The U.S. & the GAVI Alliance
The GAVI Alliance (GAVI) is an independent, public-private partnership and multilateral funding mechanism that aims to “save children’s lives and protect people’s health by increasing access to immunization in poor countries”.1 Created in 1999, GAVI was formally launched in January 2000. Through December 2013, the partnership had received over $9 billion in donor financing. Contributions to GAVI are provided by public and private donors directly, or through donor investments in two innovative financing mechanisms – the International Finance Facility-Immunisation (IFFIm) and the Advance Market Commitment (AMC).2 In turn, GAVI has disbursed over $6.4 billion in support of immunization programs in 76 low- and middle-income countries.3
The U.S. government has supported GAVI since its creation, including through direct financial contributions, participation in governance, and technical assistance. The U.S. has been one of GAVI’s top government donors, as measured by direct contributions, having provided approximately 11% of all contributions received by the Alliance from 2000 through December 2013 (Figure 1).
|Figure 1: Sources of Funding for the GAVI Alliance, Total Cash Contributions Received, 2000- Dec 2013 (US$millions)2|
|Total Contributions||% of Total|
|Donor Government Contributions||4,148.9||44.3%|
|United States of America||1,004.5||10.7%|
|Bill & Melinda Gates Foundation||2,028.8||21.7%|
|Innovative Financing Mechanisms||3,084.6||32.9%|
|International Finance Facility-Immunisation||2,475.7||26.4%|
|Advance Market Commitment (AMC)||609.0||6.5%|
GAVI has been cited by the Obama Administration as an important multilateral partner, and U.S. financial support to GAVI has grown over time.4 In June 2011, the U.S. made a multi-year funding commitment to GAVI for the first time, pledging $450 million for the three year, FY2012-FY2014, period, a pledge which has been met.5,6
In addition to providing multilateral funding for immunizations through GAVI, the U.S. also provides bilateral immunization support through USAID, CDC, and other agencies.7 The two types of assistance are intended to be complementary, with GAVI supporting the introduction of new and underused vaccines into routine immunization, and bilateral aid supporting immunization system improvements to help deliver GAVI-financed and other vaccines to populations in need.8,9 GAVI’s financing needs have grown over time, and are expected to continue to grow due to increasing country demand, the potential addition of other vaccines to the GAVI portfolio, and concerns about the sustainability of donor support and country co-financing.
The GAVI Alliance, initially created as a partnership of donors, recipient governments, and other organizations, reorganized as a Swiss Foundation with international institution status in 2009. It maintains two offices, in Geneva and in Washington D.C., but does not have program staff in-country. A team of Country Responsible Officers based in Geneva oversee the partnership at country level and work closely with country governments, partner organizations (particularly UNICEF, WHO, and the World Bank), and civil society organizations to assist countries improve national immunization programs. GAVI is governed by a broad set of public and private stakeholders, with the U.S. government involved in several of the Alliance’s core governance components.
GAVI’s 28-member board sets the funding policies and strategic direction for the partnership. Its membership is composed as follows10:
- 4 institutional seats, one each for UNICEF, WHO, the World Bank, and the Gates Foundation;
- 5 seats for the industrialized country governments (a U.S. representative, from USAID, is currently an alternate in the rotating seat representing the U.S./Australia/Republic of Korea/Japan constituency),
- 5 seats for developing country governments,
- 1 seat for the Research & Technical Health Institute constituency,
- 1 seat for the industrialized country vaccine industry constituency,
- 1 seat for the developing country vaccine industry constituency,
- 1 seat for the civil society organizations constituency;
- 9 unaffiliated seats for private, independent individuals with expertise in critical areas such as investment, auditing, and fundraising;
- 1 non-voting seat for the CEO of the GAVI Alliance.
The U.S. government also currently provides a representative on GAVI Alliances Program and Policy Committee and its constituency is represented on the Executive Committee.
