R

Sfis

JAa

b

a

ARRAA

KGDAFNIVSC

C

f

0h

Vaccine 31 (2013) 1886– 1891

Contents lists available at SciVerse ScienceDirect

Vaccine

j ourna l ho me pag e: www.elsev ier .com/ locate /vacc ine

eview

ustainability of National Immunization Programme (NIP) performance andnancing following Global Alliance for Vaccines and Immunization (GAVI)upport to the Democratic Republic of the Congo (DRC)

ean-Bernard Le Gargassona,∗, J. Gabrielle Breugelmansa, Benoît Mibulumukinib,lfred Da Silvaa, Anaïs Colombinia

Agence de Médecine Préventive, Paris, FranceSanté Rurale (SANRU), Kinshasa, Democratic Republic of the Congo

r t i c l e i n f o

rticle history:eceived 12 December 2012eceived in revised form 8 February 2013ccepted 11 February 2013vailable online 24 February 2013

eywords:AVIemocratic Republic of Congofricainancingational Immunisation Programme

mmunizationsaccinesustainabilityo-financing

a b s t r a c t

Background: The Global Alliance for Vaccines and Immunization (GAVI) is a public–private global healthpartnership aiming to increase access to immunisation in poor countries. The Democratic Republic of theCongo (DRC) is the third largest recipient of GAVI funds in terms of cumulative disbursed support. We pro-vided a comprehensive assessment of GAVI support and analysed trends in immunisation performanceand financing in the DRC from 2002 to 2010.Methods: The scope of the analysis includes GAVI’s total financial support and the value of vaccinesand syringes purchased by GAVI for the DRC from 2002 to 2010. Data were collected through a review ofpublished and grey literature and interviews with key stakeholders in the DRC. We assessed the allocationand use of GAVI funds for each of GAVI’s support areas, as well as trends in immunisation performanceand financing.Findings: DTP3 coverage increased from 2002 (38%) to 2007 (72%) but had decreased to a level below 70%in 2008 (68%) and 2010 (63%). The overall funding for vaccines increased from US$5.4 million in 2006 toUS$30.5 million in 2010 (mostly from GAVI support for new vaccines). However, during the same period,the funding from national (government) and international (GAVI and other donors) sources for routineimmunisation services (except vaccines) decreased from US$36.4 million to US$24.4 million. This dropin overall funding (33%) primarily affected surveillance, transport, and cold chain equipment.

Interpretation: GAVI support to DRC has enhanced significant progress in routine immunisation perfor-mance and financing during 2002–2010. Although progress has been partly sustained, the initial observedincrease in DTP3 coverage and available funding for routine immunisation halted towards the end ofthe analysis period, coinciding with tetravalent and pentavalent vaccine introduction. These findingshighlight the need for additional efforts to ensure the sustainability of routine immunization program performance and financing.

© 2013 Elsevier Ltd. All rights reserved.

ontents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18872. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1887

2.1. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18872.2. Overview of data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18872.3. Timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18872.4. Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1887

3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.1. Overview of GAVI support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.2. Absorption capacity and use of GAVI funds . . . . . . . . . . . . . . . . . . . . . . . .

∗ Corresponding author at: Agence de Médecine Préventive, Immeuble J.B. Say, 13 Chemax: +33 0 4 50 42 98 07.

E-mail address: jblegargasson@aamp.org (J.-B. Le Gargasson).

264-410X/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.vaccine.2013.02.024

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1887

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1887

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1887

in du Levant, 4ème étage 01210 Ferney-Voltaire France. Tel.: +33 0 4 50 40 05 30;

J.-B. Le Gargasson et al. / Vaccine 31 (2013) 1886– 1891 1887

3.3. New vaccine introduction with GAVI support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18883.4. EPI performance following GAVI support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18893.5. Domestic and external resource availability following GAVI support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1889

4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1889Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1891

. . . . . .

1

asarNTho1b

ohntlpytmcaPa

2

2

pstnospnsAFssc

2

n

--

-

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. Introduction

The Global Alliance for Vaccines and Immunization (GAVI) is public–private global health partnership whose mission is toave children’s lives and protect people’s health by increasingccess to immunisation in the world’s poorest countries [1]. Cur-ently 57 countries are eligible for GAVI support based on a Grossational Income (GNI) per capita below or equal to US$1520 [2].his includes the Democratic Republic of the Congo (DRC), whichas a GNI per capita of US$320 [3]. With 71.3% of the populationf 71 million living under the national poverty line and 170 out of000 children not reaching the age of five, the DRC is considered toe a priority country to achieve GAVI’s main mission [4–6].

