immunization since the 1970’s were threatened. At the time, GAVI was seen as aligned with the goals and mandates of the Bank at global and country level. The GAVI partnership would help achieve the MDGs related to child health, complementing Bank country programs. This alignment was the basis for the Bank’s special effort to establish IFFIm and the 42 CHAPTER 4 THE WORLD BANK AS A GOVERNANCE PARTNER AMC, providing GAVI with sufficient and stable financial resource flows. Although the Bank’s corporate priorities (such as access to services for the most vulnerable populations, health systems development, and sustainable health-sector finance) are complementary to GAVI’s mission, in practice they do not always align with GAVI’s emphasis on making new vaccines available as quickly as possible, especially where these vaccines entail large recurrent cost implications. 4.17 Bank staffers have a perception that there has been limited time for discussion and critical questions at GAVI Board and committee meetings. The lack of discussion about vaccine choice in the larger context of public health and development priorities, combined with the Bank’s decision not to accept further funding from GAVI and take on specific obligations in GAVI’s Strategy and Business plan (see below), negatively affected the Bank-GAVI relationship. The Bank’s health-sector staff, partner agency staff, and other people interviewed by IEG report a perception that it caused the Bank to “withdraw” from GAVI. Others describe that the Bank became cautious in its engagement with GAVI at the global and governance level. IEG did not see evidence that the factors contributing to lessened alignment between the Bank and GAVI have been transparently discussed.12 4.18 The degree of specificity of the Bank’s contributions to GAVI became a source for tension. In 2010, the GAVI Secretariat developed the Strategy and Business Plan 2011-15, which attempted to detail the specific responsibilities and available budget for the different partners and sought to request detailed, activity-based reporting to the GAVI Secretariat. The Bank declined to participate.13 In the Bank’s view, GAVI was in danger of transitioning from being an alliance of equal partners to a corporate organization in which contractors provide services to and on behalf of the GAVI Secretariat. GAVI staff expressed disappointment that the Bank was unwilling to take on these specific obligations and reaffirmed that accountability for deliverables is a condition for funding.14 In IEG’s opinion, very specific and prescriptive semi-contractual responsibilities are usually not the best way to manage a partnership of this nature and to deliver development results in complex and changing circumstances; hence the Bank’s declining had merit. 4.19 The consequence of all of this is that, for a period, areas of mutual concern were not addressed. GAVI’s operational staff expressed concern about the financial sustainability of immunization programs as countries get wealthier and graduate from GAVI support, sometimes without appropriate budgetary allocations for immunization. GAVI’s Secretariat expressed to the IEG a desire for Bank involvement in addressing this issue with ministries of finance. Likewise, Bank health-sector staffers have expressed concern about the financial sustainability of the broader health sector, including immunization programs, at the country level, and potential distortions of the public health-sector finance. 43 CHAPTER 4 THE WORLD BANK AS A GOVERNANCE PARTNER 4.20 Engagement in policy dialogue at the corporate level has increased recently as the Bank has been involved in shaping GAVI’s next strategy phase for 2016-2020, in addition to engaging in other areas of mutual concern, such as strengthening supply chain, resource mobilization, and financial sustainability. Lessons for Future Engagement with GAVI and other Partnership Programs 4.21 IEG would support efforts to revitalize Bank support for immunization and to reengage with GAVI. The Bank’s partnership with GAVI needs to be managed around the evolving global health priorities, the Bank’s and GAVI’s corporate priorities, and the changing international aid architecture for health. Immunization is important for public health, and the GAVI partnership is crucial. 4.22 The Bank needs to have strong internal support and dedicate staff resources to support such a complex partnership. In the beginning, a dedicated Bank staff of four professionals supported GAVI and worked hard to ensure GAVI’s success. But Bank staff working on the GAVI partnership has not been replaced, although as mentioned it is conceivable that GAVI required less support from the Bank as the organization matured. However, internal Bank funding for supporting partnership programs has become very limited, and the effectiveness of partnership support has diminished (Figure 13). Internal Bank budget decisions have reduced funding for GAVI-related activities. The relationship with GAVI is managed by the Bank’s HNP department. Its budget started to decline around 2006. This also meant that fewer resources were available for GAVI activities. The department spent US$78,000 (including staff time) in 2012 on GAVI-related activities, down from an average of about US$140,000 annually in earlier years.15 44 CHAPTER 4 THE WORLD BANK AS A GOVERNANCE PARTNER Figure 13. HNP Department Expenditures for GAVI and Immunization-related Projects, 2002-2013 Source: GAVI Alliance Website. 4.23 At the same time it is critical that both the Bank and GAVI provide structured support and organizational guidance for staff to navigate the partnership complexities. Actual and potential conflicts of interest and differences in policy priorities are common in complex partnerships and need to be transparently discussed, rather than allowed to linger. Institutional resolution of the issues affecting the Bank-GAVI partnership may entail a review and adjustment of the World Bank’s multiple roles in GAVI, including its governance, financing, and as a country and global partner. 4.24 The new World Bank Group strategy admits that “there has been little focus on corporate management of partnership programs,” and highlights the “need for more strategic decision-making around which partnerships to take on, what partnership programs to host, what roles the Bank Group should play, what type(s) of financing mechanism(s) to use, and when and how exits should be considered,” and that “institutional responsibilities for oversight of partnership programs across the Bank Group need to be clarified.”16 The findings in this review and other Global 45 CHAPTER 4 THE WORLD BANK AS A GOVERNANCE PARTNER Program Reviews support the above diagnostic. The Bank-GAVI relationship has been allowed to diminish for a substantial period of time, not so much because of any conscious decision but more because tensions went unresolved. Some of these tensions can be traced back to a major reform of GAVI governance to which the Bank contributed. These lessons imply a need for more formal corporate review and decision-making at key decision points, including when setting up a new partnership program, when reforming its governance, and when making decisions about where to host it. 46 5. Conclusions and Lessons 5.1 The new World Bank Group strategy aims to align regional and global engagements with the World Bank Group twin goals and notes that “global engagements represent an important opportunity for the Bank Group to make an impact on development, but this rapidly growing role also places additional demands on the World Bank Group that it must ensure are aligned with the goals.”1 This review finds that the Bank Group has some way to go to ensure successful alignment and development results from its engagement in major partnership programs. 5.2 The GAVI Alliance is by all accounts a successful and well-funded partnership program supporting childhood immunization, a core element of any public health system. GAVI is highly regarded and considered well-managed. GAVI has attracted US$8.4 billion from a diverse range of public, private, and foundation donors since 2000, becoming the third largest multilateral in health. Judging from its evaluations, GAVI has been successful in bringing together key stakeholders in global immunization, increasing the profile of immunization in national and international health agendas, and raising the public’s awareness of vaccines as a cost-effective intervention in poor countries. 5.3 The World Bank, together with UNICEF, WHO, and the Gates Foundation, is one of the founding Alliance partners and has made outstanding contributions to GAVI and thereby to childhood immunization in low-income countries. At its inception in 2000, GAVI was designed as an informal alliance of partners with a shared mission and with UNICEF hosting a small secretariat. In 2008, GAVI changed its organization and legal personality and became a Swiss foundation.2 The change marked a consequential shift in culture and operating modalities toward a corporate model, with an accompanying rapid growth in the Secretariat. GAVI continues to rely heavily on WHO for policy and country support, and on UNICEF for HSS and vaccine procurement, yet the essential contribution of the key partners is publicly less visible, and the Alliance dimension of the partnership has somewhat faded. 5.4 The World Bank is deeply engaged with GAVI in three different contexts: at the financial level by setting up and running two innovative financing mechanisms; the country level as development partner; and at the corporate level in the governance of GAVI.3 5.5 Financial engagement: The Bank’s most significant contribution to GAVI is the establishment and management of two innovative financing mechanisms, IFFIm and AMC, contributing a third of GAVI’s financial resources from 2000 to 2010. To operationalize these instruments required the Bank to assume financial risk, develop new systems, and make a long-term commitment. The Bank’s financial relationship 47 CHAPTER 5 CONCLUSIONS AND LESSONS with GAVI and IFFIm has been highly competent and professional, if perhaps underappreciated. The Bank provided excellent execution that successfully translated conceptual innovations in development finance (IFF and AMC) into viable pilot mechanisms that have helped finance GAVI’s rapidly expanding budget. 5.6 The Bank assumed a direct balance sheet risk on behalf of AMC and used its excellent credit rating to place IFFIm bonds. The Bank reviewed these challenges at the Board level and worked consistently to launch and implement these innovative financial vehicles. As the treasury manager for IFFIm, the Bank successfully managed problems caused by the credit downgrade of the two key donors. The Bank’s relationship with GAVI as treasury manager for IFFIm has been professional, despite the complicated governance structure of IFFIm. 5.7 Engagement at country level: The relationship with GAVI has been collegial and constructive in countries where there is engagement, but in many countries the Bank has little direct involvement in immunization. The Bank has de facto “left the immunization subsector to GAVI.” IEG considers this a missed opportunity on the analytical side. While direct vaccine support is fully covered by GAVI, the Bank, as a trusted partner at the country level, could add significant value on issues of immunization analytical work, policy and strategy, particularly on ensuring sustainability and equitable access to immunization, and in investments in health systems strengthening (HSS). These are areas of Bank comparative advantage that other partners do not systematically cover. 5.8 Aid coordination efforts such as Joint Assessments of National Strategies and the now defunct Health Systems Funding Platform (HSFP) to harmonize reporting systems have been initiated in several countries. These efforts can work if pursued with determination, as the example of Nepal shows. The Bank and GAVI should continue to seek opportunities in additional countries for better aid coordination in the context of IHP+ to alleviate cumbersome reporting mechanisms and reduce transaction costs. 5.9 Governance: The mandates and priorities of the Bank and GAVI were mutually relevant and compatible at GAVI’s inception, and relationships were excellent with the Bank providing extensive support. Interactions between the two organizations diminished for a substantial period of time after GAVI’s reorganization for two reasons: First, there was a perceived discrepancy between the Bank’s broader development objectives focusing on HSS, equitable access to services, and fiscal sustainability, and GAVI’s focused approach on accelerating introduction of new (and sometimes costly) vaccines in low-income countries. Second, the governance reform diminished the influence of the founding partners and led to concerns about handing control to an entity that might not be fully aligned with the Bank’s priorities and that, at times, appeared to treat the Bank as a 48 CHAPTER 5 CONCLUSIONS AND LESSONS contractor more than a complementary partner. The non-renewal of the ImGAVI Trust Fund by the Bank, citing conflicts of interest, is a telling example. 5.10 Unfortunately, these issues have not been transparently discussed and reviewed at the corporate level between the Bank and GAVI. Lessons for the Bank’s relationship with GAVI and other partnership programs. 5.11 The central lesson for the Bank’s relationship with GAVI is the need to discuss, update, and re-affirm the principal partnership arrangements to reflect the changing realities in which both partners operate. The 2008 governance reform profoundly changed the governance structure, and with it the dynamics of the relationship. The Bank has not, to IEG’s knowledge, reviewed what if any consequences the governance reform should have for its own contributions to GAVI’s governance; for example, it might be warranted to review whether the Bank should change its status from voting member to observer. 5.12 A second lesson is to manage governance of partnership programs more proactively and systematically, particularly during initial setup and reform. GAVI’s governance reform in 2008 was essential but had unforeseen consequences for the relationship between GAVI and the Bank. Rather than promote efforts to resolve the issues, the Bank kept a cautious distance in its engagement with GAVI. As also mentioned in the World Bank Group strategy, the Bank could benefit from managerial oversight of how its major partnerships are governed. More robust corporate attention to how major partnerships are governed and structured is warranted and should be aligned with key decision points such as setup and restructuring. 5.13 Third, the governance reform process which transformed GAVI from an informal alliance hosted by UNICEF into a new independent Swiss foundation, involved complex governance issues and legal concerns. The governance reform process, in which the Bank participated at vice presidential-level, explored organizational options. The choice of creating a new independent organization can also create an expansionary institutional dynamic, as new organizations strive for budget and recognition. The World Bank Group—and indeed the wider international community—may want to carefully weigh the pros and cons of creating new independent organizations versus housing partnerships in existing organizations. 5.14 A fourth lesson is that the Bank’s competence and experience in concessional development finance can be highly useful in future attempts to set up innovative development finance on behalf of partners. The World Bank Group strategy aims to leverage private-sector resources, partnerships, and innovative finance. The lessons from the Bank’s work on behalf of GAVI for future endeavors is that the Bank 49 CHAPTER 5 CONCLUSIONS AND LESSONS should: carefully consider if the short-term benefits of any innovative financial mechanism justify the long-term consequences for the Bank and its partners; find ways to maintain simple governance arrangements; and ensure adequate recognition as well as reasonable protection against reputational risks associated with its work on behalf of partners. 5.15 A fifth lesson is that clearer definition of roles and responsibilities at country and global level could enhance the impact of the Bank, GAVI, and other organizations’ support for immunization. The limited Bank involvement at the country level in ensuring priority of immunization, equity of access, systems support, sustainable financing of immunization, and donor coordination point to missed opportunities for both the Bank and GAVI to improve their development effectiveness. Selection of priority countries and an agreed and documented understanding between the Bank and GAVI staff on division of labor and modes of engagement would be helpful. This division of labor should be flexible and acceptable to both partners; it should permit the Bank to pursue its comparative advantages in policy dialogue and analytical work tailored to country contexts and avoid restrictive contractual approaches. 5.16 Sixth, the Bank-GAVI experience is not unique: there are often missed opportunities for stronger development results in the Bank’s engagements in partnership programs. IEG’s synthesis report of global programs in 2011 found strong operational linkages to the Bank’s country-level work in only four of 17 global programs reviewed. To remedy this, IEG has recommended a more explicit definition of roles and accountabilities in partnership programs. IEG has also recommended that the Bank put in place stronger coordination mechanisms between partnership programs and the relevant sectors and empower its representatives on program boards to work for the Bank’s corporate interests (the Bank has yet to implement a proposal that staff serving on partnership boards be guided by terms of reference that set out Bank-wide institutional positions). These steps could help fulfill the World Bank Group strategy objective of closer alignment between global engagements and Bank Group goals. 