Authors: Sostena Romano & Arika Garg, from the Clinton Health Access Initiative
The annual Gavi Joint Appraisal can be a useful tool for countries as they plan for their transition from Gavi support, serving to highlight challenges that require additional attention. Gavi and other partners have published a wide array of guidance to help countries maximize the usefulness of the JA process. We recently asked our colleagues at the Clinton Health Access Initiative (CHAI), who have participated in six recent JAs, to provide observations about how countries have effectively put this guidance into practice and to share lessons learned. Please find their responses below. – the LNCT Network Coordinators
The Joint Appraisal (JA) is an annual process undertaken by countries to review the progress and performance of Gavi support and its contribution to improving the immunization outcomes for the country. It is conducted over a period of three to five days and is typically attended by representatives from the Expanded Program on Immunization (EPI) and Ministry of Health (MOH), Gavi Senior Country Managers (SCMs) and other Gavi representatives, traditional and expanded partners, donors and civil society. The JA provides a platform to discuss the overall status of the country’s immunization program and its progress in meeting coverage and equity goals. It also provides an opportunity for countries, partners, and Gavi to jointly identify bottlenecks, develop mitigation plans, and identify areas of need for continued Gavi support. While this is a useful exercise for all Gavi-supported countries, it is particularly fruitful for countries that are approaching Transition, given the heightened need in these countries for sustainable financing and systems strengthening. CHAI teams in Indonesia, Kenya, Lao, Vietnam, Nigeria and Lesotho have participated in the JA process. The six countries are at different stages of transition from Gavi support: Indonesia transitioned in 2017, Vietnam and Lao PDR are in the late Accelerated Transition phase, Nigeria is in the early Accelerated Transition phase, and Kenya and Lesotho are in Preparatory Transition. The following are a few key observations from the JA processes in these countries that may drive the process to be productive and efficient for all participants.
EPI ownership is key throughout the process, and partners can support the EPI by ensuring that data describing partner activities and their impact is reliable and timely.
Supporting the EPI to be in the driver’s seat during the JA is crucial, as it helps to ensure government ownership during discussions and most importantly, on any next steps that are agreed upon. The importance of this is amplified in countries that are approaching Transition and are likely to experience a reduction in both funding and partner technical assistance in the near future. Since many EPI colleagues are quite stretched with their day-to-day activities, ensuring they have reliable, relevant and timely data from partners on immunization activities and the impact of these activities enables the EPI to be in the most knowledgeable position to drive the JA process. Nigeria’s recent JA provides an excellent example. The JA was coordinated by the Department of Disease Control and Immunization and EPI ownership was fostered, at least in part, by the presence of a National Immunization Technical Working Group (TWG) known as the National Emergency Routine Immunization Coordination Centre (NERICC). The NERICC is responsible for coordinating strategy and guiding implementation of immunization activities; it also regularly monitors and collates information about partner activities and analyzes how the activities are contributing to improved immunization outcomes. Having this crucial data easily accessible through its routine channels aided the Nigeria EPI in taking ownership of the JA process. While EPI teams in other countries may not have such data readily available, support from partners can go a long way in providing the EPI with data that they need on immunization activities and outcomes to lead the JA process.
Joint Appraisal discussions should focus on progress toward outcomes, rather than activities.
The JA is a unique opportunity to engage stakeholders in focused problem-solving. In order to best utilize this opportunity, discussions should focus first on progress towards immunization outcomes, rather than immunization activities. Where positive trends/progress in coverage or equity are highlighted, discussions should move to identifying the contributing factors to or enabling environment for the positive outcome. Likewise, where declines or flatlines have occurred, discussions should include an examination of the contributing factors and possible mitigating plans that can be put in place. This will likely initiate a richer discussion amongst attendees and might yield suggestions on new and innovative strategies that the country could employ. During the 2018 JA in Vietnam, for instance, participants discussed the variance of MCV2 coverage year-to-year and the shortage of the MR vaccine in December 2017. While the efforts undertaken to close the gap on the MR vaccine were outlined in detail, all stakeholders involved agreed that further interventions were required and a plan was made to, first, prioritize districts with low coverage of MCV2 and, second, conduct communication activities targeted towards caregivers and institutionalize the checking of immunization histories before school entry.
An outcomes-focused discussion will require EPI teams and partners to prepare any analyses or assessments on the impact of activities prior to the JA, with the findings ideally included in pre-meeting materials sent to participants. This can be a particularly useful exercise for transitioning countries, as it helps to routinize evidence-based program reviews and decision-making that is driven by the government.
Joint Appraisal discussions should be aligned with the broader country health context.
To increase the likelihood that any plans or next steps that emerge from the JA are operationalized, they should be aligned with pre-existing planning documents and fit within the country’s broader health strategy. A number of steps can be taken to facilitate this alignment. These include:
- Inviting representatives from all relevant ministries or agencies (e.g. Ministry of Finance, Ministry of Planning and Investment) to attend the JA and welcoming their active input during the process;
- Sharing a short primer that demonstrates how immunization fits into the broader health strategy
- Ensuring that the JA is held at a time when there is still an opportunity to include any plans/next steps discussed during the workshop in the country’s operational plan.
Operational planning of the Joint Appraisal is key
Given the multi-stakeholder nature of the JA, operational and logistical planning plays a significant role in ensuring a smooth and productive meeting. EPI teams, partners and Gavi can identify leads for the following responsibilities early in the planning process:
- Ensuring that the agenda has clear objectives for all sessions, including a list of expected outputs, tools/templates for documenting outputs, and hard copies of relevant reference documents (e.g. HSS workplan/budget, previous year’s Partner Engagement Framework activities, etc.);
- Coordinating with relevant parties to ensure that any material to be disseminated to attendees is ready at least one week in advance of the meeting, and includes all relevant materials, such as assessments of the impact of activities, national strategic health plans, etc.;
- Ensuring that any material that needs to be submitted to Gavi in advance of the JA is complete (e.g. draft JA report, HSS budget request), so that as little time as possible is spent during the JA on gap-filling activities.
For example, during a recent JA in Lao PDR, templates were made available during breakout sessions for participants to document findings or next steps that emerged in discussion. The templates enabled breakout groups to clearly and systematically share observations with the larger group and record any additional relevant comments or suggestions made for follow-up after the workshop.
While we hope that the suggestions above can aid in making the JA process as effective and efficient as possible, there are likely many other strong strategies that countries have employed that have worked well. Please share any other suggestions you have on the LNCT Discussion Forum.
We would like to acknowledge the following individuals from the Clinton Health Access Initiative for their contributions to this blog post:
- From the Nigeria team: Abiola Ojumu, Shola Dele-Olowu, Akachi Mbogu
- From the Vietnam team: Ha Pham
- From the Lao team: Praveena Gunaratnam, Heather Viola
- From the Global team: Diana Kizza, Sebastian Ilomuanya, Julia Roper and Maceda Alemu