The DRC is the third largest recipient of GAVI funding in termsf cumulative disbursed support [7]. Yet, a full review of how fundsave been used and how they have affected health outcomes hasot been conducted to date. The present study attempts to addresshis gap with a comprehensive assessment of successes and chal-enges of GAVI-supported activities and trends in immunisationerformance and financing. The underlying hypothesis of the anal-sis was that GAVI support in the DRC has acted as a catalysto enhance and sustain routine immunisation programme perfor-

ance and financing. To test this hypothesis, we evaluated theapacity of the country to absorb and utilise GAVI support as wells the temporal association between GAVI support and Expandedrogramme on Immunisation (EPI) performance or resource avail-bility for routine immunisation.

. Methods

.1. Definitions

During the analysis period (2002–2010), GAVI provided sup-ort in the five following categories: 1) immunisation servicesupport, provided to immunisation programmes; 2) health sys-em strengthening support, provided to Ministries of Health; 3)ew and underused vaccines support, for accelerated introductionf vaccines; 4) injection safety support, to provide auto-disabledyringes and safety boxes; and 5) civil society organisation support,rovided to local non-governmental organisations (NGOs) for plan-ing and delivery of immunisation services [8]. As of 2011, injectionafety support was folded into the new vaccines support category.t the same time, a new category was created, the Health Systemsunding Platform, to help countries streamline support for healthystem development and align it with national processes; since thetudy period ended at 2010, these changes were not relevant for theurrent analysis.

.2. Overview of data sources

The data included in the report were extracted from validatedational and international data sources including:

Annual progress reports to GAVI for the use of GAVI fundsComprehensive multi-year plans (cMYP) [9–11] and financial sus-tainability plans [12] for immunisation

National health development plans [13]

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1891

- Official financial statements from the DRC Ministry of Budget,GAVI, United Nations Children’s Fund (UNICEF), and World HealthOrganization (WHO).

- Immunisation coverage data was extracted from WHO–UNICEFjoint reporting forms [14]

2.3. Timeline

The timeframe for the analysis was 2002 to 2010, based on thefirst year DRC received GAVI funds (2002) and the last year datawas available at the time of analysis.

2.4. Analyses

The analysis of funding available for routine immunisationincluded specific and shared costs as well as recurrent and capitalline items. Financial results were expressed for each year from 2002to 2010 in U.S. dollars (US$). All analyses were done in MicrosoftExcel (version 2007).

The assessment included quantitative and qualitative data.Immunisation performance and financing were compared between2002 and subsequent years up to 2010. The final results were val-idated during meetings at the DRC Ministry of Health/ExpandedProgram on Immunizations and included numerous stakeholdersinvolved in immunisation services in the DRC. Interviews werecarried out with 22 key informants from the Ministry of HealthExpanded Program on Immunizations, Department of Evaluationand Planning, and Department of Disease Control; the Ministriesof Finance and Budget; WHO; UNICEF; Sabin Vaccine Institute; andthe United States Agency for International Development (USAID).

The study included only reviews of publicly available and gov-ernment financial data and interviews with persons acting intheir professional capacity. Consequently, ethical review commit-tee and institutional review board approval were neither soughtnor obtained.

3. Results

3.1. Overview of GAVI support

GAVI support to the DRC began in 2002 with funding for yel-low fever vaccine introduction. From 2002 to 2010, the totalvalue of GAVI support was US$182.02 million (Table 1) [7]. Vac-cines and injection material amounted to US$109.65 million (59%),which mostly went to the provision of pentavalent vaccine (DTP-HepB-Hib) (42%) (Fig. 1) while financial support was US$72.38million (41%). Of financial support, US$41.67 million (23% of total)went to health system strengthening, US$25.81 million (14%) toimmunisation services support, US$3.00 million (2%) to civil societyorganisations, and US$1.81 million (1%) to new vaccines introduc-tion.