50 Appendix A. GAVI: Purpose, Contributions, and Activities 1. GAVI was launched in 2000 as a partnership of public and private organizations with a mission “to save children’s lives and protect people’s health by increasing access to immunization in poor countries.”1 GAVI pools donor resources to fund vaccine introduction programs, supports the development of new and underused vaccines, and improves vaccine delivery by strengthening health systems. 2. Described as the “quintessential informal public-private partnership,” GAVI was designed as a casual alliance of partners with a shared mission and a small secretariat based at the United Nations Children’s Fund’s (UNICEF) office in Geneva. This public-private partnership is supposed to advance immunization access in poor countries by maximizing each partner’s strengths in vaccine research; vaccine procurement and delivery systems; health financing; and the vaccine market. The private sector’s expected contributions to GAVI include researching and developing vaccines that address the needs of developing countries, providing vaccine market knowledge, expanding the number of vaccine suppliers, and securing vaccine supplies. 3. GAVI started with a dual governance structure with GAVI on the programmatic side and the Vaccine Fund (later called the GAVI Fund) on the financial side.2 Over time, GAVI has become more formal with a more independent secretariat in response to the increased number of responsibilities, programs, and the large inflow of resources. A Governance and Reform Committee designed a change- management plan in 2008 that took effect in January 2009, which merged the old GAVI Board and the GAVI Fund Board into what is now called the GAVI Alliance Board in October 2008. The new governance structure is intended to reflect the strengths of public-private partnership by bringing together financial and programmatic decision-making, streamlining accountabilities, and providing operational efficiencies.3 Subsequently, administrative services were moved from UNICEF to a new GAVI corporate secretariat. 4. The current GAVI Alliance Board is comprised of 28 seats and operates on the basis of a “hybrid stakeholder-corporate” model. Permanent seats are held by the Gates Foundation, World Health Organization (WHO), UNICEF, and the World Bank. Aside from the four permanent members, Board representatives serve on a time-limited basis. The Board is supported by five standing committees and one advisory committee that oversee specific activities and the development of key policies. The six committees are: Executive Committee, Program and Policy 51 APPENDIX A GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES Committee, Governance Committee, Investment Committee, Audit and Finance Committee, and Evaluation Advisory Committee. 5. The GAVI Secretariat, with offices in Geneva and Washington, D.C., is led by the Chief Executive Officer (CEO) — currently Seth Berkley — and is supported by six departments. The Secretariat is responsible for day-to-day operations, including mobilizing resources, coordinating program approvals and disbursements, developing policy, implementing strategic initiatives, monitoring and evaluation, legal and financial management, and administration for the GAVI Alliance Board and Committees. 6. GAVI is funded by several mechanisms through direct contributions from donor governments, the Bill and Melinda Gates Foundation, and private donations, but also through three pilot, innovative financing mechanisms —International Finance Facility for Immunisation (IFFIm), the pilot Advanced Market Commitment (AMC) for pneumococcal vaccines and the GAVI Matching Fund. GAVI has committed US$8.4 billion to 76 countries (from inception until August 31, 2013) and has disbursed US$ 6.0 billion to over 70 countries (from inception until September 30, 2013). At the June 2011 London pledging conference, GAVI received further pledges of US$4.3 billion from donor countries, the Gates Foundation, and other private donors to fully finance operations during Phase III (2011–2015). World Bank has been highly engaged in the establishment and management of IFFIm and the AMC. 7. Launched in 2006, IFFIm is an innovative financing mechanism, which GAVI and the World Bank have pioneered. IFFIm raises funds from the international capital markets by issuing bonds. IFFIm bonds have raised approximately US$3.6 billion since the program’s inception and IFFIm has used the proceeds to fund GAVI programs. IFFIm’s assets are long-term, legally binding grant agreements from sovereign donors. The financial strength of IFFIm to repay the bonds is based on legally binding donor payments over a period of up to 20 years. Donors have provided grants totaling over US$6.2 billion to IFFIm (Table). Table A.1. Donor Commitments to IFFIm Country Amount Committed US$ Equivalent Currency of pledge United Kingdom US$ 2,980 million over 23 years British Pounds 1,630 million France US$ 1,719 million over 20 years Euro 1,239.96 million Italy US$ 635 million over 20 years Euro 498.95 million Norway US$ 264 million over 15 years US$ 27 million & Norwegian Kroner 1,500 million Australia US$ 256 million over 20 years Australian Dolalr 250 million Spain US$ 240 million over 20 years Euro 189.50 million The Netherlands US$ 114 million over 8 years Euro 80 million Sweden US$ 38 million over 15 years Swedish Kroner 276.15 million South Africa US$ 20 million over 20 years US$ 20 million Source: IFFIm Website. 52 APPENDIX A GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES 8. A special legal entity registered in England and Wales as a company limited by guarantee, the GAVI Fund Affiliate (GFA) was established to accept funds from pledge agreements with sovereign donors and assigned these pledges to the IFFIm Company to be securitized. GFA was established to keep IFFIm independent from the donors and to safeguard GAVI’s tax-exempt status. In February 2013, GFA was removed from the IFFIm structure in order to reduce costs and streamline operations, and GFA activities have been transferred to IFFIm and GAVI. The GFA board initiated the process of voluntary liquidation of GFA on March 28, 2013.4 Box A.1. Cost of IFFIm Management The total projected operational costs over IFFIm’s lifetime are difficult to estimate as they critically depend on future projected interest rates. The 2010 IFFIm external evaluation estimated the lifetime cost of governance and treasury management as 4.1- 4.6 percent of present value of then-current pledges. Essential running costs, such as directors insurance for IFFIm Board members, legal advice, and treasury management fees are reasonable amounting to US$5-6 million per year. Recent work by the Bank projects the cost to be closer to the 8-10 percent range, when also taking into account the potential interest paid for outstanding debt. This means that IFFIm’s management costs over the life of the facility could amount to US$150-$340 million. Source: GAVI Alliance Website 9. The AMC was launched in June 2009 with a US$1.5 billion commitment from donors with the aim “to stimulate the development and manufacture of vaccines needed in low- income countries” by providing financial incentives to vaccine manufacturers.5 Donors commit funds to the AMC to subsidize the purchase of pneumococcal vaccines at an affordable price for developing countries, thereby providing vaccine manufacturers with a long-term, guaranteed market price for the vaccines. The World Bank manages the AMC funds, GAVI funds the vaccine purchase, and UNICEF procures the vaccines from manufacturers. The World Bank’s role as the financial platform for the AMC is further discussed in Chapter 3. GAVI’s Contributions to Immunization Efforts TYPES OF SUPPORT 10. The New and Underused Vaccine Support (NVS) is available to countries with national Diptheria, Tetanus, and Pertussis (DTP3) coverage over 50 percent (based on WHO/UNICEF estimates for 2009), with the exception for Yellow Fever and Meningococcal A vaccine (Men A) applications.6 All countries applying for NVS are required to co-finance the GAVI supported vaccines from the time of introduction. The only exceptions for co-financing are measles second dose and preventive campaigns for Meningitis A and Yellow Fever. Countries approved for 53 APPENDIX A GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES NVS will also receive a one-time cash grant in the form of the Vaccine Introduction Grant to support additional costs related to new vaccine introduction and to fund pre-introduction activities. GAVI currently offers support for 10 different vaccines.7 Figure A.2. Cumulative Number of Countries Approved and Recommended for New Vaccine Support (as of 31 December 2012) Source : GAVI Alliance, 2013, GAVI Alliance Progress Report 2012. 11. In mid-2001, GAVI began offering Injection Safety Support (INS) to countries that wanted to introduce or increase the use of auto-disable syringes and safety boxes into their national immunization programs for vaccines not supported by GAVI.8 Currently, INS is associated with the NVS and GAVI typically funds auto- disable syringes and safety boxes together with the vaccines. 12. The Immunization Services Support (ISS) was established in 2000 to provide flexible, performance-based funding to countries to improve their immunization services. Countries receive funding based on the additional number of children receiving immunization after an initial two years of investment funding.9 13. The Health System Strengthening Support (HSS) is based on the principles of the International Health Partnership (IHP+) in line with the Paris Declaration on Aid Effectiveness. Commitments vary from one to five years in duration, and funding levels are determined by the size of the country's birth cohort and the national income per capita. 14. The Health System Funding Platform (HSFP or the Platform) was established in 2009 to streamline HSS support and align with country budgetary and programmatic cycles. The Platform is intended to coordinate the various international resources for health systems strengthening among partners, donors, and countries in order to better align with the country priorities. Countries 54 APPENDIX A GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES requesting new HSS funding have two funding modalities: common proposal form or funding request based on a Jointly Assessed National Health Strategy (JANS).10 15. From 2006-2010, GAVI piloted the Civil Society Organization Support (CSO) program to support the role of CSOs in immunization-related activities, strengthen coordination and representation of CSOs, and support CSO involvement in countries' HSS proposals and multi-year immunization plans. 11 APPLICATION AND APPROVAL PROCESS 16. The GAVI Secretariat announces “funding windows” each year within which GAVI-eligible countries may apply for different types of program support. To be GAVI-eligible, countries must have per capita Gross National Income (GNI) equal to or less than US$ 1,550 in order to apply for any of the support programs; 56 countries are currently eligible for GAVI support based on GNI per capita.12 Countries with GNI per capita beyond the eligibility threshold are no longer eligible to receive GAVI support for new vaccines. There are currently 17 countries graduating from GAVI support, with seven countries graduating in 2015.13 Figure A.3. Country Recipients of GAVI Support Source : GAVI Alliance, 2013, Annual Progress Report 2012. 17. Only national governments can apply for vaccine funding and the five-year plan proposals are submitted by the Ministry of Health (MoH) with signed approvals from the Ministry of Finance and the country’s Interagency Coordination Committee (ICC). Each support program has their set of conditions, including 55 APPENDIX A GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES eligibility and minimum requirements; application deadlines and guidelines are published on the GAVI Alliance Website. In addition to the standard proposal form, countries must demonstrate that their funding proposals are integrated into the broader framework of their long-term health plans by submitting a comprehensive multi-year plan for immunization when applying for GAVI support for ISS, INS, and NVS. 18. Once an application is submitted to the GAVI Secretariat, it is sent to the Independent Review Committee (IRC) for review. The IRC then recommends the country application to the GAVI Alliance Board using the following four categories: recommended for approval; recommended for approval with clarifications; recommended for approval with conditions; and recommended for resubmission. The GAVI Alliance Board or Executive Committee approves the IRC recommendation and a Decision Letter is sent to inform the country of the decision. 19. Once approved by the GAVI Alliance Board, funds are then transferred to the country for implementation. For the procurement of vaccines and associated safety supplies, countries can choose to receive either the supplies in-kind from GAVI (procured through UNICEF or the Revolving Fund of the Pan American Health Organization , or an equivalent cash grant in lieu of supplies and procure the supplies directly from the vaccine producer.14 Countries receiving GAVI support spanning several years are required to submit annual reports to the GAVI Secretariat for progress monitoring. 20. GAVI requires each country to set up an Interagency Coordination Committee (ICC) to review and approve all new proposals for NVS and ISS applications, and monitor GAVI’s immunization-related country activities for annual reports submitted to the GAVI Secretariat. The ICC is chaired by the local health ministry, and ICC members are from the government, CSOs, WHO, UNICEF, and partner agencies. In addition, countries must demonstrate that their funding proposals are integrated into the broader framework of their long-term health plans by submitting a comprehensive multi-year plan for immunization. Box A.2 offers a comparison to how other major global partnership programs have chosen to structure their country engagements. 56 APPENDIX A GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES Box A.2. How are other global partnership programs structured at country level? A growing number of global partnership programs have been added to the development landscape in recent years to channel resources to projects and programs in developing countries in their respective sectors. Like GAVI, these programs have chosen not to build up local offices, instead relying on countries and partner agencies to prepare and execute projects, with their secretariats playing varying roles ranging from hands-off to technical assistance and monitoring, but generally shying away from project execution. What follows is a brief synopsis of how some of the major global partnerships are structured at country level. The Climate Investment Funds (CIF). CIF is a partnership of the multilateral development banks (MDBs). The MDBs work with governments, in consultation with civil society, to prepare country investment plans and to prepare and execute specific projects in climate change mitigation and adaptation. CIF was designed with a light-touch approach: its Administrative Unit (Secretariat) is small and most work is done by the MDBs, including the World Bank and IFC. The Global Environment Facility (GEF). GEF Agencies are responsible for creating project proposals and for managing GEF projects. The GEF Agencies play a key role in managing GEF projects on the ground; they assist governments and NGOs in the development, implementation, and management of GEF projects. The World Bank Group is one of 10 GEF Agencies. GEF has designated political and operational focal points. These are usually national government staff and act as liaison between the GEF Secretariat and GEF Agencies implementing projects in the country. The Global Fund to Fight AIDS, Tuberculosis and Malaria. Country coordinating Mechanisms (CCMs) comprised of government, CSOs, and development partners review and endorse funding proposals based on national strategies for combating the three diseases. Lead implementation agencies execute approved grants; these can be government agencies, CSOs, academic institutions, or the UNDP. The World Bank has interacted with many Global Fund activities and is a member of some CCMs but is not a lead implementation agency. Financial oversight is contracted out to so- called local fund agents who act as the Secretariats’ fiduciary agent in the country. In respons e to criticisms of its oversight of funds in implementing countries, among other issues, the Global Fund has implemented a comprehensive reform of its funding model, business operations, financial management, and fiduciary oversight systems. Geneva-based staff of the Global Fund are spending much more time visiting countries; negotiating directly with CCMs and PRs regarding project funding levels, goals, and objectives, and working closely with accounting firms that track resources. However, the Fund itself is not opening offices or executing projects in partner countries. The Global Partnership for Education (GPE). The GPE Secretariat works with governments and development partners to develop an education plan. Developing country governments lead the process in collaboration with other members of the Local Education Group; the GPE Secretariat provides technical feedback on education programs and their monitoring. Applications for financial support are prepared and submitted by the Local Education Group. In most cases, activities financed by GPE Program Implementation Grants are implemented by the developing-country government