Goals, Key Components, & Results
- Goals. GAVI’scurrent five-year strategy, for the 2011-2015 period, includesfour core goals: 1) accelerate the uptake of new and underused vaccines; 2) help build health systems and capacity to deliver immunizations; 3) improve the predictability and sustainability of global and domestic financing for immunization; and 4) impact the vaccine market by lowering prices and increasing production.11
- Financing. In addition to receiving the more traditional direct financial contributions from public and private donors, GAVI programs have also been supported through unique innovative financing mechanisms such as IFFIm and the AMC. IFFIm uses long-term donor commitments to back the issuance of Vaccine Bonds in the capital markets, which essentially “front-loads” donor financing.12 Since it debuted in 2006, IFFIm has become an important source of funding for the Alliance (Figure 1). The AMC, which began operating in 2010, is an advance market commitment “pull mechanism” with manufacturers that aims to accelerate access to pneumococcal vaccine in low-income countries.13 To ensure stability and predictability in the Alliance’s financing going into the 2016-2020 period, GAVI and its partners are planning a second replenishment meeting expected to occur in late 2014 or early 2015 (the first occurred in 2011), to bring together donors, implementing countries, and vaccine manufacturers to mobilize support.14
- Eligibility and Country Support. Countries with a Gross National Income (GNI) per-capita below or equal to $1,570 that meet benchmarks for commitment to vaccine delivery and, depending on the vaccine, burden of disease, are eligible to apply for GAVI support.15 GAVI provides the great majority of its support to countries in the form of “new and underused” vaccines (and accompanying injection equipment), with smaller amounts of assistance provided through cash grants meant to support countries’ vaccine delivery systems, and broader health systems strengthening and civil society (Figure 2). Recipient governments are expected to share responsibility for funding their national immunization efforts through “co-financing” requirements, determined according to country income level. As countries develop economically, a greater domestic share of financing for their immunization programs is expected.16 When countries’ incomes rise above the threshold, they “graduate” from GAVI eligibility; some countries have already graduated while approximately 16 others, including countries such as Indonesia, Bolivia, and Mongolia, are expected graduate by 2018.17,18
|Figure 2. GAVI Funding for Country Programs, by Type of Support, 2000- Nov 201319|
|Window||Funding||# Countries Receiving|
|New and Underused Vaccines, including Hepatitis B, Haemophilus influenzae type b (Hib), yellow fever, pneumococcal, rotavirus, and measles (2nd dose) vaccines||$4.21B||75|
|Health System Strengthening||$508.1m||56|
|Immunization Services Support||$339.7m||63|
|Operational Costs for Immunization Campaigns||$200.1 m||16|
|Injection Safety Support||$107.8m||72|
|Vaccine Introduction Grants||$70.8 m||75|
|Civil Society Organization||$25.8 m||10|
|HPV Demonstration Cash Support||$1.6 m||9|
|Product Switch Grant||$0.4 m||1|
Results. According to GAVI, its activities since 2000 have led to 440 million children being immunized, preventing more than an estimated 6 million child deaths.20 The WHO has also estimated that GAVI support has helped to reverse previously stagnating or declining coverage rates of childhood vaccinations in low-income countries, increasing average vaccine coverage from 66% to 79% over its first decade.21
U.S. Engagement with GAVI
The U.S. has supported GAVI since its creation. President Clinton made the initial U.S. pledge to the newly formed partnership in 2000, and the U.S. donation of $47m in 2001 was the first public funding received by GAVI.22,23 Since then, U.S. support has increased. In 2011 the Obama administration made the first ever multi-year funding commitment to GAVI, pledging $450m over 3 years (2012-2014), which has been met. In FY2014, the U.S. contribution to GAVI reached its highest level ever, $175m (Figure 3), an increase over the FY2013 level of $138m (see Figure 3)24. GAVI funds are appropriated as part of the Global Health and Child Survival (GHCS) account at USAID, within the Maternal and Child Health (MCH) budget line.
While the U.S. provides direct contributions to GAVI, it does not support either of the innovative financing mechanisms, the IFFIm and the AMC, that other donors have utilized to finance GAVI programs and which together comprise a significant source of funding for the Alliance. This is due to multiple factors, particularly the inherent difficulties for the U.S. to make spending commitments (beyond non-binding pledges) for multi-year funding due to U.S. budgeting and appropriations processes, which are annually-focused.25
In addition to its role as a donor and in GAVI’s governance, the U.S. also provides GAVI with technical support and expertise in the design, implementation, and evaluation of its programs in the field through partnerships with several agencies. For example, GAVI’s accelerated introduction programs for the pneumococcal and rotavirus vaccines have been conducted with technical support from CDC and USAID, along with other partners.
Support of GAVI has been only one component of a broader set of activities the government is engaged in to increase access to immunizations in developing countries. The U.S also supports global immunization through bilateral programs implemented by the CDC, USAID and the Millennium Challenge Corporation among others. Many of the countries in which the U.S. carries out its global health programs receive support from GAVI.