3.2. Absorption capacity and use of GAVI funds

The total amount of GAVI funds used in the DRC between 2002and 2010 was US$48.20 million. The execution rate for GAVI fund-ing (i.e. the ratio between the funds used and the funds disbursed)

1888 J.-B. Le Gargasson et al. / Vaccine 31 (2013) 1886– 1891

Table 1Overview of GAVI disbursementsa to the Democratic Republic of Congo from 2002 to 2010 (US$ million); figures represent net amounts, including return of unused funds asa result of obtaining lower supply or freight prices than originally estimated, which explains occasional negative values.

Support category 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total

Financial support (US$) 0.10 2.03 2.03 4.06 5.00 6.22 52.94 0 0 72.38Immunisation services support 0 2.03 2.03 4.06 5.00 6.22 6.47 0 0 25.81Health system strengthening 0 0 0 0 0 0 41.67 0 0 41.67Civil society organisations Type A 0 0 0 0 0 0 0.1 0 0 0.1Civil society organisations Type B 0 0 0 0 0 0 2.99 0 0 2.99Vaccine Introduction grant 0.10 0 0 0 0 0* 1.71 0 0 1.81

In-kind support (US$) 0.12 3.22 3.83 1.16 8.89 10.45 15.01 24.62 42.35 109.65New vaccines support: yellow fever 0.12 1.31 2.56 1.63 1.95 2.71 2.30 0.8 3.93 17.30New vaccines support: tetravalent 0 0 0 0 6.94 7.74 −2.79 −1.54 0 10.36New vaccines support: pentavalent 0 0 0 0 0 0 15.50 25.35 34.73 75.59New vaccines support: pneumococcalb 0 0 0 0 0 0 0 0 3.69 3.69Injection safety support 0 1.91 1.28 −0.47 0 0 0 0 0 2.71

Overall Total (US$) 0.22 5.25 5.86 5.22 13.89 16.67 67.95 24.62 42.35 182.02

a Total GAVI support represents the funds disbursed to the country which are different from the funds spent or expenditures of the immunisation program.b Pneumococcal vaccine was not yet introduced into the routine vaccination calendar in DRC between 2002–2010, the time span of the analyses. However, some vaccines

w

weis

golfma

newhPt3m

ere already received by DRC in 2010.

as 66%. Most unspent GAVI funds were health system strength-ning funds with an execution rate of 39%. All funds allocated tommunisation services support and civil society organisations werepent.

Immunisation services support funds were mostly used forlobal EPI support. The main expense was for bonuses (20.41%)f personnel involved in immunisation at central and provincialevels. Immunisation services support funds were also used to payor operational costs of routine immunisation programmes such as

aintenance (17.81%), transport (12.46%), and supervision (9.08%),mongst others.

Civil society organisation funding focused on reaching unvacci-ated children by providing support to a network of field NGOs andngaging communities. Activities included training of communityorkers, referral of unvaccinated children and pregnant women toealth care centres, support for logistics, and creation of Expanded

rogram on Immunisations satellite sites. Civil society organisa-ion funds were mostly used for management (US$1.04 million;2.3%), supervision (US$0.66 million; 20.5%), and vehicles (US$0.35illion; 11.0%).

New vacc inesupp ort DTP

HepB Hib42%

New vaccin esuppor t

Pneumocc oca l2%

New vaccin esupp ort DTP-

HepB6%

New vacc inesup port Yello w

Feve r9%

Fig. 1. Distribution of GAVI support disbursed by category of supp

Implementation of GAVI health system strengthening supportwas delayed – mainly due to financial management issues – lead-ing to a budget execution rate of 39%. For example, US$41.67 millionwere disbursed to the Ministry of Health Department of Evaluationand Planning from 2002–2010 of which US$16.23 million had beenused by the end of 2010. The establishment of a Financial Man-agement Agency caused significant delay in the implementation ofactivities. Once a financial structure became operational in 2010, aportion of health system strengthening funds was spent includingUS$5.91 million for capital investments in medical equipment andmaterials (36.4%), and US$5.55 million for medicines (34.2%).