with the support of a supervising entity (either a multilateral or donor country) who oversees and reports on the use of the funds. Source: IEG staff based on Global Program Reviews and program websites. Co-financing and Graduation Policies 21. As part of GAVI’s Co-financing Policy that came into effect in December 2010, developing countries are required to co-finance the cost of most GAVI-supported 57 oads G AV Ih a s po i ne ered a co -i f nan cing m od elw hich lays h t e g o r und for e nh ance d country ownership a n dlong-term sustainability o fn ato i na l v a ccn i e co- fi n n a cin g. APPENDIX A y GAVI: S othPatc o URPOSEu,C n r ties con t rib ONTRIBUTIONSu,te ANDtoACTIVITIES the co s to fthe v acc n i es the yrec ei v e ,th e co - ancing: fn i n a cin g policy req uires a pro p ori to n ofth e vaccin e do ses to be proc u e r d with ed vaccines. The policy’s objective is to prepare countries for financial sustainability no - n G A V Ifund s.T h e ov e a r llo bjec i tve is to pe r pare co un tr ies forp h asin g ou t when GAVI support for new vaccines ends and to encourage country ownership of ofG AV Is u p p ortfo r new v a ccin es,r e cog nising h t atth e tm i e frame o f r attainn i g inancing vaccine fn i n a ciafinancing. ls ustan i abThe l iiy t degree w i llv arofa y co- cro finance ss co undepends tr ies. on countries’ income levels, rces for and countries with GNI per capita above US$1,550 are no longer eligible to receive and GAVI C o- finsupport a n cing (Figure l e vels arA.4.). e d et There erm ineare d bcurrently y e ac h co17 un countries tr y ' s exp e graduating cted abili ty from to payGAVI . anagers support. A s e conBetween o micallyJanuary s to r nge 2011 rc o uand nt rieAugust s ap pr2013, o ach co-financing g rad ua i to n,cpayments o-p aym enfrom ts w l il grad ually beneficiary increa se countriesto co ve totaledr h t e fu US$125llc o sto fv million,accines . representing 8 percent of GAVI’s total org/about/ vaccine support to the co-financing countries.15 mme- g/ GAVI’s Figure co-financing A.4. How model GAVI’s Co-financing Policy Works, 2013 Source: GAVI Alliance, 2013, Program Bulletin November 2013. Note: The countries’ co-financing obligations are based on their country co-financing group: 1) the low-income group’s co-financing obligation is 20 cents C per o u dose n tr with ie no s a r annual e e n c increase; 2) u o r the a g e d t o intermediate fo ll group’so w co na ti -financingo n a lp obligation ro c woulde d u start r at es US$ a n 0.20 d per re g dose u l anda tio ns increases f byo r 15%th e annually; and 3) the graduating group’s co-financing obligations start at 20% of the projected price of the vaccine in the year GAVI support ends, increases linearly fu lfilm e n t o f c o - fin a n over four years to reach projected price. c in g . A s a n alte rn a tiv e t o p ro cu rin g th e re q uir e d c o - .fi n a n c i ng a m o u n t th ro u g h e it h e r U N IC E F o r P A H O ’s R e v o lv in g F u n d ,a c o u n tr y m a yt h ere o f res e l f-pro curether eq uiredp o r to i no ft h eG A V - Isu pported v accines ,w ih t the exc ept ion ofp ne um oc occ alv a cci n e .Due to t h e AM C 22. Although co-financing has supported country ownership of immunization a greem e nt, c ountrie sm ust po r curet hec of -ina ncingr equ r iem e t nsf or decisions, the policy has contributed little to creating a stable and predictable p ne umo co cca lvac cin e tho ru ghUN ICE F Su pp y l D i v s i o i n n i orderto a ccess the financial a greed pframework ri c e. for immunization, particularly for low-income countries. There is a substantial risk that graduating countries may fail to sustain the financial investment in immunization and the performance of immunization programs after 58 2 PROGRAMME BULLETIN | November 2013 APPENDIX A GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES GAVI’s support ends. In 2012, two graduating countries, Angola and the Republic of Congo, failed to fulfill their co-financing commitments to GAVI (a situation known as “default”). In both countries the problem was weak budgetary and planning capacity rather than the availability of fiscal space.16 GAVI’S INFLUENCE IN VACCINE MARKET SHAPING 23. Market shaping has always been part of GAVI’s strategy in ensuring the financial sustainability of vaccines once countries graduated, and GAVI has recently been successful in negotiating lower vaccine prices. GAVI has been able to secure pentavalent vaccines for US$1.19 per dose (a reduction of more than 60 percent compared with US$2.98 in 2010), Human Papillomavirus (HPV) vaccines for US$4.50 per dose, and pneumococcal vaccine for US$3.30 per dose (from 2014 onwards).17 IEG finds no evidence that the World Bank has been active in vaccine market shaping. Independent Evaluations of GAVI 24. The Evaluation of the GAVI Phase 1 Performance report was conducted by Abt Associates and assessed the period from 2000 to 2005. The evaluation commenced in November 2007 and the report was released in October 2008. The objectives of the evaluation were: 1) to identify lessons learned in GAVI Phase 1, including how well it has evolved and learned from experience over the period 2000–2005; 2) to contribute to the adjustment of GAVI policies in the next strategic phase of work; and 3) to document the impact and effectiveness of the GAVI Alliance’s use of resources during Phase 1. 25. The overall assessment of GAVI’s activities and performance during Phase 1 was fair and comprehensive, praising the successes GAVI was able to accomplish in a short time period but also providing criticism of GAVI’s weaknesses and failures. But by the time the evaluation and recommendations were finally released, GAVI was already embarking on new activities and organizational changes. By October 2008, the time when the final report was released, GAVI had already decided to merge GAVI Alliance and GAVI Fund into one entity to improve decision-making and governance issues, to introduce pneumococcal and rotavirus vaccines, and to offer HSS funding. The report recommended for GAVI to improve support to countries, improve strategic decision-making, strengthen evaluation mechanisms, ensure an effective dialogue with partners, analyze funding flows for immunization, understand vaccine market dynamics, and reassess strategies for sustainability. 26. The Second Evaluation Report, the most recent external evaluation of the GAVI Alliance, was completed in September 2010. Commissioned by the GAVI Alliance and conducted by Cambridge Economic Policy Associates (CEPA), the Report assessed the period from GAVI’s inception to 2009, but primarily focused on 59 APPENDIX A GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES the GAVI’s performance from 2006 to 2009. The Report commenced in December 2009 and was completed and presented to the Board in September 2010. The evaluation design sought to answer two high-level questions: 1) to what extent has the GAVI Alliance met its four strategic goals and 2) to what extent has the GAVI Alliance added value at the global and country levels, over and above what would have been accomplished without the Alliance.18 27. The report was comprehensive in reviewing GAVI outputs, outcomes, and impacts, as well as the financial, programmatic, and organizational value added by GAVI at the global and national levels. The evaluation teams did not review GAVI governance structure since the governance structure was recently reviewed and reorganized at the time of the evaluation. Five country studies supplemented the team’s findings and analysis. 28. The report praises GAVI’s many achievements, particularly attracting increased funding for immunization, the development of innovative financial instruments, the accelerated introduction of vaccines in low-income countries, and GAVI’s “country ownership” approach. The evaluation teams found GAVI’s support to be a cost-effective intervention and found that the NVS program has accelerated the introduction of life-saving vaccines in countries. 29. The evaluation teams also reported the weaknesses of GAVI’s strategy and performance framework, particularly how GAVI’s activity has not sufficiently aligned with its strategy.19 The report notes: the need for better prioritization of secretariat and partner resources; GAVI’s failure to prioritize monitoring and evaluation (M&E); and the poor accountability between GAVI and its implementing partners. The report also highlights GAVI’s weak performances in reducing vaccine prices and its issues with the HSS delivery model. Furthermore, the report notes that GAVI’s choice of vaccines and basic funding model has had negative implications for country financial sustainability.20 30. The Evaluation of the IFFIm Report was published in June 2011. The GAVI Secretariat, on behalf of the IFFIm Board, commissioned an evaluation of IFFIm by the HLSP. The evaluation assesses the extent to which IFFIm has been an effective and efficient financing instrument to raise money for immunization and health systems in GAVI eligible countries, and the extent to which IFFIm has contributed to enhancing GAVI’s impact on immunization and health. A detailed description is provided in Chapter 4. 31. The excellent evaluation concludes that IFFIm has proven to be a “very efficient second best solution” to the development financing problem and a major source of funding for GAVI, but might not to be easily replicable for other health-sector initiatives. The external evaluation report remarks that the “World Bank’s reputation, credibility, and strong AAA ratings were absolutely critical to IFFIm 60 APPENDIX A GAVI: PURPOSE, CONTRIBUTIONS, AND ACTIVITIES being able to qualify as a supranational; 0 percent risk weighting, AAA credit ratings, and investor confidence all depended in part on the World Bank’s participation.”21 Without the World Bank’s participation, IFFIm’s entire structure would have been different and the feasibility of IFFIm would need to be re- evaluated. 32. The Advanced Market Commitments for Pneumococcal Vaccines Process and Design Evaluation, commissioned by the GAVI Alliance and undertaken by Dalberg Global Development Advisors, was published in February 2013. The report is intended to provide the international development community with insights and lessons learned from the implementation of the Pneumococcal AMC Pilot by focusing on how key decisions were made in the design and implementation processes. The evaluation did not discuss the overall impact of the Pneumococcal AMC as the GAVI Secretariat has commissioned a separate outcome evaluation to be conducted in 2014. 33. The report praises the design and implementation process as having contributed towards the objectives of increasing the supply and accelerating the uptake of pneumococcal vaccines in low-income countries. Overall, the report states that the AMC as a concept has been successfully translated into a pilot program for the pneumococcal vaccine, and that the international development community has been able to design, establish, and administer an AMC. The report recommends further work to reduce the tail price, strengthen performance measurements, and ensure the 2014 outcome evaluation is well designed. 34. In recent years, development partners have also assessed GAVI in terms of value added, aid effectiveness, and alignment and relevance to their development objectives. The United Kingdom Department for International Development (DFID) Multilateral Aid Review 2011 assessed 43 organizations on relative value for money spent. GAVI is rated as a “very good value for money” for delivering cost-effective health interventions, being innovative and transparent, and taking a country-led approach. The review also notes that GAVI needs to focus on further reducing vaccine prices. 35. In Sweden’s 2011 assessment, GAVI is rated as highly relevant to Swedish development assistance policy, and that GAVI has a very high level of internal and external effectiveness with an efficient and responsive Secretariat. The Australian Multilateral Assessment of GAVI, released in March 2012, rates GAVI highly in the areas of delivering results, transparency and accountability, partnership behavior, cost and value consciousness, strategic management and performance, contribution to the multilateral system, and alignment with Australia’s interest. 61 Table A.2. Linkages between Four Global Partnership Programs and the World Bank’s Country Programs Types of Global Fund to Fight Acquired Immune Stop Tuberculosis (TB) Partnership Global Environment Linkages Deficiency Syndrome ( AIDS), GAVI Facility (GEF) Tuberculosis, and Malaria Strategic The Global Fund and Bank strategies are Stop TB and Bank strategies are closely The mandates and strategies of the GEF The policies and strategies of the GAVI most closely aligned in low-income aligned. The Bank exercised its and the Bank Group have been highly Alliance and the Bank Group are closely countries where fighting communicable convening power at Stop TB’s formative compatible and mutually relevant, both in aligned in ensuring childhood diseases is a high priority. However, the stage and seconded staff to Stop TB to the past and today. However, a number immunization. However, the Bank Bank pursues multisectoral approaches to assist with policies and strategy of factors have significantly diminished pursues multisectoral approaches to improve health outcomes, while the Global proposals. the relevance of the design of the Bank improve health, while GAVI’s approach is Fund focuses on three specific diseases. Group-GEF partnership over time. categorical - immunization focused. Financial The World Bank is the limited trustee of The Bank has supported Stop TB since The Bank is the Trustee of the GEF and The Bank operationalized two innovative the Financial Intermediary Fund (FIF) that inception through Development Grant related trust funds, and one of the original financing mechanisms - FFIm and the AMC- supports the Global Fund, disbursing Facility (DGF) Window 1. Before the three Implementing Agencies of GEF-funded providing alternative avenues for donors to funds to grant recipients on the creation of the Global Fund, the Bank projects. The Bank’s share of GEF funding finance GAVI. The Bank is the Treasury instructions of the Global Fund was the largest financial provider for TB has declined over time due to the growing Manager for IFFIm and provides the financial Secretariat. The Bank is not responsible control. number of GEF Agencies and the platform for the AMC, including taking on for fiduciary oversight to ensure that grant introduction of new resource allocation financial risks on its own balance sheets. disbursements are used for the intended systems in the GEF. purposes. Operational The Bank does not play an explicit The Bank provides financial support to Repeated reforms to the GEF’s project Since GAVI was set up, the Bank has operational role in the Global Fund. countries through multiple lending cycle and Agency fees have contributed reduced its immunization engagement, However, Global Fund and Bank staff operations. Stop TB seconded staff to ineffective management, slow except for polio. Active collaboration with has had some degree of engagement — members to the Bank. processing speed, and duplication of GAVI has occurred but is rare. The Bank from information-sharing to active work. However, the GEF and the World has been active in donor coordination for collaboration — in about 65 countries in Bank are currently piloting a major project aid effectiveness. which both organizations have been cycle simplification intended to reduce active in the health sector. these inefficiencies. Institutional The Bank is a permanent, non-voting Stop TB is hosted by WHO, and the Bank The Bank and other GEF Agencies have The Bank is a permanent, voting member institutional member of the Global Fund is a member of the coordinating board. little role, as invited observers, in GEF of the GAVI Board and sits on three Board by virtue of its trustee role. The Stop TB’s principle is for partners to work Council decision-making today. The committees. Since GAVI’s governance various initiatives associated with the cooperatively towards the common goal Agencies’ roles in the preparation of GEF reforms in 2008, the Bank has been less Global HIV/AIDS Program and the without renouncing the independence policy and strategic documents have engaged and decided to stop receiving International Health Partnership has and individual mandates of partners. become less collaborative and more GAVI funding for country-related contributed to both global and country- consultative over time. operations. level engagement. TTLs = task team leaders. Sources: Independent Evaluation Group (IEG’s) Global Program Reviews on the Global Fund (2012), Stop TB (2009), the World Bank Group’s Partnership with the GEF (2013), and GAVI Alliance (2014). 62 Appendix B. Replicability of Innovative Financial Mechanisms 1. Innovative financing mechanisms enable the international community to respond to international development and global health priorities by leveraging a variety of financial resources. The World Bank has been critical for the establishment and very effective in the management of two globally innovative financial instruments, IFFIm and the AMC. Working with partners, the Bank has effectively operationalized new financial instruments, devoting significant time and resources to this task, and assuming financial risks for the AMC and potential reputational risks (both AMC and IFFIm). The Bank’s experience in operationalizing these innovative financial mechanisms provide lessons for other innovative financing mechanisms beyond the sector. 