Background: Despite the increase in Health System Strengthening (HSS) grants, there is no consensus among global health actors about how to maximize the efficiency and sustainability of HSS programs and their resulting gains. To formally analyze and compare the efficiency and sustainability of Gavi's HSS grants, we investigated the factors, events and root causes that increased the time and effort needed to implement HSS grants, decreased expected outcomes and threatened the continuity of activities and the sustainability of the results gained through these grants in Cameron and Chad.
Methods: We conducted 2 retrospective independent evaluations of Gavi's HSS support in Cameroon and Chad using a mixed methodology. We investigated the chain of events and situations that increased the effort and time required to implement the HSS programs, decreased the value of the funds spent and hindered the sustainability of the implemented activities and gains achieved.
Results: Root causes affecting the efficiency and sustainability of HSS grants were common to Cameroon and Chad. Weaknesses in health workforce and leadership/governance of the health system in both countries led to interrupting the HSS grants, reprogramming them, almost doubling their implementation period, shifting their focus during implementation toward procurements and service provision, leaving both countries without solid exit plans to maintain the results gained.
Conclusions: To increase the efficiency and sustainability of Gavi's HSS grants, recipient countries need to consider health workforce and leadership/governance prior, or in parallel to strengthening other building blocks of their health systems.