3.3. New vaccine introduction with GAVI support

At the time of DRC submission for yellow fever vaccine sup-

port in 2001, no minimum DTP3 vaccination coverage levels wererequired to receive GAVI funding for vaccine support [8]. Fortetravalent, pentavalent and pneumococcal conjugate vaccine sup-port, GAVI required countries to have a DTP3 vaccination coverage

Civil SocietyOrganiza� on

2%

Hea lth Syste mStrengthening

23%

Injec�onSaf ety

Sup por t1%

Immuniz a�onServi cesSup por t

14%

New vaccineintroduc� on

gran t1%

ort in the Democratic Republic of Congo from 2002 to 2010.

J.-B. Le Gargasson et al. / Vaccine 31 (2013) 1886– 1891 1889

Table 2Diphtheria-tetanus-pertussis third dose (DTP3) vaccination coverage and drop-out rate in the Democratic Republic of Congo from 2002 to 2010.

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010

Vaccine presentation DTP DTP-hepatitis B DTP-hepatitis B- Haemophilusinfluenzae type b

DTP3 vaccination coverage rate estimates [14] 38% 41% 54% 60% 62% 72% 68% 77% 63%DTP1 vs DTP3 drop-out rate [14] 19% 23% 18% 12% 13% 6% 7% 5% 6%Yellow fever vaccination coverage estimates [14] N/A 5% 25% 42% 50% 59% 54% 65% 62%Polio vaccination coverage estimates [14] 40% 47% 52% 60% 62% 71% 61% 74% 72%

%

S

>>

2wlwitTctirniatrmv

3

(62aiateh[ntp

3s

e2avlrtmsc

Measles vaccination coverage Estimates [14] 42% 49% 57

ource: WHO–UNICEF Joint Reporting Forms.

50% [8]. Currently, GAVI requires a DTP3 vaccination coverage of70% for new vaccine support [2].

GAVI new vaccines support increased significantly between002 and 2010 (Table 1). Three new vaccines, funded by GAVI,ere introduced in DRC’s routine immunisation programme. Yel-

ow fever vaccine was introduced in 2003, DTP-hepatitis B)as introduced in 2007, and pentavalent DTP-HepB-Haemophilus

nfluenzae type b) vaccine in 2009. Pneumococcal vaccine introduc-ion was initially scheduled for 2010 but was postponed to 2011.he main challenges reported regarding new vaccine introductiononcerned insufficient cold chain capacity, increased vaccine dis-ribution costs, and stock-outs of vaccines in some areas [15]. Thentroduction of the pentavalent vaccine faced significant challengeselated to insufficient preparation and lack of adherence to WHOorms during pre-introduction activities [16]. During the post-

ntroduction phase, delays in training and delivery of vaccine dosesnd injection material occurred. In certain areas, stocks of injec-ion material ran out due to the delayed arrival of syringes andeceptacles. In addition, EPI staff and partners had trouble sendingaterial to some provinces due to high transportation costs. Lastly,

accination waste continued to be burned in most health centres.

.4. EPI performance following GAVI support

DTP3 vaccination coverage increased from 2002 (38%) to 200772%) followed by declines in 2008 (68%), and 2009/2010 (77% to3%) (Table 2). Immunisation service delivery improved between002 and 2010 [14]. For example, the dropout rate between DTP1nd DTP3 decreased from 2003 (23%) to 2010 (6%) [14]. Geograph-cal coverage of DTP3 vaccination during the GAVI support periodlso improved: during 2002, 15% of districts had DTP3 vaccina-ion coverage >80% compared to 49% during 2010 [14]. Surveystimates for DTP3 coverage were of 45% in 2006 (demographicealth survey) and 61% in 2009 (multiple indicator cluster survey)14]. During 2003, the year yellow fever vaccine was introduced,ational yellow fever vaccination coverage was 5% and increasedo 61% 2009 (Table 2) [14]. Vaccination coverage for measles andolio also increased significantly over the period (Table 2).

.5. Domestic and external resource availability following GAVIupport

Funding for routine immunisation activities from domestic andxternal sources increased from 2002 (US$13.37 million) [12] to010 (US$55.01 million) [11]. A comparison of the last two avail-ble comprehensive multi-year plans showed that funding foraccines increased from US$5.4 million in 2006 to US$30.5 mil-ion in 2010 (Fig. 2) [9,11]. During the same period, funding foroutine immunisation services from all funding sources, excluding

he value of vaccines, decreased from US$36.4 million to US$24.4

illion (Fig. 2). This 33% drop in overall funding primarily affectedurveillance (US$4.9 million), transport (US$3.7 million), and coldhain equipment (US$1.8 million).