2. IEG concurs with the external IFFIm evaluation and finds that in its present format and with the current governance structure, as a UK charity, IFFIm is unlikely to be replicable for other health-sector initiatives. IFFIm was set up in 2004 with the principal donors requesting that commitments could be accounted for “off budget” requiring a favorable ruling by the regulators (Eurostat). It is unlikely that after the dramatic changes in the financial landscape in 2008 such a ruling could be obtained again today. The mechanism is transaction intensive and not inexpensive. 3. The total projected operational costs over IFFIm’s lifetime are difficult to estimate as they critically depend on future projected interest rates. The 2010 IFFIm external evaluation estimated the lifetime cost of governance and treasury management as 4.1- 4.6% of present value of then-current pledges. Essential running cost, such as directors insurance for IFFIm Board members, legal advice, and treasury management fees amount to US$5-6 million per year. Recent work by the Bank projects the cost to be closer to the 8- 10% range, when also taking into account the potential interest paid for outstanding debt. This means that IFFIm’s management costs over the life of the facility could amount to $150-$340 million.1 4. Thus, unless frontloading is absolutely critical and the recipient is a mature organization with an established pipeline of activities ready for financing, direct funding by donors would seem to be easier and a lower cost option for the recipient. 5. The AMC – a so called “pull mechanism”-was a pilot operation to operationalize and test the concept of an “advanced market commitment. The AMC was intended to cover the capital cost for pneumococcal vaccine production for established manufacturers in order to make the vaccine rapidly available for GAVI eligible countries. Because the AMC for pneumococcal vaccines was the first AMC ever, its design process was driven by learning by doing. The recent process and design evaluation considers the AMC a success. IEG concurs with this assessment. 63 APPENDIX B. REPLICABILITY OF INNOVATIVE FINANCIAL MECHANISMS 6. However, the choice and modification of an existing pneumococcal vaccine for the pilot and its cost has attracted considerable criticism from civil society organizations, such as Doctors without Borders. The long-term nature of the commitment and its consequences for GAVI finances—forecast at about a third of overall GAVI outlays for the next decade—have also been pointed out. 7. Recently several new vaccines, such as MenAfriVac, Oral Cholera, and Japan Encephalitis, have been effectively developed by using so called “push mechanisms,” facilitating technology transfer to manufacture the vaccine with the provision of up-front funding to meet a specific target. Most important is the new low-price conjugate vaccine for Meningitis in Africa (MenAfriVac) to combat epidemic meningitis in the African meningitis belt. It was developed with a US$70 million grant from the Gates Foundation and is now manufactured in India at a cost of US$0.40 per dose. Not counting vaccine prices, development costs using a push mechanism have been a fraction (less than 5 percent) of that of the AMC. 2 64 Appendix C. Timeline of GAVI Alliance and Related Events in the World Bank and Elsewhere YEAR GAVI Alliance World Bank Other 1997 (September) World Bank HNP (Health Nutrition and Population) Sector Strategy launched. Strategy underscores importance of institutional and systemic changes to improve health outcomes for the poor, improve health system performance, and achieve sustainable health sector financing. With a portfolio of 154 active and 94 completed HNP projects, for total cumulative value of $13.5 billion (1996 prices), the Strategy states that Bank has become the largest single source of external HNP financing. Strategy calls for sharpening strategic focus but gives relatively little attention to disease control. 1998 (March) With immunization rates in low-income countries in decline and slow progress introducing new vaccines, World Bank President James Wolfensohn convenes a Vaccine Summit involving WHO, UNICEF, vaccine industry leaders, bilateral aid agencies & independent academics. 1999 (July) Proto-Board for the Global Alliance for Vaccines and (March) 2nd Vaccine Summit at Rockefeller Foundation's Immunization (GAVI) establishes mission, objectives, Study Centre lays foundations for new global coalition to functions and governance structure. UNICEF offers to revitalize immunization rates in poor countries and support house GAVI's Secretariat in Geneva. purchase of new vaccines like hepatitis B, yellow fever and (August ) First GAVI Board Meeting Haemophilus influenzae type b (Hib). (November) The Bill & Melinda Gates Foundation pledge a gift of US$ 750 million over five years to establish the Global Fund for Children's Vaccines, the institution set-up to finance the GAVI Alliance. 2000 (January) GAVI publically launched. A global alliance of Bank joins Global Alliance for Vaccines and Immunization public/private stakeholders in immunization, uniting WHO's (GAVI) at inception and provides funding from its technical expertise, UNICEF's vaccine purchasing power, Development Grant Facility (DGF). financial know-how of the World Bank, the R&D market The World Bank has taken a leading role in the GAVI knowledge of vaccine industry & the voices of developing Financing Task Force countries The World Bank acts as co-chair of the Immunization 65 APPENDIX C. TIMELINE OF GAVI ALLIANCE AND RELATED EVENTS IN THE WORLD BANK AND ELSEWHERE YEAR GAVI Alliance World Bank Other Financing and Sustainability Task Team 2001 (May) After cooperating with the U.N. and others on definition of the MDGs, the Bank announces that it will join with the U.N. as a full partner to implement the MDGs and put them at the heart of its development agenda. FY2001 World Bank and IDA commitments for HNP amount to $1.3 billion. 2002 World Bank commitments for HNP during FY02 were $1.4 billion, including $320 for communicable diseases. More than 30 countries reported to benefit from Bank support for tuberculosis control, with 45 active projects supporting malaria control. (FY02 World Bank Annual Report) 2003 (July) GAVI's five-year commitments to immunize children (April) 13th Replenishment of IDA becomes effective with (June) The Global Polio Eradication Partners applaud Rotary in the world's poorest countries top US$ 1 billion. Some 68 three years of funding at $23 billion. International for its US $88,557,000 pledge to polio countries now receive support for health infrastructure, eradication. vaccines and supplies through GAVI funding (October) Partners of the Global Polio Eradication Initiative welcome a landmark resolution by the Organization of the Islamic Conference (OIC) to wipe out polio from remaining polio-infected OIC countries. (November) UNICEF receives a $10 million grant from the Bill & Melinda Gates Foundation to fight maternal and neonatal tetanus. (December) Iran and Turkey launch the largest and most ambitious measles campaigns in the world with the support of the Measles Initiative. 2004 (March) With the last case of polio reported in 2002, Somalia is removed from the list of polio-endemic countries. 2005 (July) GAVI starts to offer health system strengthening (February) Negotiations on 14th IDA Replenishment (March) WHO in partnership with UNICEF develops the support (HSS) parallel with vaccine support. This will help concluded, for about $35 billion over three years. (Annual “Effective Vaccine Store Management” initiative. countries create more integrated health plans that remove Report) bottlenecks in the delivery of immunization and other (December) Bank study, Reaching the Poor: What Works, health services. For example, funding health worker What Doesn’t, and Why, warns of gaps between intentions training. and verifiable results and reports that health programs (December) GAVI designates US$ 37 million to fund the designed to reach poor people often end up helping the Hib Initiative better off instead. Report offers governments key policy steps to make sure that disadvantaged people get crucial 66 APPENDIX C TIMELINE OF GAVI ALLIANCE AND RELATED EVENTS IN THE WORLD BANK AND ELSEWHERE YEAR GAVI Alliance World Bank Other health services. 2006 (November) GAVI's International Finance Facility for The Health System Strengthening Task Team. It supports (February) Global Polio Eradication Initiative declares Egypt, Immunisation (IFFIm) raises US$ 1 billion through the the formulation and implementation of HSS components in polio-free. inaugural issue of bonds to institutional investors. IFFIm the GAVI work plan. The World Bank is a member among Vietnam eliminates maternal and neonatal tetanus as a public converts long-term government pledges of aid into others. health problem. immediately available cash by issuing bonds in the capital The World Bank It helped to set up, and acts as financial markets. advisor and treasury manager to, the International (November) GAVI to finance rotavirus vaccines Finance Facility for Immunisation (IFFIm) 2007 (February) Advance Market Commitment (AMC) launched The World Bank acts as a co-chair of the GAVI (May) First National Campaign to eliminate tetanus in to create a market in the world's poorest countries for a Immunization Financing and Sustainability Task Team. mothers and newborns is launched in Guinea-Bissau with the new vaccine against pneumococcal disease. Canada, The World Bank agrees to hold AMC funds in trust for support of UNICEF. Italy, Norway, the Russian Federation, the UK and the Bill GAVI on behalf of donors. (Jun) New phase of largest-ever measles vaccination & Melinda Gates Foundation commit US$ 1.5 billion. campaign begins in Pakistan with the support of the Measles With health systems performance a dominant theme, (September) GAVI signs-up to the International Health Bank Annual Report highlights $1.83 billion in new HNP Initiative. Partnership (IHP) mission to strengthen health systems in commitments in FY07. developing countries by addressing health worker staffing, infrastructure, health commodities, logistics, tracking (September) Updated Bank HNP strategy focuses on HSS progress and effective financing. and calls for redoubling efforts to improve results, protect households from illness, and improve sector governance. Strategy observes significant increase in complexity of HNP assistance architecture and relatively reduced financial role of Bank. IFC-World Bank study of Business of Health in Africa finds that private sector delivers about half of Africa’s health products and services and calls for close partnership between public and private sectors. (September) Bank joins International Health Partnership. (November) Norway announces $105 million Health Results Innovation Grant for Bank to pilot results based financing to link funding to verifiable better health care for mothers and their infants, in keeping with MDGs. (December) Negotiations completed on 15th IDA Replenishment, with pledges of $41.7 billion, including debt relief and new financing by 45 donor countries of $25.2 billion. (FY08 Annual Report) 2008 (March) Second International Finance Facility for In FY08 International Bank for Reconstruction and (March) The Global Polio Eradication Initiative announces Immunisation (IFFIm) bond sale secures US$ 223 million Development (IBRD)/IDA committed $948 million to HNP eradication of polio in Somalia. from private investors in Japan. operations. Thanks to a trust fund financed by Norway, the (June) GAVI Board agrees to consider future support of Bank pledged $100 million for results based HNP new and underused vaccines against four deadly diseases financing in at least four countries. (World Bank Annual 67 APPENDIX C. TIMELINE OF GAVI ALLIANCE AND RELATED EVENTS IN THE WORLD BANK AND ELSEWHERE YEAR GAVI Alliance World Bank Other in the developing world: HPV, typhoid, Japanese Report) encephalitis and rubella 2009 (March) Vaccine investment ISA goes on sale in the UK, In 2009, the Bank partners with GAVI and the Global Fund (November) PATH Malaria Vaccine Initiative (MVI) launches aiming to raise GBP 50 million for the International to Fight AIDS, Malaria and Tuberculosis in setting up a pivotal efficacy trial of RTS,S, the world’s most clinically Finance Facility for Immunisation (IFFIm). joint Health System Funding Platform, part of a broader advanced malaria vaccine candidate, in seven African (June) Advance Market Commitment (AMC) pilot project international effort to build stronger country health countries: Burkina Faso, Gabon, Ghana, Kenya, Malawi, against pneumococcal disease activated. systems that can deliver health care efficiently, equitably Mozambique and Tanzania. and sustainably. UNICEF and WHO launch The Global Action Plan for (June) GAVI, hosted by UNICEF since its launch in 2000, becomes an independent international institution - the first (March) Progress report to Board on implementation of Prevention and Control of Pneumonia (GAPP). organization to receive such recognition under the Swiss 2007 HNP strategy underscores HSS and importance of Host State Act. strengthening the HNP portfolio, cites examples of results- based financing, underscores multisectorality of HNP support, mentions that about one-half of Poverty Reduction Support Credit operations have an HNP aspect, and stresses IHP+ cooperation. (April) IEG releases evaluation of $17 billion in World Bank support for HNP since 1997, two-thirds with satisfactory outcomes, but portfolio performance stalling. IEG finds the Bank financing a smaller share of HNP support and observes that excessive earmarking of foreign aid for communicable diseases (their reduction being an objective of 35 percent of HNP operations) can distort allocations and reduce health system capacity. It recommended that the Bank carefully assess decisions to finance additional freestanding communicable disease programs in countries where other donors are contributing large amounts of earmarked disease funding. 2010 (October) At a high-level meeting entitled "Saving (September) Bank releases study of Unfinished Business: (January) Bill and Melinda Gates Foundation pledges $10 children's lives - a call for action and resources for the Mobilizing New Efforts to Achieve the 2015 Millennium billion over the next 10 years to help research, develop and GAVI Alliance", GAVI donors and partners agree to Development Goals for U.N. MDG review summit outlining deliver vaccines for the world’s poorest countries. convene the Alliance's first pledging conference in June developing countries’ progress in overcoming poverty until (June) Myanmar achieves maternal and neonatal tetanus 2011. Its objective: ensuring that the Alliance has sufficient recent food, fuel, and financial crises. Report estimates elimination (MNTE). funding to introduce new vaccines against the two biggest that as a result of these crises, 64 million more people are killers of children - pneumonia and diarrhea - between living in extreme poverty in 2010, and some 40 million (November) Mozambique eliminates Maternal and Neonatal 2010 and 2015. more people went hungry in 2009. By 2015, 1.2 million Tetanus MNT. (October) Former Norwegian Minister of Health Dagfinn more children under five might die. (December) The Program for Appropriate Technology in Høybråten unanimously elected by the GAVI Alliance Health (PATH) and WHO launch MenAfriVac. Board as its new Chair. WHO, UNICEF, the National Institute of Allergy and (December) Nicaragua introduces pneumococcal vaccine. Infectious Diseases (NIAID) and the Bill & Melinda Gates Foundation launch Decade of Vaccines Collaboration. 68 APPENDIX C TIMELINE OF GAVI ALLIANCE AND RELATED EVENTS IN THE WORLD BANK AND ELSEWHERE YEAR GAVI Alliance World Bank Other 2011 (February) Global roll out of pneumococcal vaccine. (June) World Bank IFC affiliate issues assessment of how (Apr) Bill Gates and ONE launch the Living Proof Campaign (March) GAVI appoints Dr. Seth Berkley as its new Chief governments and private health sector work together in 45 in France. Executive Officer. African countries. (June) Bill & Melinda Gates Foundation to provide Sabin (May) GAVI commits US$ 100 million to supporting the Vaccine Institute with $12 million to fund multiple phase 1 roll-out of a new life-saving vaccine MenAfriVac in clinical trials and further product development for human Cameroon, Chad and Nigeria. hookworm vaccine. (June) A record 50 GAVI-eligible countries applied for (July) Uganda announced elimination of Maternal and GAVI's vaccine funding, nearly double the previous high of Neonatal Tetanus MNT. 27 countries. (August) The Government of Japan extends a loan of 5.63 (June) Major public and private donors commit US$ 4.3 billion rupees to the Government of Pakistan, which the billion at the first pledging conference held by GAVI. Gates Foundation will repay if Pakistan meets polio eradication targets by 2013. (September) The United Nations Foundation reveals Shot@Life, a new campaign to expand access to life-saving vaccines for children in developing countries. (October) UNICEF launches new website, Polio Info, to provide updates on the latest social data related to polio. World leaders from Australia, the United Kingdom, Canada, Nigeria and Pakistan join Bill Gates in pledging $122 to the Global Polio Eradication Initiative. (November) Ghana announces elimination of Maternal and Neonatal Tetanus (MNT). (December) The Government of Japan and UNICEF signed the Exchange of Notes for Grant Assistance to Afghanistan amounting to approximately US$9.3 million for the “Project for Infectious Disease Prevention for Children” through UNICEF”. 