Review of Gavi’s Performance-Based Funding component of its Health System Strengthening support

In 2018 the Gavi Evaluation Unit commissioned an independent review of Gavi’s Performance Based Funding (PBF) component of Gavi’s Health System Strengthening (HSS) support to countries. This review was conducted by Duke University between April and September 2018.

OBJECTIVES

The objectives of the review were to:

Assess the design, implementation and results of the Gavi’s PBF component of the HSS support.
Provide actionable recommendations to inform the future Gavi’s PBF design and implementation

METHODS

The review of Gavi’s PBF uses an evaluation framework based on four dimensions: (i) PBF design, (ii) implementation, (iii) results (ability to earn reward payments, motivational aspects of the reward, changes in coverage and equity), and (iv) lessons learned. The evaluation was based on key informant interviews with the Gavi secretariat, Gavi’s partners, and country level stakeholders; review of relevant written materials; analysis of financial data on eligibility, performance payments, and disbursements; a benchmarking exercise to compare Gavi’s PBF approach with that of the Global Fund and the Mesoamerican Health Initiative; review of the key literature on PBF and results-based financing (RBF) for health improvement in low- and middle-income countries to establish criteria for assessing the design of Gavi’s PBF; and five country deep dives (Burundi, Ethiopia, Lao PDR, Sudan, and Tanzania).

KEY FINDINGS

Lack of equitable access: Distribution of performance payments across countries Gavi’s PBF model mostly benefits countries with high (≥90% DTP3) baseline coverage. Countries with low baseline coverage (<90% DTP3) find it difficult to earn reward payments due to data issues and/or lack of progress.
DTP3 payments to low baseline coverage countries continued to decline throughout the period with no country from the low baseline coverage group receiving a performance payment for increased DTP3 coverage in 2017.
Several countries that received a PBF payment showed rising immunization coverage and improvements in equity but a causal link between the payment and changes in coverage/equity cannot be proved.
Francophone and fragile countries rarely qualify for performance payments. Only two francophone countries from Africa ever qualified for the performance payment, and only 4 out of 18 countries from Gavi’s fragility list ever did.¹

¹At the time of writing this report, 18 countries were on Gavi’s fragility list; since then, Nigeria and Ethiopia have been removed.