61% 63% 66% 61% 67% 68%

The share of routine immunisation funding supported bydomestic resources remained below 13% during the study period[10–12]. The absolute amount of domestic funding for routineimmunisation increased from 2002 (US$0.3 million) [17] to 2005(US$3.9 million)[9] but decreased in 2010 (US$2.5 million) [10]. Todate, the DRC government has not contributed to the purchase oftraditional vaccines for routine immunisation, which instead hasbeen supported mostly by UNICEF. From 2008 onwards, the gov-ernment committed to increasing its contribution to the purchaseof new vaccines and injection material [11]. However, despitethe 2009 creation of a budget line dedicated to the purchase ofvaccines, the execution rate for the allocated funds was 23.5%during 2009 (23.5%) and 42.6% during 2010 [18,19]. Furthermore,the DRC remains in partial default of its co-financing obligationsfor new vaccines for the year 2011 [20]. Until this co-financingissue is resolved, the DRC will not be eligible for vaccine supportthat requires co-financing [21].

4. Discussion

In less than 10 years, from 2002 to 2010, the value ofGAVI support provided to the DRC was US$182.02 million,which was channelled through five different categories of sup-port. This support mainly focused on vaccine provision but alsoaimed at strengthening the health system and improving rou-tine immunisation services. Financial support provided to theDRC accounted for 41% of all GAVI support, while in-kind sup-port represented 59%. The overall budget execution rate ofGAVI funding was 66%. Most unspent funds were health systemstrengthening funds with an execution rate of 39%. With GAVIsupport, three new vaccines (yellow fever, tetravalent, and pen-tavalent) were introduced into the DRC’s routine immunisationprogramme. Significant improvements were made when com-paring the baseline year (2002) to the final year of the analysisperiod (2010) regarding DTP3 vaccination coverage (increase of25%) and routine immunisation financing (increase of US$41.6 mil-lion) [9–12,14].

Some GAVI support has faced implementation and financialmanagement challenges. The difficulty in using health systemstrengthening funds can be primarily explained by the absence ofa functional financial structure to receive and transfer the fundsto the sub-national levels until 2010 [22]. Concerning immun-isation services support, although substantial personnel bonuseswere provided, the incentives did not benefit staff in the field.A more equitable distribution of these bonuses could have hadthe effect of motivating personnel directly involved in immunisa-tion service delivery. An external audit of immunisation servicessupport fund management identified the absence of an effectiveaccounting system and budget management system at EPI [23].

The relative success of civil society organisation funding (in termsof activities implemented and budget execution rate) shows thatproviding support through NGOs with a long-term presence in thefield can be effective, including in reaching remote health zones

1890 J.-B. Le Gargasson et al. / Vaccine 31 (2013) 1886– 1891

0

5

10

15

20

25

30

35

40

2002 2003 2004 2005 2006 2010

USD

mill

ions

Financing for rou�neimmuniza�on (excluding thevalue of the vaccines)

Financing for vaccines (new,underused and tradi�onal)

GAVI funds used by EPI(financial support)

Fig. 2. Financing for routine immunisation, vaccines and GAVI funds used by the expanded program on immunisations (EPI) in the Democratic Republic of Congo from2

iGbt

pDit2am

agtFd2

otims22Da[t(

lbitta

iTo(ncamioi

002–2006 and 2010.

n post-conflict areas [24]. Lastly, in 2011 an agreement betweenAVI and the DRC Ministry of Health was signed to determine theest financing channel for GAVI cash support and additional stepshat may be needed to reduce financial risk [25,26].

Despite implementation challenges, GAVI support has enhancedrogress in routine immunisation performance and financing in theRC. According to an external evaluation commissioned by GAVI

n 2007, GAVI immunisation services support funding had a posi-ive effect on DTP3 vaccination coverage rates between 2003 and007 [27], possibly because these funds were used to support oper-tional cost items of the routine immunisation programme (i.e.aintenance, transportation, and supervision).The progress achieved has been partly sustained as indicated by

n increase from the 38% DTP3 vaccination coverage during 2002 toreater than 60% since 2006 [14] and districts with >80% vaccina-ion coverage increased from 15% during 2002 to 49% during 2010.urthermore, the DTP1-DTP3 dropout rate has declined sustainablyuring GAVI support from 23% in 2003 to around 5% to 7% during007–2010.