2012 (February) US grant to GAVI is requested at US$ 145 (July) The World Bank's Board of Executive Directors (February) India is officially struck off the list of polio-endemic million, an increase of US$15 million over the proposed approves US$95 million to assist the Government of countries by WHO. allocation of US$ 130 million to GAVI for FY 2012. Dec) Nigeria, as part of a global polio eradication effort, Project (March) UN Secretary-General Ban Ki-moon launches the (June) The GAVI Alliance Board meeting is held in ID: P130865 first polio eradication campaign of 2012 in Angola. Washington DC, USA from 12-13 June 2012. (October) The World Bank's Board of Executive Directors (April) Ghana introduces pneumococcal and rotavirus “La Caixa” Foundation donates €4 million (US$ 5.3 million) approves US$24 million to assist Pakistan in its efforts vaccines at the same time with support from UNICEF. through the GAVI Matching Fund to buy pneumococcal under its Polio Eradication Initiative (PEI). Project ID: P132541 UNICEF Executive Director Anthony Lake, alongside partners vaccines for GAVI-supported countries in Latin America. in the newly renamed Measles and Rubella Initiative, launch (July) GAVI Alliance with support from UNICEF, WHO, a new global strategy aimed at reducing measles deaths and USAID introduces PCV 13 in Zimbabwe. congenital rubella syndrome to zero. (September) Helen Evans, Deputy CEO of the GAVI (May) World health ministers endorse the Global Vaccine Alliance addresses the 65th session of the WHO Regional Action Plan. 69 APPENDIX C. TIMELINE OF GAVI ALLIANCE AND RELATED EVENTS IN THE WORLD BANK AND ELSEWHERE YEAR GAVI Alliance World Bank Other Committee for South-East Asia in Yogyakarta, Indonesia. (June) UNICEF engages community leaders and parents to (December) Medecins Sans Frontieres formally raises the increase vaccine coverage and eliminate polio in DRC. issue of access to the same prices GAVI pays for vaccines (September) UNICEF publishes its report Committing to Child at the GAVI Board meeting. Survival: A Promise Renewed. In-depth review of HSS support to Sierra Leone is Islamic Development Bank to assist with a three-year $227 launched. million financing package to Pakistan, and a $3 million grant Since 2010 Germany has continually increased its to Afghanistan for the eradication of Polio. contributions from €4 million to €30 million. (October WHO formally declares that China has eliminated Maternal and Neonatal Tetanus (MNT) 2013 (January) The GAVI Alliance appoints Simon Lamb as (February) The World Bank approves a $100 million grant (January) UNICEF, WHO, the World Bank Group and the UN Managing Director of Internal Audit. from the IDA to help the government of Afghanistan report ‘Levels and trends in child mortality’ concludes that In its first ever Multilateral Organization Performance expand the scope, quality, and coverage of basic health global child deaths down by almost half since 1990. Assessment Network (MOPAN) review the GAVI Alliance and essential hospital services. The PATH Malaria Vaccine Initiative (MVI) and Inovio was commended for its effectiveness in increasing access The World Bank mobilizes US$120 million to help Ethiopia Pharmaceuticals, Inc. announce a follow-on collaboration to to immunization and for its focus on results. continue its progress towards meeting the 2015 MDGs for advance malaria vaccine development and new vaccination (May) Kenya becomes the first country to protect girls health. The Bank’s Board of Executive Directors approved delivery technologies. against cervical cancer with GAVI-supported human the Ethiopia Health MDGs Program-for-Results (PforR). (April) First Global Vaccine Summit in Abu Dhabi. papillomavirus (HPV) vaccines. (July). Rwanda becomes first country in sub-Saharan Africa to (June) GAVI Board asks to begin preparations for (September) World Bank Group to invest US$700 Million introduce measles and rubella dual vaccine through support introduction of inactivated polio vaccine and considers from IDA by 2015 to improve women and children’s health from the Measles and Rubella initiative. investment in other new vaccines. in poor countries. (May) The Government of Uganda, with support from (July) The GAVI Alliance and Lions Clubs International UNICEF, WHO, the World Bank and other partners, launches announces a unique partnership designed to protect tens PCV immunization program. of millions of children in the world’s poorest countries (October) Japanese encephalitis vaccine is prequalified by against measles - Lions Clubs Lions to raise US$ 30 WHO. million for immunization, matched by US$ 30 million from UK Government and Bill & Melinda Gates Foundation IFFIm raises US$ 700 million to support GAVI’s immunization programs. (November) GAVI announces its support to the new and first national campaign against yellow fever in Nigeria. GAVI alliances supports introduction of pneumococcal vaccine and measles-rubella vaccine in Senegal. GAVI hosts its Mid-Term Review in Stockholm, Sweden. The GAVI Alliance is to begin providing support for the introduction of inactivated poliovirus vaccine (IPV) as part of routine immunization programs in the world’s 73 poorest countries. Source: World Bank Group, WHO and GAVI Alliance Website. 70 Appendix D. Members of the GAVI Alliance Board Constituency Member Position Organization/ Country Secretary General of the Chair Dagfinn Høybråten Secretary General Nordic Council of Ministers Representative Seats Bill & Melinda Gates Bill & Melinda Gates Orin Levine Foundation Foundation Director for Health, Nutrition World Bank Tim Evans World Bank and Population UNICEF Geeta Rao Gupta Deputy Executive Director UNICEF World Health Organization Flavia Buestro World Health Organization Developing countries: Senior Presidential Advisor Christine J.D. Ondoa Uganda Anglophone Africa on Public Health Developing countries: Awa Marie Coll-Seck Minister of Health Senegal Francophone Africa Minister for Health and Developing countries: Asia A.F.M. Ruhal Haque Bangladesh Family Planning Developing countries: Acting Minister of Public Suraya Dalil Afghanistan Middle East Health Developing countries: Latin America and Eastern Andrei Usatii Minister of Health Moldova Europe Director of the Global Public France/ Luxembourg/ Goods Directorate, Health Ministry of European and Gustavo Gonzalez-Canali EC/ Germany and Human Development Foreign Affairs, France Department Pasteur Institute - Fondazione Italy/ Spain Angela Santoni Scientific Director Cenci Bolognetti Denmark/ Netherlands/ Ambassador for Global Ministry for Foreign Affairs, Anders Nordström Norway/ Sweden Health Sweden Incoming Head of the Department for International Ireland/ Canada/ UK Donal Brown Global Funds Department Development, United Kingdom 71 APPENDIX D MEMBERS OF THE GAVI ALLIANCE BOARD Assistant Director General, Australia/ Japan/ Korea/ Jenny Da Rin Health Education and AusAID, Australia USA Scholarships Branch Vaccine industry – Johan Van Hoof Managing Director Crucell Industrialized Vaccine industry – Mahima Datla Managing Director Biological E. Limited Developing Founder and Executive Future Generations CSOs Joan Awunyo-Akaba Director International Noordin Noormahomed Sheriif Endowed Professor Research & technical Zulfiqar A. Bhutta and Founding Chair, Aga Khan University, Pakistan health institute Division of Women and Child Health GAVI CEO Seth Berkley CEO, Executive Office GAVI Alliance Independent Seats Independent Wayne Berson CEO and Partner BDO USA LLP Independent Dwight L. Bush Retired President and CEO Urban Trust Bank Independent Ashutosh Garg Founding Chairman Guardian Lifecare Pvt Ltd Retired Partner and Vice Independent George W. Wellde Jr Chairman of Securities Goldman, Sachs & Co Division Her Royal Highness the Director, International Independent “La Caixa” Foundation Infanta Cristina of Spain Programs President and Executive Foundation for the National Independent Maria C. Freire Director Institute of Health Independent Yifei Li China Chair Man Group Independent Richard Sezibera Secretary General East African Community Source: GAVI Alliance Website. 72 Appendix E. Findings from the Country Visits 1. The countries visited were a purposive sample based on the following (not mutually exclusive) criteria: (a) countries that are pilot countries for the Health Systems Funding Platform, (b) countries where both GAVI and the World Bank have been active in the health sector since GAVI was founded in 2000, (c) countries in which there has been some engagement (collaboration, complementarity, or consultation) between GAVI and the World Bank (based on prior desk reviews and interviews), and (d) countries to which the ImGAVI Trust Fund has provided technical assistance. MISSION SUMMARY: ETHIOPIA 2. Ethiopia’s immunization coverage rates have been steadily rising over the last 10 years, but most vaccines only cover between 60 and 80 percent of infants. Bacille Calmette-Guerin (BCG) and DTP1 vaccine rates have fallen from 90 to 80 percent over the last few years. The Ethiopian government expects the GAVI-supported new vaccines, such as rotavirus, will help the country achieve single-digit under-five mortality by 2030. However, a gap exists between official immunization coverage and survey-estimated coverage rates raising the question of what happened to the vaccine doses provided. The government, GAVI, and other donor partners need to find ways to ensure effective vaccine distribution and improve coverage. 3. Since 2001, GAVI has disbursed US$ 469 million and committed US$ 740 million for vaccines, health system strengthening, and immunization services support in Ethiopia. The government’s routine immunization spending has increased since 2001 when GAVI funds started. In 2009, the Ethiopian Expanded Program on Immunization’s (EPI) expenditures totaled US$56.7 million with the government financing about 12 percent of routine immunization spending. This increased to 51 percent in 2010 with the government spending US$26 million (US$17 per infant) on routine immunization. (WHO 2013). 4. GAVI-financed vaccines have contributed to the country’s strong reduction in child mortality, and GAVI has been a pioneer in Ethiopia in aligning its finances for HSS. The program disburses into the pooled MDG Performance Fund, which finances the government’s Health Sector Development Program. The government and partners in Ethiopia generally have a positive perception of the GAVI Alliance, in particular for its large-scale, front-loaded, predictable financing for new vaccines, and recent declines in the prices of some new vaccines. 5. The lack of GAVI country presence combined with lack of an effective partnership appears to result in missed opportunities to strengthen immunization results via operational support and health and immunization policy dialogue, for 73 APPENDIX E. FINDINGS FROM THE COUNTRY VISITS example on how to speed up immunization in lagging regions and for disadvantaged groups. Immunization is highly inequitable between the highest and lowest income quintiles in Ethiopia. In 2011, there was a substantial gap between the poorest and richest income quintiles with nearly 15 and 50 percent respectively of 1- year-olds immunized. There are also large urban/rural gaps in Ethiopia. In 2005, NDHS data illustrated that 10 percent of children in Affar had adequate immunization coverage whereas nearly 90 percent were adequately covered in Addis Ababa.1 6. The World Bank has supported immunization in ways that are broadly complementary to GAVI’s program. It helps finance health worker salaries under Promoting Basic Services (PBS, a multidonor operation, now in its third phase). This support is clearly enabling for the immunization program. PBS I and II also financed some medical procurement. The World Bank is starting analytical work on basic services for the bottom 40 percent (also the group that doesn’t receive immunization). Thus, World Bank and GAVI support seem broadly complementary. MISSION SUMMARY: NEPAL 7. Community-based programs were successfully implemented in Nepal, which resulted in full immunization coverage increasing from 43 percent in 1996 to 87 percent in 2011. Currently, most vaccine coverage fluctuates around an average of 85-90 percent. According to the NDHS in 2011, DTP3 coverage was 92 percent and measles was 88 percent among 1-year-olds. The Hib3 vaccine was recently introduced in 2011 and Nepal is scheduled to introduce pneumococcal vaccines in 2014 and rotavirus vaccines in 2016. Pneumococcal disease is the leading cause of pneumonia – Nepal’s number two killer of children under five years of age with 16 percent of total deaths in 2010. Following that, rotavirus, the leading cause of severe childhood diarrhea, is the sixth fatal disease for children under five with 6 percent of the total deaths in 2010. (WHO 2010) 8. Total expenditures on health have historically fluctuated between 5-6 percent of the Gross Domestic Product (GDP) in Nepal, 55 percent of which are out-of- pocket payments. Health expenditure per capita is around $33. The Nepalese government has noted that efficiency will play a huge role in creating additional fiscal space for the health sector. Linking payment to performance may be the best option for the government to get more value for the money spent on health care (World Bank 2012, UHC Forward 2008). 9. The MoH faces funding issues due to the absence of an elected government and a frozen budget. This has caused the health sector to be under-financed. The total amount of disbursements from GAVI between 2001-2012 was around US$ 59 million with US$ 110 million committed. Of this support, 61 percent can be attributed to 74 APPENDIX E FINDINGS FROM THE COUNTRY VISITS vaccine support and 39 percent to financing non-vaccine support such as HSS and immunization services support. 10. The Nepal Health Sector Program 2010-2015 (NHSP II), under the Sector-wide Approach (SWAp) framework, is dedicated to creating equal access to health care and lowering out-of-pocket payments for services, and it is also the basis for the HSFP. The SWAp uses a Joint Financing Agreement (“JFA”) to pool funding from five donor agencies (World Bank, GAVI, DFID, Kreditanstalt fuer Wiederaufbau (German Development Bank) (KFW) and Australian Agency for International Development (AusAID) – referred to as Pooling Partners.) The Non-Pooling partners who have signed the JFA are U.S. Agency for International Development (USAID), UNICEF, United Nations Population Fund (UNFPA), and WHO. The agreement has been in effect since August 2010. 11. Nepal was a pilot country for HSFP and is the only country so far where the HSFP has been implemented; however the Global Fund is not a party to the HSFP in the country. Nepal has demonstrated that close donor coordination can be achieved, that joint funding based on a JFA outlining the rights and obligations of pooling and non-pooling signatories is critical, and that the SWAp provides an excellent mechanism in achieving this objective. Although the World Bank is an active member of the Health Sector Coordination Committee (HSCC), it is not a member and does not participate in the ICC. MISSION SUMMARY: INDONESIA 12. The country’s strong centralized government structure rapidly decentralized in 1999 which led to significant funding increases to the health sector and placed service delivery in the hands of local government. Although the country has made improvements in health outcomes since decentralization, it has been much slower than its peers in maternal mortality, nutritional status, and underweight rates. Inequality remains a problem in Indonesia with 46 percent of the population living below the basic needs poverty line of US$2 per day in 2010 and large gaps in infant mortality rates between the rich and the poor. (World Bank 2012). 13. The Indonesian government considers immunization to be a health priority. Immunization trends have shown relatively little change over the last decade with an average coverage mean around 75 percent. Around 2006, the rates of BCG, DPT, Polio (Pol3) and Hepatitis B (HepB3) vaccine coverage declined. Conversely, measles’ coverage rates have steadily increased since induction from around 75 percent to 90 percent. Pentavalent vaccine has been introduced in Indonesia and Pneumococcal vaccines were planned for introduction in 2013. Although overall immunization distribution has increased from 55 percent to 59 percent between 1997 and 2007, it still remains inequitable across income quintiles and urban and rural populations. 75 APPENDIX E. FINDINGS FROM THE COUNTRY VISITS 14. Health spending has been historically low in Indonesia with an average of 0.5 percent of GDP over the last decade and a half since decentralization. With private payments capturing 70 percent of disbursements, the country has struggled with high levels of out-of-pocket payments and informal user fees resulting in little protection against catastrophic spending. However, public spending following decentralization has increased and focused primarily on vertical disease-specific programs, investments in facilities and salaries. Indonesia currently covers a substantial part of immunization costs and is graduating from GAVI support. GAVI has committed US$ 95.5 million to Indonesia of which US$17.5 million in vaccine costs and US$38.3 million in vaccination oriented HSS t has been disbursed. 15. As a GAVI graduating country, Indonesia is co-financing support and carries the majority of immunization costs. GAVI is the only partner in health actively supporting the Government’s immunization program. The sustainability of the health financing system faces decentralization challenges. Government has stressed health as a priority sector and increased expenditures; however, sustainability at the central level does not promise sustainability at the provincial and district levels. Unfortunately, there has been inadequate funding from district offices for operational costs. 