GAVI has been recognized as an important multilateral partner for the U.S. government in efforts to introduce new vaccines, support immunization programs, and improve health in developing countries. Going forward, some key policy issues facing the Alliance and the U.S. as a key GAVI partner include: ensuring that donor support will meet its future financing needs, which are expected to grow as current programs are expanded and new vaccines (such as a potential new malaria vaccine) are added to the GAVI portfolio; the expected graduation of many countries from GAVI eligibility even as those countries are home to under-immunized populations, creating the need for greater country co-financing and/or more flexibility for GAVI in its financing approaches as a result; how much future U.S. support for GAVI will be available, given ongoing fiscal constraints in the U.S. federal budget; how to make the greatest progress toward goals and objectives for global immunization through the most effective combination of support to GAVI and to U.S. bilateral programs; and how to leverage U.S. expertise for GAVI through technical assistance and governance engagement with the Alliance.
GAVI Website, “GAVI’s Mission” http://www.gavialliance.org/about/mission/.
GAVI Website, “GAVI Donor Contributions and Pledges”, http://www.gavialliance.org/funding/donor-contributions-pledges/.
GAVI Website, “Disbursements by country”, http://www.gavialliance.org/results/disbursements/.
Smith G. “Renewed Commitment to Global Vaccines and Immunizations Will Save Lives.” White House Blog, June 15, 2011. http://www.whitehouse.gov/blog/2011/06/15/renewed-commitment-global-vaccines-and-immunizations-will-save-lives.
Kaiser Family Foundation Policy Tracker. “USAID Administrator announces 3-year, $450 million pledge to GAVI”. http://kff.org/policy-tracker/usaid-administrator-announces-3-year-450-million-pledge-to-gavi/.
Note: the full pledged amount of $450m was budgeted over those three years, but due to sequestration in FY2013 the actual final amount of assistance to GAVI fell below $450m.
DefeatDD.org. “U.S. Investments in Global Immunization.” http://www.defeatdd.org/sites/default/files/node-images/US%20Investments%20in%20Global%20Immunization%20%20FINAL_0.pdf.
Trostle M, Shen AK. Three decades of USAID investments in immunization through the child survival revolution. Emerging Microbes and Infections 3, e13; doi:10.1038/emi.2014.13; published online 26 February 2014.
CDC Website. “Global Vaccines and Immunization.” http://www.cdc.gov/globalhealth/immunization/.
GAVI Website. “Governing GAVI.” http://www.gavialliance.org/about/governance/.
GAVI Website. “GAVI’s Strategy.” http://www.gavialliance.org/about/strategy/.
GAVI Website. “International Finance Facility –Immunisation.” http://www.gavialliance.org/funding/IFFIm/.
GAVI Website. “Pneumococcal AMC.” http://www.gavialliance.org/funding/pneumococcal-amc/.
GAVI. “The Road to Replenishment 2016-2020: Resourcing GAVI’s long-term country demand.” Report to the GAVI Board, November 2013. http://www.gavialliance.org/about/governance/gavi-board/minutes/2013/21-nov/.
GAVI Website. “Countries Eligible for Support.” http://www.gavialliance.org/support/apply/countries-eligible-for-support/.
GAVI Website. “Graduation Policy”. http://www.gavialliance.org/about/governance/programme-policies/graduation/.
Saxenian H, Hecht R, Kaddar M, Schmitt S, Ryckman T, Cornejo S. Overcoming challenges to sustainable immunization financing: early experiences from GAVI graduating countries. Health Policy and Planning. first published online February 8, 2014 doi:10.1093/heapol/czu003.
GAVI Website, “Graduating Countries” http://www.gavialliance.org/support/apply/graduating-countries/.
GAVI Website. “Disbursements by Country.” http://www.gavialliance.org/results/disbursements/.
GAVI Website. “GAVI’s Impact”. http://www.gavialliance.org/about/mission/impact .
GAVI Alliance. GAVI Alliance Strategy and Business Plan 2011-2015.
CRS. Health In Developing Countries: The U.S. Response. RL30793, Feb 2001.
Originally, $145m was proposed for FY2013, but due to the sequestration passed by Congress that year, the final appropriation amount was reduced to $138m.
Leo, B. Can Donors be Flexible Within Restrictive Budget Systems? Options for Innovative Financing Mechanisms. Center for Global Development Working Paper 226, October 2010.