The Gavi Mid-Term Review: Progress to Date and Prospects for 2021 and Beyond

Gavi, The Vaccine Alliance, is making good progress toward meeting its current targets and is adapting its programs to continue delivering lifesaving products to the world’s poorest populations in the face of significant external pressures and challenges. However, as Gavi looks ahead to its next strategic phase and considers how conflicts and humanitarian crises, climate change, urbanization, and population growth will affect its work, it will need to evolve its partnership model and market-shaping approaches to ensure that the large numbers of poor children, including, potentially, many who live in non-eligible countries, are fully immunized. The Alliance highlighted its accomplishments and challenges faced thus far during the 2016-2020 work phase at a mid-term review held December 2018 in Abu Dhabi. The more than 300 participants included heads of state and ministers of health, as well as representatives of vaccine manufacturers, private sector organizations, donor governments, and implementing agencies. Over plenaries, panels, and breakaway sessions the diverse mix of Gavi partners considered ways to make the Alliance more effective in a changing geopolitical environment as it gears up for its next replenishment, to be held in 2020.

The meetings highlighted several important trends:

• Gavi is making good progress in reaching its 2016-2020 target of immunizing 300 million more children and preventing more than 5-6 million deaths . As of 2017, 127 million additional children had been immunized, 2.5 million lives saved, and at least $50 billion in savings realized.¹


• Gavi is on track to transition 20 countries from Alliance support by 2020. A country’s eligibility for Gavi support is determined by its average annual gross national income (GNI) per capita over a three-year period; to be eligible for Gavi support, a country’s average annual GNI per capita must be equal to or below $1,580. When countries develop economically and pass the eligibility threshold, they enter a transition phase during which they pay incrementally more each year for vaccines procured with Gavi support. By the time of the December meetings, 16 countries had fully transitioned and were self-financing vaccine purchases. Gavi’s ongoing commitment to transitioned countries has enabled several to introduce the human papillomavirus (HPV) vaccine with a one-time Alliance investment. The majority of the countries that have fully transitioned from Gavi appear to be sustaining immunization coverage and increasing budget commitments for immunization programs. However, for a small number of “high-risk” transitioning countries that have faced challenges, including Angola, the Republic of the Congo, Papua New Guinea, and Timor-Leste, the Board in 2017 approved a “tailored approach,” allocating $30 million through 2020 to facilitate the preparation of customized country plans to help them successfully complete the graduation process.²


• Gavi is responding to difficult disordered conditions by adapting its approaches to support needy populations . In 2016, Gavi’s Board authorized a special commitment of vaccines and cold chain equipment to support partners providing immunizations for children in Syria, where coverages had dropped significantly since the onset of civil war. At the time, Syria was still classified as a middle-income country and not eligible for regular Gavi support.³ However, because Syria has lost economic momentum due to the ongoing conflict, it has been recently reclassified as a low-income country by the World Bank and, as of 2019, is now eligible for the full package of Gavi assistance.⁴ The Alliance’s 2017 policy on “Fragility, Emergencies, and Refugees” offers Gavi-eligible countries experiencing conflict, instability, or humanitarian crisis certain programmatic, administrative or financial flexibilities in order to meet the immunization needs of particularly vulnerable groups. In some cases, Gavi can also work directly with civil society organizations (CSOs), rather than governments, to introduce vaccines to special populations.⁵


• Private sector partners eager to work with Gavi continue to grow and diversify . Private sector entities collaborating with Gavi have expanded beyond pharmaceutical companies and medical device manufacturers to include global logistics and transportation organizations; blockchain specialists; software companies specializing in data integration; drone companies; and cell phone companies. Many of these organizations were early participants in Gavi’s Innovation for Uptake, Scale, and Equity in Immunization (INFUSE) program, which was rolled out at the 2016 World Economic Forum in Davos as a way to encourage the application of new and proven technologies to vaccine delivery challenges. At the Abu Dhabi review, Mastercard and Gavi announced plans to digitally encode immunization records on plastic cards. This pilot project will enable health providers in five countries to track immunizations children have received and still need to receive, with plans to scale up to all Gavi-eligible countries after an initial two-year period.⁶ Working with operational partners, who contribute services and expertise, enables the Alliance to help strengthen capacity for the delivery of vaccines, particularly at the country and local levels.


• Gavi’s public-private partnership model enables it to collaborate well with other global health organizations. Since 2013, Gavi has worked with the Global Polio Eradication Initiative (GPEI) to ensure delivery of inactivated polio vaccine (IPV) to low-income countries.⁷ The Global Fund to Fight AIDS, Tuberculosis, and Malaria’s Executive Director, Peter Sands, was in Abu Dhabi to emphasize the importance of Gavi-Global Fund cooperation as new vaccines for malaria, tuberculosis, and potentially HIV become available. Gavi can work with the Global Fund and GPEI to share expertise, coordinate when working in fragile settings, and discuss how to improve transparency and accountability in program management.

A number of serious challenges remain, despite encouraging reports of progress, the integration of new operational partners, and evidence that the Alliance’s flexibility with respect to transitions and emergencies allows it to provide support in economically unstable or fragile settings. Many will persist beyond the end of the 2016-2020 work period.