16. The country will graduate from GAVI in 2015 and has been recipient of both GAVI and World Bank funding. The World Bank and GAVI have both made important contributions to the Indonesian health sector. GAVI support has focused mainly on vaccination financing whereas the World Bank set up programs after decentralization dealing with HSS. The World Bank financed three prominent projects after decentralization focused on direct support for the decentralization efforts and operational costs of immunization. (GAVI 2010). The ICC, which implemented and monitored GAVI support for direct immunization costs merged in 2011 with the HSCC to work on similar issues in immunization, management, and health system objectives. The World Bank used to be a participating member of the ICC, but has been removed in 2010 from the list of signatories due to too little engagement on its part. 17. A comprehensive sub-sector review of immunization activities was completed for Indonesia. At present there is no regular direct communication at the country level between the GAVI and World Bank staff. Other donors expressed regret about this, since enhanced collaboration would be mutually beneficial. The government did not consider the Bank a vital partner with regards to technical assistance for vaccine sustainability. Instead JICA, UNICEF, and the WHO were cited. Development partners expressed an interest in having the Bank participate more actively in regular meetings with the donor community at large in order to coordinate efforts more closely. Indonesia does not use UNICEF for vaccine procurement. Instead it requires single-source procurements from the national supplier BIOFARMA resulting in excessively high vaccine prices. 76 APPENDIX E FINDINGS FROM THE COUNTRY VISITS MISSION SUMMARY: TAJIKISTAN 18. With relation to health indicators, Tajikistan has some of the lowest in the region with an infant mortality rate of 34 per 1000.2 The National Development Strategy in Tajikistan prioritizes the reduction of infectious disease and vaccine- preventable diseases, and the National Immunization Program (NIP) in Tajikistan has deemed immunization as a health priority for the government. A National Immunization Program Review undertaken in 2012 by the Ministry of Health, UNICEF, JICA, USAID, and the Agha Khan Foundation emphasized the need for more health sector funding, equitable health services, better monitoring, and vaccine stock management. Although the government reported the immunization rate between 2008 and 2012 for children under 1 year to be in the high 90s, the Review highlighted serious deficiencies, with 71 percent of children having had all 8 vaccinations, vague monitoring and reporting systems, shortfalls in state and regional funding, aging infrastructure, and limited health worker skills.3 Surveillance and equity issues were magnified in 2010 by the polio outbreak that occurred after a 13-year absence of the disease. The outbreak also raised concerns about the weaknesses of the routine immunization and the reliability of reported coverage.4 19. The government introduced pentavalent vaccines in 2008 with help from GAVI, JICA, and other international organizations. Plans to introduce the rotavirus vaccine have been stalled until 2015 due to financial difficulties and the pneumococcal vaccine should be introduced in 2014-2015.5 Regardless of the government’s interest, WHO advised against introducing the HPV vaccine at the present time. 20. Total health expenditures have been around 5-6 percent of GDP over the last decade; however, public funds only cover a small proportion causing out-of-pocket payments to be rather high for the European and Central Asian region. According to the World Bank, in 2009 households contributed about 72.4 percent of total health expenditure in the form of user fees and out –of-pocket payments. Informal payments have also been a problem due to the low incomes of health care workers. In terms of immunization, the government only covers 12.5 percent of costs and relies heavily on international donor contributions. Health-sector reforms must be put in place to build a sustainable financing system. 21. There are large inequities in the health service provision of Tajikistan. Tajikistan’s mountainous terrain makes health access difficult for those in hard to reach villages, and childhood malnutrition remains a problem for some of the poorest regions. 2012 immunization data shows large inequities between income quintiles with a 26.8 percent gap in immunization distribution between the highest and lowest quintiles.6 77 APPENDIX E. FINDINGS FROM THE COUNTRY VISITS 22. Currently, the government has only been able to make small obligatory co- payments on vaccination costs; in order to keep within GAVI regulation, the government has doubled its co-payments for vaccine purchases to US$550,000 in 2013. Although the Ministry of Health has requested more funding, the Minister of Finance is reluctant to distribute more money towards health spending. Furthermore, there is little health policy dialogue between the two branches of government. Development partners are unsure of Tajikistan’s ability to finance its own immunization services since GAVI and donors subsidize a majority of the immunization costs. As a result, immunization is consequently under-financed by the government, highly dependent on donors, and lacks political support. 23. The ICC in Tajikistan has not effectively addressed sustainability and HSS issues. Other coordination committees have also been formed to discuss HSS issues and immunization respectively. The World Bank is no longer part of the ICC due to infrequent meetings; however, it is an active member of another committee. WHO’s support is largely limited to technical assistance, UNICEF acts mainly as a procurement agency, and the Bank is absent. The World Bank considers immunization as GAVI’s sole responsibility; however, there has been little engagement between GAVI and the government on strategy and sustainability of immunization activities. 24. Unfortunately, the necessary policy dialogues to reinforce the priority of immunization in the national development agenda and to ensure the financial sustainability of the immunization program have not occurred. As effective childhood immunization constitutes a cornerstone of any healthcare system and is the major intervention to reduce childhood mortality (MDG 4), the vacuum in policy dialogue is not only a lost opportunity for meaningful health sector involvement for the World Bank, but also a critical shortcoming in the partnership with GAVI. Better collaboration between the two organizations and the government could procure health policy aimed at the creation of a more sustainable, equitable health financing system with respect to immunization. 78 Appendix F. Results of the Electronic Survey of World Bank Task Team Leaders 1. An electronic survey was administered in April-May 2013 to 112 World Bank Task Team Leaders of Bank-supported health projects during the period 2006–2012, in which either child health or health systems performance have been listed as themes. Only 24 TTLs responded to the survey for a response rate of 21.4 percent. The results lack statistical validity and should be interpreted cautiously. The results are reported here only for documentation purposes. Background Questions to World Bank Task Team Leaders 2. Question 1. Please indicate all the countries and the respective time periods during which you were the TTL of record for Bank-supported health projects between 2006 and 2012, inclusive. Region Number of Countries Indicated Africa 16 East Asia & Pacific 5 Latin America & Caribbean 6 South Asia 5 Europe & Central Asia 13 Middle East & North Africa 2 Total 47 3. Question 2. If you identified more than one country, please answer this survey from the point of view of the country in which you worked the longest during 2006– 2012 and in which GAVI was active in the country. Please identify this country. World Bank TTL Respondents by Region Region Number of Respondents Share of Respondents Africa 5 + 2 (7) a b 32% East Asia & Pacific 3a + 3 b (6) 27% Latin America & Caribbean 2a 9% South Asia 2a + 2 b (4) 18% Europe & Central Asia 2a 9% Middle East & North Africa 1 b 5% Total 22 a. Respondents identified more than one country and selected a country in this region to answer the survey. b. Respondents identified only one country. 79 APPENDIX F RESULTS OF THE ELECTRONIC SURVEY OF WORLD BANK TASK TEAM LEADERS World Bank’s Involvement in Immunization 4. Question 3. During the years that you were working in this country, in which of the following immunization-related activities were you, other Bank staff, or consultants reporting to you involved? (Please indicate all that apply.) Response Count Share of Respondents Policy dialogue 13 57% Investment projects 16 70% Technical assistance 5 22% Economic and sector work 7 30% Other 0 0% None of us were involved in any immunization-related 2 9% activities supported by the Bank during 2006-2012 5. Question 4. Did you ever supervise or implement any World Bank activities funded by the ImGAVI Trust Fund? (The ImGAVI Trust Fund financed immunization-related health systems strengthening activities during the 2007–2010 period.) Response Count Share of Respondents Yes 7 30% No 16 70% Total 23 100% 6. Question 5. What results did the Immunization and GAVI Trust Fund (ImGAVI)-financed activities achieve? (Respondents answered this question only if they have supervised or implemented any World Bank activities funded by the ImGAVI Trust Fund.) 80 Respondents Comments 1 1. Strengthening the technical and management capacity of NIP staff at the different levels of health care, to ensure a systematic, effective, and quality delivery of immunization services, within the framework of comprehensive health care; 2. Strengthening supervision and monitoring to ensure compliance with vaccine standards, quality and safety, and tracking results at the different levels; 3. Effectively covering municipalities with at-risk areas due to difficult access; 4. Strengthening the Epidemiological Surveillance System, detecting and investigating suspected cases of vaccine- preventable diseases as well as launching immediate responses; 5. Reviewing the EPI budget and sources of funds. 2 Financed two studies related to quality of child health services including immunization and child health statistics in Tajikistan. 3 The GAVI funding has made it possible to address the core problems that afflict immunization services in Ukraine: (a) low knowledge on the major part of key medical workers about vaccine safety and efficacy; (b) gaps and inconsistencies in adverse events following immunization surveillance and response systems and communications related to it. The activities involved regular technical consultation and joint training implementation by UNICEF, the World Bank Office in Ukraine, the WHO Country Office, WHO Euro and the Ministry of Health have been ensured throughout the project. WHO Euro and the WHO Country Office provided technical support, recommended qualified consultants, and provided guidance for the development of the country assessment tool. The Ministry of Health ensured participation of medical workers via its Ministerial Orders. Ministry of Health specialists participated in the training sessions and delivered presentations.1 4 Helped identify key issues being faced by immunization program and fiscal and operation issues which need to be addressed to introduce new vaccine in Pakistan. 5 They helped to complete the CSR health sector report and to define an HSS strategy, ultimately supported by a lending project. At this time, GAVI was providing the only available trust fund for HSS. Note: These are answers by survey respondents and do not necessarily reflect IEG’s findings. 7. Question 6. In your opinion, how did these ImGAVI-financed activities contribute to the country’s immunization-related activities? Please explain. (Respondents answered this question only if they had supervised or implemented any World Bank activities funded by the ImGAVI Trust Fund.) Respondents Comments GAVI contributions were: The project contributed to achieve key elements within the NIP, which strengthened its operations and deliver high quality, safe immunization services in a sustainable and effective manner, within the framework of comprehensive care and wide inter- and intra-sectoral and 1 community participation. Still, the sustainability of program strategies and financial support is essential and arrangements should be made to fill gaps and ensure that activities continue. GAVI Funds such as this fund used in 2011 in Nicaragua serve as a key agglutinators in support of the goals stated in institutional plans. Strengthened the immunization program, provided training, and supported immunization program 2 supervision. The studies revealed some critical gaps in services in Tajikistan, and have been used by the Bank and other 3 development partners in formulating current and future priorities for HSS in Tajikistan. 81 APPENDIX F RESULTS OF THE ELECTRONIC SURVEY OF WORLD BANK TASK TEAM LEADERS Respondents Comments The activities funded under the Trust Fund aimed to: A. Understand the perception of households on health service quality in general and immunization services in particular. B. Conduct a formal assessment of the Adverse Effects from Immunization (AEFI) surveillance and response system (detection, reporting, and causality assessment) in order to identify existing gaps and ways to improve it; C. Develop and implement trainings on AEFI and crisis communication in relation to AEFI for health professionals in order to equip them with better skills and knowledge on AEFI as well as improve skills on communication with the media following adverse events. These activities and training have led to adjustments in the Ukrainian AEF) surveillance and response system which will contribute to formation of a more efficient system for management of AEFI 4 cases. Trainings on AEFI and crisis communication in relation to AEFI for medical workers funded under the GAVI Trust Fund is expected to boost their capacity to respond efficiently to AEFI and communicate more accurately with media on AEFI. As a result of the initiative, it is expected that medical workers will gain clarity on what AEFI is, how causality assessment is done, and how to collect and analyze data from the field. Once a better understanding on these issues is obtained, inaccurate communication and argumentation by speakers on AEFI issues to the media is expected to decrease. As a result, concerns of medical workers, journalists, and the public on safety of vaccines will decrease. In a longer-term perspective, doctors’ confidence on immunization issues is expected to increase and consequently vaccination refusal levels decrease. Although it raised the understanding of the issues faced by the program - its impact on making policy and 5 related changes are just appearing - to date the impact has been minimal. As for the ESW part, the impact was very indirect, given that we were looking at the overall health system. 6 As for the lending product (prepared thanks to the ESWs), the impact is more clear, as the product is a Results-based Financing project, which includes an indicator on immunization. World Bank’s Partnership with GAVI at the Country Level 8. Question 7. To what extent was GAVI active in the country during the years you were working on the country? Rating Response Count Share of Respondents Negligibly 1 5% Modestly 1 5% Substantially 13 59% Highly 3 14% No opinion 4 18% Total 22 100% 9. Question 8. What were the principal frameworks within which World Bank- GAVI engagement occurred? (Please indicate all that apply.) (Sorted in descending order.) Response Share of Count Respondents Health Systems Funding Platform 8 36% ImGAVI Trust Fund 7 32% International Health Partnerships+ 7 32% Request from the national government 6 27% Joint Assessment of National Strategies 4 18% Sector-Wide Approach (SWAp) 4 18% Request from other GAVI implementing partners (UNICEF and/or WHO) 4 18% Initiative of GAVI (such as GAVI’s Country Responsible Officers) 4 18% 82 APPENDIX F RESULTS OF THE ELECTRONIC SURVEY OF WORLD BANK TASK TEAM LEADERS Response Share of Count Respondents None 3 14% Personal initiative of the World Bank TTL 2 9% Other 1 5% Intervention of World Bank’s sector director/ manager 0 0% 10. Question 9. During the years that you were working in the country, in which of the following GAVI related country-level committee(s) did the World Bank participate? (Please indicate all that apply.) Response Count Share of Respondents Interagency Coordination Committee for Immunization (ICC) 5 23% Health Sector Coordination Committee (HSCC) 7 32% None of the above 11 50% 11. Question 10. During the years that you were working in the country, in which ways was the World Bank involved in country-level activities that directly or indirectly contributed to the work of GAVI? (Please indicate all that apply.) (Sorted in descending order.) Response Count Share of Respondents Financing investments in relation to immunization-related health 11 50% systems strengthening Helping to prepare country strategies (such as the five-year plan 10 45% proposal or the immunization strategy) Supporting analytical work in relation to the financial sustainability of 7 32% immunization activities Supporting analytical work in relation to immunization-related health 7 32% systems strengthening Helping with oversight/supervision of GAVI-supported activities (such 6 27% as participating in joint supervision missions) Helping to prepare grant applications to GAVI 5 23% Reviewing immunization strategies (such as introducing new vaccines) 4 18% Helping with implementation of GAVI-supported activities (including 3 14% financial management and procurement) None 3 14% Other 1 5% 12. Question 11. In your experience, which of the following factor(s) have made it easier or more difficult for the World Bank to engage with GAVI-supported activities at the country level? (Sorted in descending order from “much easier” to “much more difficult.” ) 83 APPENDIX F RESULTS OF THE ELECTRONIC SURVEY OF WORLD BANK TASK TEAM LEADERS Neither Some- Somewhat Much Much easier nor Response by Sub-question what more more Total easier more easier difficult difficult difficult The World Bank and GAVI participate in the Health Systems Funding Platform 4 7 9 0 0 20 The focus of GAVI on low-income 4 5 11 0 0 20 countries The fact that GAVI provides financial assistance in the form of grants 4 3 12 1 0 20 The World Bank and GAVI are partners in the International Health Partnership 1 8 10 0 1 20 The World Bank participates in the Interagency Coordinating Committee 1 5 13 0 0 19 The absence of written Bank-wide guidelines or directives for engaging with 1 2 9 7 1 20 GAVI beyond the general language contained in the 2007 HNP Strategy The absence of a Memorandum of Understanding between the GAVI and 1 1 12 4 2 20 the World Bank for collaborating at the country level The World Bank and GAVI participate in the Joint Assessment of National 0 8 12 0 0 20 Strategies The limited country presence of GAVI 0 1 8 7 4 20 The different project cycle of GAVI compared to the World Bank 0 0 15 5 0 20 13. Question 12. Indicate other factors, if any, which have made it EASIER for the World Bank and GAVI to engage at the country level.  