However, most of the gains in DTP3 vaccination coverageccurred between 2002 and 2006. Since the introduction ofetravalent vaccine in 2007 and pentavalent vaccine in 2009,mprovements in DTP3 vaccination coverage have halted. Further-

ore, the percentage of districts having a vaccination coverageuperior to 80% has evolved irregularly between 2007 (68%) and008 (54%), and between 2009 (78%) and 2010 (49%) [14]. Based on010 WHO/UNICEF DTP3 vaccination coverage estimates [14], theRC now is one of 12 countries that have DTP3 vaccination cover-ge <70%, which is a threshold for new vaccine support eligibility2,20]. Survey estimates for DTP3 coverage were even lower thanhe WHO–UNICEF coverage estimates [14] in 2006 (45%) and 200961%) [14].

Similarly, WHO–UNICEF vaccination coverage estimates for yel-ow fever vaccine indicate an increase since introduction, which haseen sustained above 50% since 2006, reaching 61% in 2009 follow-

ng GAVI new vaccine support [14]. For measles containing vaccine,he WHO–UNICEF coverage estimates increased from 42% in 2002o 68% in 2010, but again progress was concentrated between 2002nd 2006; a similar situation existed for polio vaccine.

There are multiple potential explanations for findings related tommunisation performance during the end of the analysis period.he failure of DTP3 vaccination coverage to increase could haveccurred due to a focus on other vaccines such as yellow feverroutine) or measles and polio (campaigns). However this expla-ation does not explain the similar halt in improving vaccinationoverage for yellow fever, measles and polio vaccines. Addition-lly, the halt in DTP3 vaccination coverage increase during 2010

ay have occurred because of programme deficiencies in introduc-

ng the pentavalent vaccine [16]. A static vaccination coveragef 60–70% could also have occurred if the program had reachedts maximum potential considering structural factors in DRC that

hamper the operational performance of the EPI programme, includ-ing bad road conditions, sub-optimal cold chain quality, limitedhuman resource availability and training) that are critical forimproving immunisation performance.

We also identified a decrease in routine immunisation financingfrom GAVI and other external sources coinciding with an increase infunding for vaccines following introduction of tetravalent and pen-tavalent vaccines (Fig. 2). New vaccine introductions may divertfinancial and human resource costs from routine immunisationoperational costs. Indeed, the cost for a fully vaccinated child in aGAVI-eligible country increased from US$1.37 in 2001 to US$30.45in 2010 [28] following the introduction of new vaccines in immun-isation programs. For this reason, some authors have suggestedthat there is an imbalance between the support of new vaccineintroduction and supporting traditional EPI vaccine delivery [28].Other authors have noted that although GAVI has a strategic objec-tive of strengthening immunisation service delivery, less than15% of GAVI’s budget is for non-commodity support (for all GAVIcountries) [29].

The contribution of domestic resources for routine immun-isation has remained marginal across the evaluation period anddecreased in absolute amount between 2005 and 2010 [9,10]. Otherevaluations in the DRC have found that GAVI support to immun-isation services support has not ensured cost-sharing with thegovernment or financial sustainability [24]. EPI partners such asthe Sabin Vaccine Institute, WHO, and UNICEF have agreed that theDRC needs to increase their contribution to immunisation activi-ties to ensure financial sustainability of the routine immunisationprogramme [30]. To achieve this objective, DRC will need to over-come allocation and execution issues linked to bottlenecks in thebudgetary process.

This study has limitations as our results have been affected bydata availability and reliability of existing data sources. No datawere available on routine immunisation financing for some specificyears (2007–2009). Therefore, those years were excluded from theanalysis on immunisation financing. As a consequence, our assess-ment only provides a partial picture of the decrease in fundingidentified between 2006 and 2010. Data on the use of GAVI funds inthe annual progress reports and other sources of funding for routineimmunisation are included in documents produced by the country,such as the annual progress report and cMYP, and we did not reviewthese data. This could impact the reliability of the data on the useof funds and the associated execution rate of GAVI funding.

