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      Challenges to implementing Gavi’s health system strengthening support in Chad and Cameroon: results from a mixed-methods evaluation

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          Abstract

          Background

          Since 2005, Gavi has provided health system strengthening (HSS) grants to address bottlenecks affecting immunization services. This study is the first to evaluate the Gavi HSS implementation process in either Cameroon or Chad, two countries with significant health system challenges and poor achievement on the child and maternal health Millennium Development Goals.

          Methods

          We triangulated quantitative and qualitative data including financial records, document review, field visit questionnaires, and key informant interviews (KII) with representatives from the Ministries of Health, Gavi, and other partners. We conducted a Root Cause Analysis of key implementation challenges, guided by the Consolidated Framework for Implementation Research.

          Results

          We conducted 124 field visits and 43 KIIs in Cameroon, and 57 field visits and 39 KIIs in Chad. Cameroon’s and Chad’s HSS programs were characterized by delayed disbursements, significant deviations from approved expenditures, and reprogramming of funds. Nearly a year after the programs were intended to be complete, many district and facility-level activities were only partially implemented and significant funds remained unabsorbed. Root causes of these challenges included unpredictable Gavi processes and disbursements, poor communication between the countries and Gavi, insufficient country planning without adequate technical assistance, lack of country staff and leadership, and weak country systems to manage finances and promote institutional memory.

          Conclusions

          Though Chad and Cameroon both critically needed support to strengthen their weak health systems, serious challenges drastically limited implementation of their Gavi HSS programs. Implementation of future HSS programs in these and similar settings can be improved by transparent and reliable procedures and communication from Gavi, proposals that account for countries’ programmatic capacity and the potential for delayed disbursements, implementation practices that foster learning and adaptation, and an early emphasis on developing managerial and other human resources.

          Electronic supplementary material

          The online version of this article (10.1186/s12992-017-0310-0) contains supplementary material, which is available to authorized users.

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          Most cited references19

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          Development assistance for health: past trends, associations, and the future of international financial flows for health.

          Disbursements of development assistance for health (DAH) have risen substantially during the past several decades. More recently, the international community's attention has turned to other international challenges, introducing uncertainty about the future of disbursements for DAH.
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            Implementation science and its application to population health.

            Implementation science studies the use of strategies to adapt and use evidence-based interventions in targeted settings (e.g., schools, workplaces, health care facilities, public health departments) to sustain improvements to population health. This nascent field of research is in the early stages of developing theories of implementation and evaluating the properties of measures. Stakeholder engagement, effectiveness studies, research synthesis, and mathematical modeling are some of the methods used by implementation scientists to identify strategies to embed evidence-based interventions in clinical and public health programs. However, for implementation science to reach its full potential to improve population health the existing paradigm for how scientists create evidence, prioritize publications, and synthesize research needs to shift toward greater stakeholder input and improved reporting on external validity. This shift will improve the relevance of the research that is produced and provide information that will help guide decision makers in their selection of research-tested interventions.
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                Author and article information

                Contributors
                edanse@uw.edu
                yode_m@yahoo.fr
                squirese@uw.edu
                h_mimche@yahoo.fr
                charbel@uw.edu
                Journal
                Global Health
                Global Health
                Globalization and Health
                BioMed Central (London )
                1744-8603
                16 November 2017
                16 November 2017
                2017
                : 13
                : 83
                Affiliations
                [1 ]ISNI 0000000122986657, GRID grid.34477.33, Institute for Health Metrics and Evaluation, , University of Washington, ; 2301 5th Avenue, Suite 600, Seattle, WA 98121 USA
                [2 ]GRID grid.440616.1, University of N’Djamena, ; Avenue Mobutu, BP 1117 N’Djamena, Chad
                [3 ]ISNI 0000 0001 2173 8504, GRID grid.412661.6, Institut de Formation et de Recherche Démographiques, , University of Yaoundé II, ; 1556 Yaoundé, Cameroon
                Article
                310
                10.1186/s12992-017-0310-0
                5691914
                29145871
                f5613c21-9ef7-4fe8-9db8-ac03706121ed
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 5 May 2017
                : 6 November 2017
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100001125, GAVI Alliance;
                Award ID: PP45680815A4, PO006331
                Categories
                Research
                Custom metadata
                © The Author(s) 2017

                Health & Social care
                health system strengthening,hss,gavi,implementation science,process evaluation,chad,cameroon

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