Regular communication from GAVI Secretariat about the developments, especially application process for HSS platform.  More commitment of the recipient.  Common goals of Bank project under implementation  Multi-agency “oversight” group looking at GAVI and Global Fund health system strengthening work, including World Bank.  The presence of an established donor coordination mechanism through SWAp.  Personalities that respect each other’s corporate background and mandate.  Whenever there was a visit from Geneva, we met, beyond that there was very little engagement or coordination.  Willing to enter into partnership. The Bank engagement is wider so GAVI was used to facilitate their financing support. But unfortunately that has been one sided - they listen to the Bank and if it is supportive they appreciate it, but if issues and concerns are raised they usually sidetrack them. 84 APPENDIX F RESULTS OF THE ELECTRONIC SURVEY OF WORLD BANK TASK TEAM LEADERS  IHP+ has helped, as well as the HSS platform (we created one in Benin, with the World Bank, GAVI, and the Global Fund). 14. Question 13. Indicate other factors, if any, which have made it MORE DIFFICULT for the World Bank and GAVI to engage at the country level.  Better presence of GAVI at the country level.  The absence of the above bodies at the country level.  GAVI’s policy of withdrawal.  Limited country capacity. Political context.  GAVI not based in the country, only intermittent missions.  The fact that there were not clear guidelines or mandate for collaboration and no clear outcomes from collaboration made it very vague and as a result there was little actual effort.  GAVI sidetracking issues being raised by the Bank and just pushing their financing. 15. Question 14. In your experience, how would you best characterize the relationship between the World Bank and GAVI during the years that you were working in the country? (Choose only one.) Response Share of Count Respondents Collaborative: The two organizations’ staff, consultants, and agents worked together 5 25% on common activities in the pursuit of commonly agreed objectives. Complementary: The two organizations’ staff, consultant, and agents worked 3 15% alongside each other in the pursuit of common objectives. Consultative: The two organizations’ staff, consultants, and agents consulted each 2 10% other regularly in the course of their own activities. Sharing information only: The two organizations’ staff, consultants, and agents only 7 35% shared information about each other’s activities. Unrelated and independent: The two organizations worked independently of each 1 5% other supporting different health initiatives in the country. Competitive: The two organizations competed for business among the same 0 0% potential clients. Other 2 10% 85 APPENDIX F RESULTS OF THE ELECTRONIC SURVEY OF WORLD BANK TASK TEAM LEADERS 16. Question 15. In your opinion, should the World Bank have been more or less engaged with GAVI during the years you were working in the country? Response Count Share of Respondents More engaged 6 30% Neither more or less engaged. The degree of engagement was 12 60% appropriate. Less engaged 2 10% World Bank’s Partnership with GAVI at the Global Level 17. Question 16. Overall, to what extent do you consider the World Bank currently to be a partner of GAVI at the following levels? Negligible Modest Substantial High Total COUNTRY level 4 10 5 1 20 GLOBAL level 0 7 10 3 20 18. Question 17. GAVI is now the largest provider of financial resources for childhood immunization in developing countries. In your opinion, to what extent has GAVI’s presence had the following impacts on the World Bank since its establishment in 2000? Much Much Response by Sub-question Lower No change Higher Total lower higher World Bank lending to the overall health sector is LOWER OR HIGHER than it 0 0 18 2 0 20 otherwise would have been? World Bank lending for childhood immunization is LOWER OR HIGHER 1 6 11 1 1 20 than it otherwise would have been? World Bank lending for health systems strengthening is LOWER OR HIGHER 0 1 15 3 1 20 than it otherwise would have been? 86 APPENDIX F RESULTS OF THE ELECTRONIC SURVEY OF WORLD BANK TASK TEAM LEADERS Question 18. Which of the following do you consider the most important COMPARATIVE ADVANTAGES OF GAVI among international development agencies in terms of achieving results for child immunization at the country level? Please rank in order of importance with “1” being the most important and “7” being the least important. (Sorted in ascending order from “1” being the most important and “7” being the least important.) Priority Rating Average Mobilizing donor resources for childhood immunization in the short term 2.85 Building institutional and human resource capacity for immunization 3.45 Promoting country-owned strategies for immunization 3.55 Developing specialized expertise in childhood immunization 3.7 Lowering the transaction costs of development assistance from the point of view of 4.45 beneficiaries Sustaining financial resources for childhood immunization over the long term 4.5 Promoting a results focus to development assistance 5.5 87 Appendix G. World Bank Immunization-related Operations Identification Strategy of World Bank Immunization Operations 1. Projects were identified via Business Warehouse. The identification theme codes employed for the search were: Child Health; Other Communicable Disease; Health System Performance; Nutrition and Food Security; Population and Reproductive Health; HIV/AIDS; Non-Communicable Disease and Injury; Malaria, and Tuberculosis. The sector codes used were: Health; Compulsory Health Finance; Public Administration – Health; and Non-Compulsory Health Finance. A total of 607 projects were identified. These were narrowed down to projects managed by the HNP, Social Protection (SP), and Poverty Reduction and Economic Management (PREM) Sector Boards. Further after an initial screening projects that were not health related and falsely coded were dropped leaving 390 projects in total. From these the objectives and components were coded for immunization, where a total of 51 projects were initially identified. After a detailed project document review only 15 were eliminated since they were not relevant. Out of the remaining 36 immunization-related operations, seven were polio specific support projects, financing a total of US$ 1,085 million in supporting the global polio vaccination eradication program in key problem countries. KEY TABLES Table G.1. All World Bank Immunization-related Operations Region Country Approval Project Name GAVI FY Eligibility AFR Benin 2010 BJ-Health System Performance project (FY10) yes Congo, Democratic 2006 ZR-Health Sec Rehab Supt (FY06) yes Republic of Congo, Republic of 2008 CG-Health Sector Service Dev Project (FY08) yes Ethiopia 2006 Protection Of Basic Services yes 2009 ET-Protect. Basic Serv. Phase II (FY09) yes Guinea 2005 GN-Health Sec Supt SIL (FY05) yes Mali 2012 ML-Strengthening Reprod Health (FY12) yes Mozambique 2011 MZ-Health Commodity Security Project yes Nigeria 2003 NG-Polio Eradication (FY03) yes Senegal 2005 First Poverty Reduction Support Credit yes 2006 Senegal - PRSC II yes 2007 SN-PRSC III DPL (FY07) yes Uganda 2006 Uganda Poverty Reduction Support Credit 5 yes EAP Cambodia 2008 KH-Second Health Sector Support Program yes 88 Appendix G Region Country Approval Project Name GAVI FY Eligibility China 2008 CN-Rural Health no Philippines 2006 PH-NP Support for HNP no Timor-Leste 2004 Timor-leste Transition Support Program II yes LCR Argentina 2004 AR-Prov. Maternal-Child Hlth Adj PMCHSAL no 2007 AR-Essential Public Health Functions no Bolivia 2003 Social Safety Net Structural Adjustment Credit yes 2004 BO-Social Sector Programmatic Credit yes 2008 BO-Exp. Access to Reduc Hlth Ineq (APL3) yes Brazil 2004 BR Disease Surveillance & Control APL 2 no Colombia 2004 Co: Programmatic Labor Reform And Social Structural no Adjustment Loan Dominican Republic 2010 DO (APL2) Health Ref II no El Salvador 2006 SV Social Protection & Local Dev (FISDL) no Nicaragua 2004 Nicaragua PRSC I yes 2010 NI Response to epidem emergencies yes MNA Yemen, Republic of 2011 RY-Health & Population yes SAR Afghanistan 2003 Afghanistan Health Sector Emergency Reha yes India 2007 IN: RCH II yes 2009 IN: Ntnl VBD Control&Polio Eradication yes Pakistan 2003 Partnership for Polio Eradication yes 2006 Second Partnership for Polio Eradication yes 2009 PK: 3rd Partnership for Polio Erad. yes Sri Lanka 2004 LK: Health Sector Development yes Table G.2. World Bank Immunization-related Operations by Sector Board Region Country HNP SP PREM Total number of projects AFR Benin 1 1 Congo, Democratic Republic of 1 1 Congo, Republic of 1 1 Ethiopia 2 2 Guinea 1 1 Mali 1 1 Mozambique 1 1 Nigeria 1 1 Senegal 3 3 Uganda 1 1 EAP Cambodia 1 1 China 1 1 Philippines 1 1 Timor-Leste 1 1 LCR Argentina 2 2 Bolivia 2 1 3 Brazil 1 1 Colombia 1 1 Dominican Republic 1 1 89 Region Country HNP SP PREM Total number of projects El Salvador 1 1 Nicaragua 1 1 2 MNA Yemen, Republic of 1 1 SAR Afghanistan 1 1 India 2 2 Pakistan 3 3 Sri Lanka 1 1 Grand Total 25 5 6 36 Table G.3. World Bank Projects by Agreement Type Agreement Type Country Number of projects IBRD Argentina 2 Brazil 1 China 1 Colombia 1 Dominican Republic 1 El Salvador 1 Philippines 1 IDA Afghanistan 1 Benin 1 Bolivia 3 Cambodia 1 Congo, Democratic Republic of 1 Congo, Republic of 1 Ethiopia 2 Guinea 1 India 2 Mali 1 Mozambique 1 Nicaragua 2 Nigeria 1 Pakistan 3 Senegal 3 Sri Lanka 1 Timor-Leste 1 Uganda 1 Yemen, Republic of 1 Grand Total 36 90 Appendix H. List of Persons Consulted Person Position Organization Dagfinn Høybråten Board Chair Independent Geeta Rao Gupta Deputy Board Chair, Deputy Executive Director (UNICEF) UNICEF Gustavo Gonzales-Canali Board Member, French Ministry of European & Foreign Affairs France Marcus Koll Board Member, German Ministry of Economic Cooperation Germany Alan Hinman Board Member, US Task Force for Global Health US Task Force Flavia Buestreo Board Member, Assistant Director General (WHO) WHO Helen Evans Deputy CEO GAVI Alliance Tony Dutson Senior Director & Chief Accounting Officer GAVI Alliance Minzi Lam Senior Manager, Financial Planning, Analysis and AMC GAVI Alliance Debbie Adams Managing Director, Governance and Legal GAVI Alliance Santiago Cornejo Senior Specialist, Technical Support, Country Programs GAVI Alliance Nina Schwalbe Managing Director, Policy and Programs GAVI Alliance Daniel Thornton Chief of Staff GAVI Alliance Mari-Ange Saraka-Yao Director, Resource Mobilization GAVI Alliance Paul Kelly Director, Country Programs GAVI Alliance Ranjana Kumar Manager, Country Programs GAVI Alliance Peter Hansen Director, Monitoring and Evaluation GAVI Alliance Bernadin Assiene Director, Transparency and Accountability GAVI Alliance David Ferreira Managing Director, Innovative Finance GAVI Alliance Gian Gandhi Special Advisor UNICEF Henri van den Homberg Senior Advisor Immunization UNICEF Amie Batson Deputy Assistant Administrator USAID Joe Naimoli Health Scientist USAID Nicole Klingen Sector Manager, HNP World Bank Julian Schweitzer Former Director HNP World Bank Cristian Baeza Former Director HNP World Bank Andrea Stumpf Senior Legal Counsel World Bank Albertus Voetberg Lead Health Specialist World Bank Julie McLaughlin Sector Manager, HNP South Asia World Bank Robert Oelrichs Senior Health Specialist World Bank Armin Fidler Lead Advisor for Health Policy and Strategy World Bank Rama Lakshminarayanan Senior Health Specialist (former GAVI focal point) World Bank Susan McAdams Director, Multilateral and Innovative Financing World Bank 91 APPENDIX H LIST OF PERSONS CONSULTED Person Position Organization Derek Strocher Senior Financial Officer World Bank Wezi Msisha Health Specialist World Bank Toomas Palu Sector Manager, HNP-EAP World Bank Eva Jarawan Senior Public Health Advisor, Former Sector Manager AFR World Bank K.O. Antwi-Agyei Programme Manager, EPI Ghana MoH George Amofah Deputy Director General, Ghana Health Service Ghana MoH Ibrahim Hodgson Director Research, Ghana Health Service Ghana MoH Carole Presern Director, Partnership for Maternal, Newborn & Child Health WHO/Geneva Alya Dabbagh Immunization Officer WHO/ Geneva Persons Consulted during Country Visit to Indonesia, November 2012 Person Position Organization Government of Indonesia Dr. Gunawan Former Head of Planning Indonesia MoH Dr. Madiono Former Head of Planning and Budgeting Indonesia MoH Theresia Sandra EPI Manager Indonesia MoH Andi Muhadir Director, Directorate of Surveillance, Immunization Quarantine, and Indonesia MoH Matra Health Isti Ratnaningsih Former Head, Decentralization Group Indonesia MoH Imam Subetki Former Head of International Affairs Indonesia MoH Untung Sutarjo Chairman, Health and Human Resources; former Head of Policy Unit Indonesia MoH Siamet Riyadi Yuwono Director General of Nutrition and Maternal and Child Health Indonesia MoH Dr. Widiyarti Head Division of Bilateral and Multilateral Health Cooperation Indonesia MoH Setiawan Soeparan Director General of Pharmacy Indonesia MoH World Bank Novira Asra Senior Financial Management Specialist, Indonesia Country Office World Bank Darran Dorkin Human Development Manager, Indonesia Country Office World Bank Pandi Harimurti Health Specialist, Indonesia Country Office World Bank Puti Marzoeki Senior Health Specialist, Indonesia Country Office World Bank William Wallace Senior Advisor, Indonesia Country Office World Bank Development Partners Rachel Cintron Deputy Director Office of Health USAID Harmain Harun Senior Advisor GtZ Rooswanti Soeharno Health Advisor ADB 92 APPENDIX H LIST OF PERSONS CONSULTED Person Position Organization Rabin Hattari Public Finance Economist ADB Bardan Jung Rana Medical Officer, EPI WHO Kenny Peetosutan Health Specialist, EPI UNICEF Maria Marisa Ricardo Health Specialist, EPI Officer UNICEF Robin Nandy Child Survival Development Cluster UNICEF Persons Consulted during Country Visit to Nepal, March 2013 Person Position Organization Government of Nepal Baburam Marasini Project Coordinator, Health Sector Reform Unit Nepal MoHP Praveen Mishra Secretary, Nepal Ministry of Health and Population (MOHP) Nepal MoHP Padam Bahadur Chand Chief (Policy, Planning & International Cooperation) Nepal MoHP Tara Porkhel Director, Child Health Division Nepal MoHP World Bank Manav Bhattarai Health Specialist, Nepal Country Office World Bank Development Partners Shanker Pandey Local Representative, Business Area KFW Matt Gordon Service Delivery Team Leader, Health & HIV/AIDS Advisor, Nepal DFID Hendrikus Raaijmakers Chief of Health, Nepal UNICEF Lin Aung WHO Country Representative to Nepal WHO Rajana Porkhel Immunization, Nepal WHO Praveen Atuldahal Program Evaluation, Nepal WHO Persons Consulted during Country Visit to Tajikistan, September 2013 Person Position Organization Government of Tajikistan Azamjon Mirzoev Deputy Minister Tajikistan MoH Shamsiddin Jobirov Director Tajikistan MoH Mr. Hafizov Budget and Planning Officer Tajikistan MoH World Bank Sarvinoz Barfieva, Health Sector, Tajikistan Country Office World Bank Development Partners 93 APPENDIX H LIST OF PERSONS CONSULTED Person Position Organization Pavel Ursu WHO Country Representative, Tajikistan WHO Kazuya Sueta Resident Representative to Tajikistan JICA Makiko Uehara Project Formulation Officer, Tajikistan Office JICA Muazamma Djamalova National Program Officer Swiss Development Cooperation Malika Makhambaeva USAID Rudoba Rakhmatova Senior Program Officer, Health Aga Khan Foundation Dr. Sabir Kurbanov Program Officer UNICEF Veronique Geoffrey Program Manager, Tajikistan Office European Union Persons Consulted during Country Visit to Ethiopia, September 2013 Person Position Organization Government of Ethiopia Amir Aman Hagos State Minister of Health MoH Dr. Mekdim GAVI Focal Person MoH Dr. Tewodros Director of Maternal & Child Health MoH Dr. Abduljilil Rashad Director Resource Mobilization MoH World Bank Senior Health Specialist World Bank Mohamed Ali Kamil Rupert Bladon Public Sector Specialist Gandhan Ramana and other Lead Health Specialist members of the PforR team Lars Christian Moller Lead Economist World Bank Development Partners Sisay Gashu NPO/Surveillance WHO Angela Spilsbury Advisor DFID Peter Salama Representative UNICEF 94 References Barder O., Kremer M., and Levine R. 2005. 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For 2014, the GNI eligibility threshold is US$ 1,570. 3 4 More details about GAVI’s results are in Appendix A. 5 Vaccine, 2013, Global Vaccine Action Plan, B5-B31. 