In conclusion, significant progress in immunisation programmeperformance and financing was achieved in the DRC between 2002and 2010 following GAVI support. Although the progress achievedas of 2006 was partly sustained, improvements since then have

not occurred. The introduction of new vaccines (tetravalent, pen-tavalent) coincided with a constant or declining DTP3 vaccinationcoverage for certain years, as well as a decrease in funding for theroutine immunisation programme.

Vaccin

A

fMILtMi

rikacpttasd

o‘(swts

dSt

R

[

[

[

[

[

[

[

[

[

[

[

-

[

[

[[

[

[

[

[

[

J.-B. Le Gargasson et al. /

cknowledgements

We thank Dr. Bradford Gessner and Dr. Laurence Pierson, bothrom AMP, for their valuable input to the project; Dr. Audry

ulumba Wa Kamba, EPI director in the DRC; Dr. Benoît Kebelalunga from the Ministry of Health Disease Control department.astly, we are grateful to the Ministry of Health, Disease Con-rol department (4eme Direction), the EPI and the INRB (Professor

uyembe and Mrs. Annie Mutombo) in Kinshasa, DRC, for facilitat-ng the RVP-DRC project.

Contributors: JBLG wrote the methodology, the scientific studyeport, the first draft of the article and performed analysis andnterpretation of the data. JGB was the project leader and madeey contributions to the project design and implementation andssisted with writing of the article. BM undertook primary dataollection for the project and contributed to data analysis. ADSrovided valuable input for designing the study and facilitatedhe contact with the health authorities in the DRC. AC providedechnical guidance on the methodology, guided data analysisnd interpretation and assisted with writing of the scientifictudy report and of the article. All authors agreed on the finalraft.

Role of the funding source: This article was funded by Glax-SmithKline as part of a project implemented by AMP called

Rotavirus Vaccine Project in the Democratic Republic of Congo’RVP-DRC). The funding source for this study had no role in thetudy design, data collection, data analysis, data interpretation, orriting of the article. The corresponding authors had full access

o all data analyses and had final responsibility for the decision toubmit for publication.

Conflicts of interest: JBLG, JGB, ADS and AC work for the Agencee Médecine Préventive, which receives unrestricted funding fromanofi Pasteur and grant-specific support from Crucell, Sanofi Pas-eur, Pfizer, Merck, and GlaxoSmithKline.

eferences

[1] GAVI Alliance. GAVI alliance glossary. http://www.gavialliance.org/glossary/f-j/; [accessed 06.02.13].

[2] GAVI Alliance. Country eligibility policy – finance & programmaticpolicies, http://www.gavialliance.org/about/governance/programme-policies/country-eligibility/; 2012 [accessed 06.02.13].

[3] World Bank. GNI per capita, PPP (current international $) data table,http://data.worldbank.org/indicator/NY.GNP.PCAP.PP.CD; 2012 [accessed06.02.13].

[4] US Department of State, Bureau of African Affairs Background Note: Demo-cratic Republic of the Congo, http://www.state.gov/r/pa/ei/bgn/2823.htm;2012 [accessed 20.09.12].

[5] WHO. Under-five mortality rate (probability of dying by age 5 per 1000 livebirths), http://apps.who.int/gho/indicatorregistry/App Main/view indicator.aspx?iid=7; [accessed 06.02.13].

[6] GAVI Alliance. GAVI’s mission, http://www.gavialliance.org/about/mission/;

2012 [accessed 06.02.13].

[7] GAVI. Total disbursement to countries from GAVI Alliance,http://gaviweb.org/table/; 2010 [accessed 06.02.13].

[8] GAVI Alliance. GAVI Alliance handbook: country proposal and monitoring pro-cesses; 2008.

[

e 31 (2013) 1886– 1891 1891

[9] Ministry of Health DRC. Comprehensive Multi-Year Plan Costing Tool2007–2011; 2009.

10] Ministry of Health DRC. Comprehensive Multi-Year Plan of the DRC,2008–2012; 2008.

11] Ministry of Health DRC. Comprehensive Multi-Year Plan of the DRC,2011–2015; 2010.

12] Ministry of Health DRC. Financial sustainability plan of the expandedprogramme on immunization, http://www.who.int/immunization financing/countries/cod/congodr fsp.pdf; 2005 [accessed 06.02.13].

