Perspective and investments in health system strengthening of Gavi, the Vaccine Alliance: a content analysis of health system strengthening-specific funding.

BACKGROUND: This paper aimed to compare the health systems strengthening (HSS) framework of Gavi and WHO and to analyze resource allocation in HSS by Gavi.

METHODS: Among 76 countries which received HSS funding from Gavi from 2006 to 2013, summary reports of 44 countries and approved proposals of 10 countries were collected. After comparing the HSS framework of WHO and Gavi, each activity described in documents was categorized according to Gavi's framework and funding allocation was analyzed.

RESULTS: Compared with WHO's HSS framework, Gavi's has a distinctive function within the building block 'Drugs, Equipment, Supplies, Facilities' and a distinctive function of 'providing incentive and bonuses' under the building block 'Human Resource/Performance Management'. Gavi has steadily invested 10% of their total budget on HSS, but 47% were allocated in these categories, whereas 78% were for activities arguably not covered by WHO's HSS framework. In Africa, 70% of Gavi's budget fell under 'Drugs, Equipment, Supplies, Facilities' and 92.8% were for activities arguably not deemed as HSS by WHO.

CONCLUSIONS: Gavi's HSS support emphasized inputs with short-term measurable outcomes. Harmonization of the concept of HSS and collaboration between Gavi and multilateral international agencies, such as World Bank and WHO, are needed.