6 Vaccine, 2013, Global Vaccine Action Plan. 7 The evaluation report notes instances where GAVI has launched programs or committed to activities, such as the pilot delivery models for the Civil Society Organization (CSO) and HSS programs, that do not explicitly link to desired outputs and specific objectives which contribute to the achievement of a strategic goal. GAVI has since addressed this issue in its Phase III strategy. CEPA, 2010, GAVI Second Evaluation Report, pp. 7, 29. 8 CEPA, 2010, GAVI Second Evaluation Report, pp. 19. 9 World Bank. 2013. World Bank Group Strategy. 10 It stated that “engaging and collaborating with global partners contributes both to Bank capacity to serve client countries and to global partners’ own capacity... Bank engagement with global partners is fragmented and requires sharper strategic direction… the Bank will assess its engagement with its partners to ensure effective and sustainable partnerships. For example, the Bank will seek a better balance in its partnerships and its regional work on low-income countries and Middle- income country priorities, particularly on health systems and will substantially increase its strategic engagement with WHO, the Global Fund, and GAVI in low-income countries”. See World Bank, Healthy Development: The World Bank Strategy for Health, Nutrition, and Population (HNP) Results, 2007. 11. See globalevaluations.org and IEG 2011a. Chapter 2 1 Pearson and others, 2011, Evaluation of the International Finance Facility for Immunisation. 2 Pearson and others, 2011. 3 In February 2013, GFA was removed from the IFFIm structure in order to reduce costs and streamline operations, and GFA activities were transferred to IFFIm and GAVI. 4 Pearson and others, 2011. 5 In 2011, Brazil pledged US$20 million to IFFIm, but has yet to sign a grant agreement to become IFFIm’s tenth donor. 6 Not all funds are available to be frontloaded as the World Bank considers a financial cushion–the IFFIm gearing ratio limit–a core element of its credibility as a triple-A rated supranational. This financial cushion reduces IFFIm’s costs on bond issuance significantly. 7 Bank staff calculations based on the most recent financial statement from GAVI, accessed on GAVI’s website December, 2013. 8 Pearson and others, 2011, The Evaluation of the International Finance Facility for Immunisation Report, pp. 17. 9 In the original IFFIm structure, the GAVI Fund Affiliate (GFA) accepted funds from pledge agreements with sovereign donors and assigned these to the IFFIm Company to be securitized. GFA also approved funding of programs with IFFIm proceeds. GFA, registered in England and Wales as a company limited by guarantee, was established to keep IFFIm independent from the donors and to safeguard GAVI’s tax-exempt status. In February 2013, GFA was removed from the IFFIm structure in order to reduce costs and streamline operations. 10 The original TMA came into effect in October 2006 and ended in September 2011. After considering amendments to the TMA, the TMA with the Bank was renewed in the present form without any changes for another five years in October 2011. 99 ENDNOTES 11 Drewnowski, 2009, “Managing Change in Maturing Partnerships: Lessons Learned from CGIAR, EFA-FTI and GAVI,” pp. 19. 12 International Finance Facility for Immunisation., 2013, Annual Report of the Trustees Annual Financial Statements: Year Ended December 31, 2012, pp. 28, 31. 13 International Finance Facility for Immunisation., 2013, Annual Report of the Trustees Annual Financial Statements: Year Ended December 31, 2012, pp. 13. 14 Standard and Poor’s, 2013, RatingsDirect: International Finance Facility for Immunisation, pp. 7. 15 Pearson and others, 2011, The Evaluation of the International Finance Facility for Immunisation Report, pp. 17. 16 Pearson and others, 2011, pp. 91 17 Standard and Poor’s, RatingsDirect: Research Update: International Finance Facility for Immunisation, pp. 2. 18 As of November 8, 2013, IFFIm is currently rated AA with stable outlook by Standard & Poor’s, AA+ with stable outlook by Fitch, and Aa1 with negative outlook by Moody’s. 19 The International Finance Facility for Immunisation. Annual Report of the Trustees Annual Financial Statements: Year Ended December 31, 2012, pp. 39. 20 International Finance Facility for Immunisation., 2013, Annual Report of the Trustees Annual Financial Statements: Year Ended December 31, 2012, pp. 39. 21 Pearson and others, 2011; Annex B. 22 Pearson and others, 2011, Evaluation of the International Finance Facility for Immunisation Report, pp. 105-106. 23 Pearson and others, 2011, Evaluation of the International Finance Facility for Immunisation Report, pp. 106. 24 Barder O., Kremer M., Levine R., 2005, Making Markets for Vaccines: Ideas to Action. Working Group Report. 25. Chau, V., V. Hausman, W. Deelder, A. Rastegar, M. Monte, Y. Aizenman, P. Pina, C. Chen, and L. Goecker, 2013, The Advance Market Commitment for Pneumococcal Vaccines Process and Design Evaluation. pp. 31. 26 Cernuschi, T., E. Furrer, S. McAdams, A. Jones, J. Fihman, and N. Schwalbe, 2011, “The Pilot Advance Market Commitment for Pneumococcal Vaccines (AMC): Lessons Learned on Disease and Design Choices and Processes,” pp. 7. 27 World Bank Group, 2010, Trust Fund Annual Report, p. 31. 28. Advance Market Commitments for Vaccines, 2012, Creating Markets to Save Lives. 29 Advance Market Commitments for Vaccines, 2012, Creating Markets to Save Lives. 30 GAVI Alliance Website. Pneumococcal AMC. www.gavialliance.org/funding/pneumococcal-amc 31 GAVI Alliance, 2013, Advance Market Commitment for Pneumococcal Vaccines: Annual Report 1 April 2012 – March 31, 2013, pp. 13. 32 GAVI Alliance, 2013, Advance Market Commitment for Pneumococcal Vaccines: Annual Report 1 April 2012 – March 31, 2013, pp. 25. 33 International Bank for Reconstruction and Development, 2013, Management’s Discussion & Analysis and Financial Statements June 30, 2013, pp. 106. 34 Chau, V., V. Hausman, W. Deelder, A. Rastegar, M. Monte, Y. Aizenman, P. Pina, C. Chen, and L. Goecker, 2013, The Advance Market Commitment for Pneumococcal Vaccines Process and Design Evaluation, pp. 39. Chapter 3 1 World Bank. 2013. World Bank Group Strategy. 2 See for example IEG. 2004. Addressing the Challenges of Globalization: An Independent Evaluation of the World Bank's Approach to Global Programs; and World Bank. 2007. Meeting the Challenges of Global Development. 3 GAVI has country responsible officers based in Geneva who travel intermittently to countries and maintain communication with country partners. 100 ENDNOTES 4 GAVI’s Strategy and Business Plan is one tool to help coordinate and fund specific activities by partners. The Bank chose not to participate in the 2011-15 Business Plan, see Chapter 4. 5 GAVI’s other activities in supporting countries with the financial sustainability for vaccines include a dedicated Immunisation Financing & Sustainability Task team, graduation assessments, and financial grants to graduating countries. GAVI Alliance. Report to the GAVI Alliance Board Meeting 21-22 November 2013: GAVI Engagement with Graduating Countries. November 2013. 6 GAVI Alliance, 2013, Mid-Term Review Report, pp. 5-6. 7 GAVI Alliance, 2013, Report to the GAVI Alliance Board 11-12 June 2013: Risk Management Update, pp. 3. 8 CEPA, 2010, GAVI Second Evaluation Report, pp. 10. 9 Glassman, A., J. I. Zoloa, and D. Duran, 2012, Measuring Government Commitment to Vaccination. 10 A high-level task force on innovative international financing for health systems, chaired by then UK Prime Minister Gordon Brown and World Bank President Robert Zoellick, recommended in 2009 to “establish a HSFP for the Global Fund, GAVI Alliance, the World Bank and others to coordinate, mobilize, streamline, and channel the flow of existing and new international resources to support national health strategies.” This pertains particularly to the areas of maternal and child health and health systems strengthening in which all three agencies are active. A main purpose of the HSFP was a more efficient channeling of HSS funding in countries, by having one common financial management framework, one M&E framework, and one joint review process. World Bank, the Global Fund, GAVI Alliance, WHO, 2010, Health Systems Funding Platform: Frequently Asked Questions. 11 World Bank, 2007, Healthy Development: The World Bank Strategy for Health, Nutrition, and Population Results, pp. 191. 12 Bezanson, K. and P. Isenman. Challenges, Weaknesses and Lessons Learned in the Governance of Global Multi- Stakeholder Partnerships for Development. 13 IEG did not evaluate the relationship between GAVI and its other partners and has no position on whether it is structured in a manner that is satisfactory to them. 14 World Bank, 2013, World Bank Group Strategy. Chapter 4 1 Article 15 of the GAVI Alliance Statutes states: "The Board will use all reasonable efforts to make decisions by consensus. If no consensus can be reached, any decision of the Board shall require a two-thirds majority of members present and voting.” GAVI Alliance. GAVI Alliance Statutes. Article 15: Board Decision-making. 2011. Geneva: GAVI Alliance. 2 Chee, G., V. Molldrem, N. Hsi, and S. Chankova, 2008, Evaluation of the GAVI Phase 1 Performance (2000-2005), pp. 15. 3 Chee, G., V. Molldrem, N. Hsi, and S. Chankova, 2008, Evaluation of the GAVI Phase 1 Performance (2000-2005), pp. 86. 4 GAVI has headquarters agreement with the Swiss government that affords it certain privileges and immunities. 5 Drewnowski, 2009, Managing Change in Maturing Partnerships: Lessons Learned from CGIAR, EFA-FTI and GAVI, pp. 33. 6 Drewnowski, 2009, Managing Change in Maturing Partnerships: Lessons Learned from CGIAR, EFA-FTI and GAVI, pp. 33.: It has been noted that “support from Bank central units was not requested until late in the [GAVI’s governance reform] process. Consequently an opportunity was missed to obtain different institutional perspectives on the governance choices presented by CEPA, the consultant hired by the GAVI Secretariat." 7 IEG 2011a. 8 Commenting on an earlier version of this report, GAVI’s Secretariat stated that “While the GAVI Alliance was established as a Swiss Foundation, the Headquarters Agreement in which the Government of Switzerland recognized the GAVI Alliance’s international legal personality became effective on 1 January 2009. Under that agreement, the GAVI Alliance, its Board members and officials benefit from privileges and immunities in Switzerland that are virtually the same to those enjoyed by international organizations such as WHO, UNICEF and the World Bank. GAVI Alliance Board members, therefore, enjoy immunity from jurisdiction (criminal and civil) in Switzerland for acts carried out in the performance of their duties for GAVI.” 9 See IEG, 2011a, Trust Fund Support for Development: An Evaluation of the World Bank’s Trust Fund Portfolio, Appendix F, for a brief description of all the FIFs managed by the Bank. 101 ENDNOTES 10 CEPA, 2010, GAVI Second Evaluation Report, pp. 15. 11 GAVI Alliance Board Meeting 11-12 June 2013. Review of decisions. Geneva, Switzerland, June 2013. 12 Contributing to this situation is the fact that the Bank has still not systematized the practice of requiring staff serving on partnership boards to be guided by specific terms of reference that set out Bank-wide institutional positions. Such terms of reference are a longstanding IEG recommendation, which World Bank management accepted in a “Partnership Program Framework Paper” of July 2013. One result of this is that some GAVI Secretariat staff is under the false impression that the loyalty of the Bank’s representative on GAVI’s Board would primarily be to GAVI (it is of course to the Bank). 13 GAVI Alliance, 2010, GAVI Alliance Strategy and Business Plan 2011-2015: Part II Strategic Goals and Cross-Cutting Issues. 14 Commenting on an earlier draft of this report, GAVI’s Secretariat emphasized that they view the Bank as a core partner, not a contractor. However, as with all GAVI partners, they seek to hold the Bank accountable for deliverables funded by GAVI, this being a specific requirement of GAVI’s Board and donors. In their view, this caused tensions with the Bank. 15 Over the 12-year partnership, the HNP anchor spent a total of US$1.7 million of the Bank’s budget on GAVI activities. The ImGAVI Trust Fund did not generate significant new resources for managing the partnership, since its resources were mostly used to support country-level HSS activities. By 2012, there were no trust funds for GAVI work, and the HNP department relied exclusively on the Bank’s administrative budget. 16 World Bank. 2013. World Bank Group Strategy. Chapter 5 1 World Bank. 2013. World Bank Group Strategy. 2 GAVI has headquarters agreement with the Swiss government that affords it certain privileges and immunities. 3 Table 10 in Annex A gives an overview of linkages between the Bank and GAVI, and compares them to other Global Partnership Programs with Bank engagement. Appendix A 1. CEPA, 2010, GAVI Second Evaluation Report. 2 Drewnowski, 2009, Managing Change in Maturing Partnerships: Lessons Learned from CGIAR, EFA-FTI and GAVI. 3 GAVI Alliance, 2008, Progress Report 2007, pp. 64. 4 International Finance Facility for Immunisation, 2013, Annual Report of the Trustees Annual Financial Statements: Year Ended 31 December 2012, pp. 8. 5 Cernuschi, T., E. Furrer, S. McAdams, A. Jones, J. Fihman, and N. Schwalbe, 2011, The Pilot Advance Market Commitment for Pneumococcal Vaccines (AMC): Lessons Learned on Disease and Design Choices and Processes. 6 The DTP3 coverage filter will be increased to 70 percent after the June 2011 proposal round. Source: GAVI Alliance, 2011, “Guidelines on Country Proposals for Support for: New and Underused Vaccines,” pp. 4. 7 GAVI current offers support for the following vaccines as of November 2013: Human papillomavirus vaccine, inactivated poliovirus vaccine, Japanese encephalitis vaccine, Measles vaccine, Meningitis A vaccine, Pentavalent vaccine, Pneumococcal vaccine, Measles-Rubella vaccine, Rotavirus vaccine, and Yellow Fever vaccine. 8 GAVI Alliance Website, retrieved on April 11, 2012, from www.gavialliance.org/support/nvs/ins. 9 Currently, the amount of funding is equal to US$ 20 per extra child immunized above the number previously reached. GAVI Alliance Website, retrieved on April 11, 2012, www.gavialliance.org/support/iss. 10 GAVI Alliance Website, retrieved on April 11, 2012, from www.gavialliance.org/support/apply/hsfp. 11 GAVI Alliance Website, retrieved on April 11, 2012, www.gavialliance.org/support/cso. 12 From 2000-2010, the GNI eligibility threshold was US$ 1,000. In Phase I, 74 countries were initially eligible for GAVI support and this was reduced to 72 countries in Phase II. The current GNI eligibility threshold of US$ 1,550 took effect on January, 1, 2011. 13 GAVI Alliance, 2013, Mid-Term Review Report, pp. 14. 102 ENDNOTES 14 GAVI Alliance Website, retrieved on April 11, 2012, from www.gavialliance.org/support/apply. 15 GAVI Alliance, 2013, Mid-Term Review Report, pp. 5-6. 16 GAVI Alliance, 2013, Report to the GAVI Alliance Board 11-12 June 2013: Risk Management Update, pp. 3. 17 GAVI Alliance, 2013, Progress Report 2012, pp.50. 18 The Report was organized around GAVI’s four strategic goals: 1) to contribute to strengthening the capacity of the health system to deliver Immunization and other health services in a sustainable manner; 2) to accelerate the uptake and use of underused and new vaccines and associated technologies and improve vaccine supply security; 3) to increase the predictability and sustainability of long-term financing for national immunization programs; and 4) to increase and assess the added-value of GAVI as a public-private global health partnership through improved efficiency, increased advocacy, and continued innovation. 19 The evaluation report notes instances where GAVI has launched programs or committed to activities, such as the pilot delivery models for the CSO and HSS programs, that do not explicitly link to desired outputs and specific objectives which contribute to the achievement of a strategic goal. GAVI has since addressed this issue in its Phase III strategy. CEPA, 2010, GAVI Second Evaluation Report, pp. 7, 29. 20 CEPA, 2010, GAVI Second Evaluation Report, pp. 19. 21 Pearson and others, 2011, Evaluation of the International Finance Facility for Immunisation Report, pp. 106. Appendix B 1 Pearson and others, 2011, The Evaluation of the International Finance Facility for Immunisation Report, and Personal Communication with World Bank staff. 2 Hargreaves, J.R., Greenwood, B., Clift, C., Goel, A., Roemer-Mahler, A., Smith, R., Heymann, D.L., 2011, Making New Vaccines Affordable: A Comparison Of Financing Processes Used To Develop And Deploy New Meningococcal And Pneumococcal Conjugate Vaccines, The Lancet, 37,1885-93. Appendix E 1 The Save the Children Fund, 2012, Halfway There: Delivering on the Promise of Immunization for All. 2 Statistical Agency under the President of the Republic of Tajikistan (SA), Ministry of Health [Tajikistan], and ICF International, 2013, Tajikistan Demographic and Health Survey 2012. 3T ajikistan Ministry of Health, UNICEF, WHO, JICA, USAID, AKHS, 2012, National Immunization Program Review Tajikistan, 2012. 4 Tajikistan Ministry of Health, UNICEF, WHO, JICA, USAID, AKHS, 2012, National Immunization Program Review Tajikistan, 2012. 5 Tajikistan Ministry of Health, UNICEF, WHO, JICA, USAID, AKHS, 2012, National Immunization Program Review Tajikistan, 2012. 6 Statistical Agency under the President of the Republic of Tajikistan (SA), Ministry of Health [Tajikistan], and ICF International, 2013, Tajikistan Demographic and Health Survey 2012. Appendix F 1 Note, however, that the core problems that afflict immunization services in Ukraine still remain, and immunization coverage across all vaccines have decreased over time. 103