13] Ministry of Health DRC, General Secretariat. National Health DevelopmentPlan; 2010.

14] WHO. WHO vaccine preventable diseases: monitoring system 2010 globalsummary Immunization Reference Indicators DRC, http://whqlibdoc.who.int/hq/2010/WHO IVB 2010 eng.pdf; 2010 [accessed 06.02.13].

15] USAID (Maternal and Child Health Integrated Program). Impact of newvaccine introduction on developing country immunization programs: areview of the grey literature, http://www.mchip.net/sites/default/files/Impact%20of%20NVI%20on%20Developing%20Country%20Imm%20Programs-%20Grey%20Lit%20Review%20(2).pdf; 2011 [accessed 06.02.13].

16] Ministry of Health DRC, WHO, UNICEF, USAID. Post introduction evaluationreport of Hib vaccine; 2009.

17] Ministry of Health DRC. Financial sustainability plan costing, financing and gaptool; 2005.

18] Ministry of Budget, General secretariat to the Budget, Directorate of budgetpreparation and monitoring. Budget monitoring statements of expenses bynature in 2009; 2009.

19] Ministry of Budget, General secretariat to the Budget, Directorate of budgetpreparation and monitoring. Budget monitoring statements of expenses bynature in 2010; 2010.

20] GAVI. Programme update: country programmes, Report to the GAVI AllianceBoard Board-2012-Mtg-2-Doc B, 12–13 June 2012, www.gavialliance.org/about/governance/gavi-board/minutes/2012/12-june/minutes/b—programmeupdate—country-programmes; 2012 [accessed 06.02.13].

21] GAVI Alliance. Resolutions of the GAVI Alliance Board, GAVI AllianceBoard meeting, Dhaka, Bangladesh, http://www.gavialliance.org/about/governance/gavi-board/minutes/2011/; 2011 [accessed 06.02.13].

22] Carlson C, Maw H, Mafuta E. GAVI health system strengthening sup-port evaluation, DRC case study, http://www.google.fr/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&ved=0CDUQFjAC&url=http%3A%2F%2Fwww.gavialliance.org%2Fcountry%2Fdrc%2Fdocuments%2Fhss-evaluation%2Fhss-evaluation-congo%2C-democratic-republic-of-the%2F&ei=ANJaUNkZgqnQBa2RgQg&usg=AFQjCNHSxOsq3yetI6rdzmCIownYtY8Z-g&sig2=xhHBB79P8HIUhbPTLPhmyw; 2009 [accessed 06.02.13].

23] Fiduciary Guy De Smet. Financial audit report of GAVI funds of year 2003; 2007.24] GAVI Alliance. GAVI Alliance funding for civil society organizations case stud-

ies in Afghanistan, DR Congo, Ethiopia, Pakistan, www.gavialliance.org/library/publications/gavi/gavi-alliance-funding-for-civil-society-organisations–case-studies/; 2010 [accessed 06.02.13].

25] Government of the DRC. Aide-mémoire governing financial management ofGAVI funds for Health System Strengthening (HSS), Immunization ServicesSupport (ISS), Civil Society Organization support (CSO) in the DemocraticRepublic of the Congo; 2011.

26] GAVI. GAVI’s Transparency & Accountability Policy (TAP) – Q&A for GAVI eligi-ble countries; 2009.

27] Abt Associates. Evaluation of the First Five Years of GAVI Immuniza-tion Services Support Funding, http://www.gavialliance.org/library/documents/gavi-documents/evaluations/evaluation-of-the-first-five-years-of-gavi-immunisation-services-support-funding/; 2007 [accessed 06.02.13].

28] MSF. The right shot, extending the reach of affordable and adapted vaccines[Internet], http://www.msfaccess.org/sites/default/files/MSF assets/Vaccines/Docs/VACC report RightShot ENG 2012Update.pdf; 2012 [accessed 06.02.13].

29] Fields R. A stakeholder consultation on investment strategies for rou-tine immunization in Africa [Internet], http://arise.jsi.com/files/2012/

08/Arise StakeholderConsultation final508 8.27.12.pdf; 2012 [accessed06.02.13].

30] Kabambi E, Kamwa M. The drive to increase resources for children’s vaccines:galvanizing the members of parliament of the DRC. WHO Information Bulletin;2009.