• Significant numbers of un- and under-immunized children are living in countries experiencing economic development at such a rate that they may quickly be ineligible for Gavi support. Recently, the Gavi Board authorized an exceptional extension of support to Nigeria, which has the highest number of under-immunized children in the world and significant sub-regional variations in coverage, but, for reasons of annual GNI per capita, was scheduled to transition away from Gavi support by 2021. Concerned about the high numbers of un- and under-vaccinated children and worried that an outbreak of vaccine-preventable disease in this country of more than 200 million people could threaten the health security of the West Africa region, the Board postponed Nigeria’s transition until 2028. As agreed in a customized transition plan, during the extension period Nigeria will complement Gavi support with a significant investment of domestic resources for immunization programs, increase national coverage for the pentavalent vaccine, and commit to expanding the overall budget for health. ⁸


• Low-income countries that have benefitted from Gavi assistance and technical support are establishing and maintaining higher immunization coverages than many middle-income countries that have never had Gavi support. The Gavi Board, Secretariat, and partners should explore how to provide non-eligible, middle-income countries with technical advice, perhaps by expanding the Learning Network for Countries in Transition, or how to reconsider the eligibility criteria to be able to assist middle-income countries at the sub-national level, where large pockets of under-immunized children remain.


• The Gavi model of market-shaping, which focuses on negotiating low prices for vaccines and encourages the entry of new producers to compete and drive down prices, is showing signs of strain. The overall cost to fully immunize a child with the pentavalent, pneumococcal, and rotavirus vaccines dropped from $20 in 2015 to $17 in 2017.⁹ But over the past year, one supplier stopped producing pentavalent vaccine because the Gavi-negotiated price was too low for it to continue manufacturing the product. The producer’s departure from the pentavalent market reinforces the importance for Gavi of balancing the effort to lower costs with ensuring manufacturers are able to remain invested in offering lower-cost products for Gavi-eligible countries. At the same time, the market has not produced sufficient supplies of rotavirus and HPV vaccines, forcing some countries to delay launching those products and integrating them into national immunization plans.¹⁰ Gavi will need to continue recruiting and working with a diverse network of producers worldwide to mitigate supply challenges.


• The goal of reaching children in the lowest income quintiles, sometimes referred to as “the 5th child,” remains elusive. Increasingly, the proliferation of conflicts in recent years has made reaching these “invisible” children, many of whom live in remote rural or peri-urban settings, even more difficult. Gavi’s Health Systems Strengthening (HSS) support helps eligible countries target regions or populations with the lowest immunization coverage, and in 2016-2017 HSS grants prioritized gender-based approaches that educated and empowered mothers to bring their children to health clinics for vaccines.¹¹ But the efforts to reach the poorest and most under-immunized populations will require continued tailoring and adjustment. A presentation in Abu Dhabi by Ola Rosling, president of the Stockholm-based Gapminder Foundation, reminded the audience that even the concept of lowest income quintile is relative: A child in the lowest quintile in a middle-income country may be wealthier than the wealthiest child in a lower income country, but she is still likely to be comparatively worse off in terms of access to health care, including immunizations, than her wealthier counterparts in her own country.

Gavi is not expected to finalize its vision for 2021-2025 until after the Board approves the proposed strategic plan this coming June. A replenishment meeting will then be scheduled once the Alliance determines what resources it will need to meet its goals over the next period. At the 2015 replenishment conference in Berlin, Gavi asked donors for $7.5 billion for the 2016-2020 work phase.¹² At the time, donors were assured 2016-2020 was the peak period for Gavi; by 2020, Gavi expects that 15 percent of all program financing will be covered by the implementing countries, themselves.¹³ But with new vaccines being added to the list of products Gavi supports, the Alliance will certainly need to keep existing donors engaged while attracting new ones for the next work period. Japan, which holds the presidency of the G20 in 2019, signaled its intent to emphasize support for global health issues, including immunizations, on the agenda at the Osaka summit next June. Governments and other donors will be considering and formulating their pledges up until the replenishment meeting, whenever it is scheduled.

Beyond preparing a plan for the next five-year phase of work, the Alliance must maintain its focus on increasing global immunization coverage rates and transitioning countries from support while grappling with the challenges that climate change and urbanization pose for the emergence of new infectious diseases and the potential need for new vaccines to deal with unanticipated outbreaks. The issue of vaccine hesitancy, which has led to decreased immunization coverage in some parts of the United States, been linked to the resurgence of measles in Europe, and now threatens to expand to other world regions must also be considered. The Alliance will need to pay higher attention to the impact this could have on Gavi-supported countries in the 2021-2025 period.

At the meeting in Abu Dhabi, several speakers noted that Gavi, which was launched in 2000 at the World Economic Forum, had, as an organization, matured and reached “adulthood.” Over the nearly two decades that the Alliance has grown and diversified, it has proven itself capable of being flexible, changing course when necessary, and learning from mistakes. As the partnership looks beyond the mid-term review to its next phase of work, that resilience and capacity for creative problem-solving will serve it well in adapting to an ever more complex social and political environment.

Katherine E. Bliss is senior associate (non-resident) with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C. and principal at Girasol Global Policy Consulting in Dallas, TX.

This report is made possible by the support of the Bill & Melinda Gates Foundation.

This report is produced by the Center for Strategic and International Studies (CSIS), a private, tax- exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

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