The U.S. & the GAVI Alliance
The GAVI Alliance (also known as 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 began operations in January 2000 and by the end of 2010 had received over $5 billion in donor financing and disbursed over $2.8 billion to support immunization programs in 76 low- and middle-income countries.
The U.S. government has supported GAVI since its creation, including through financial contributions as well as technical assistance. The U.S. has been one of GAVI’s largest donors, providing 12.5% of all contributions received by the Alliance through the end of 2010 (Figure 1). 1 Many of the countries in which the U.S. carries out its global health programs also receive support from GAVI.
|Figure 1: Sources of Funding for the GAVI Alliance, Total Cash Contributions Received, 2000-2010 (US$millions)|
|Total Contributions||% of Total|
|International Finance Facility-Immunization (Largest IFFIm supporters: U.K., France, Italy, Norway)||1,875.7||36.2%|
|Bill & Melinda Gates Foundation||1,212.8||23.4%|
|United States of America||646.7||12.5%|
|Advance Market Commitment (AMC)||42.9||0.8%|
Still, funding GAVI is only one of several ways in which the U.S. supports immunization programs in developing countries – most U.S. financing for immunization is through bilateral aid – and discussions continue regarding the amount of U.S. funding for GAVI, and the ways in which that assistance is best channeled. For example, while the U.S. provides its contributions directly, it has chosen not to participate in two innovative financing mechanisms that rely on long-term donor pledges to finance GAVI (the International Finance Facility-Immunization, or IFFIm 2, and the Advance Market Commitment, or AMC) 3, even as the Administration has emphasized the importance of innovation for achieving its development goals. 4 Such discussions have only grown sharper in light of GAVI’s projected funding shortfall in the face of growing country demand and the lingering effects of the global economic crisis on donors. 5
At the same time, the Obama Administration has placed an increased emphasis on multilateral engagement and partnerships, including as part of its Global Health Initiative 6, but also through its broader development policy as outlined in the QDDR and the Presidential Policy Directive on development,7, 8 and has cited GAVI as an important multilateral partner for the U.S. It recently chaired, with the Government of Norway, a meeting of GAVI supporters to address GAVI funding needs, which resulted in the announcement of the Alliance’s first ever pledging conference, held in June 2011.9
The GAVI Alliance, initially created in 2000 as a partnership of donors, recipient governments, and other organizations, became an incorporated Swiss Foundation in 2009. It maintains a Secretariat in Geneva and an office in Washington D.C. but does not have program staff in-country, relying instead on its partner organizations (particularly UNICEF, WHO, and the World Bank), country governments, and civil society organizations for work done at the field level. GAVI is governed by a broad set of 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 follows 10:
- 4 Institutional seats (permanent): one each for UNICEF, WHO, the World Bank, and the Gates Foundation;
- 14 Constituency seats (rotating), including:
- 5 donor country governments (the U.S. currently occupies a seat representing the U.S, Canada, and Australia; the representative comes from USAID),
- 5 developing country governments,
- 1 Research/Technical Health Institute,
- 1 industrialized country vaccine industry representative,
- 1 developing country vaccine industry representative,
- 1 civil society representative;
- 9 Unaffiliated seats for private, independent individuals with expertise in critical areas such as investment, auditing, and fundraising, with the Board Chair drawn from this group;
- 1 Non-voting seat for the CEO of the GAVI Alliance. The U.S. is currently represented on a number of GAVI Board sub-committees including the Audit and Finance, and Program and Policy Committees.
Approach, Financing and Impact
GAVI has entered its third 5-year period (2011-2015) after having undergone important changes in its goals, financing approaches, and country eligibility requirements during the previous 5 years. 11
- Goals. GAVI’s core goals for the 2011-2015 period are to: 1) accelerate the uptake of vaccines; 2) help build health systems and capacity to deliver immunizations; 3) improve the predictability and sustainability of financing for immunization; and 4) impact the vaccine market by lowering prices and increasing production. 12
- Financing. In addition to receiving the more traditional direct financial contributions from donors, GAVI programs have also been supported through two unique innovative financing mechanisms, the IFFIm and the AMC. The IFFIm uses long-term donor commitments to back private investment bonds, which essentially “front-loads” donor financing. Though it debuted only in 2006, the IFFIm has become the largest single 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.
- Eligibility and Country Support. Countries with a Gross National Income (GNI) per-capita under $1,500 that meet benchmarks for commitment to vaccine delivery and, depending on the vaccine, burden of disease, are eligible to apply for GAVI support.13 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 (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. 14
|Figure 2. GAVI Funding for Country Programs, by Financing Window, 2000-2010|
|Window||Funding||# Countries Receiving|
|New and Underused Vaccines (NVS), including Hepatitis B, Haemophilus influenzae type b (Hib), yellow fever, pneumococcal, rotavirus, and measles (2nd dose) vaccines||$2.06B||73|
|Health System Strengthening (HSS)||$315m||42|
|Immunization Services Support (ISS)||$291m||63|
|Injection Safety Support (INS)||$108m||72|
|Civil Society Organization (CSO)||$13.7m||9|
- Impact. According to GAVI, its activities since 2000 have led to 288 million children being immunized 15, and the World Health Organization (WHO) has estimated that this has translated into the prevention of nearly 5 million future child deaths. 16 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. 12
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 17, and the U.S. donation of $48m in 2001 was the first public funding received by GAVI. 18 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; 19 the pledge represents the amount sought by the administration but final annual appropriations are determined by Congress. In FY2012, the U.S. contribution reached its highest level, $130m (Figure 3), and for FY2013 the administration requested an increase in funding for GAVI, to $145m. 20 GAVI funds have been appropriated as part of the Global Health and Child Survival (GHCS) account at USAID.
The U.S. has so far chosen to provide its contributions directly to GAVI but not to 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 the largest source of funding for the Alliance. Multiple factors have contributed to this, particularly the inherent difficulties of supporting multi-year funding commitments through typical U.S. budgeting and appropriations processes, which are annually-focused. 21
In addition to its role as a donor, the U.S. is involved in GAVI’s governance, currently occupying one of its Board seats and with a presence on multiple advisory committees.10 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 government agencies. For example, GAVI’s accelerated introduction programs for the pneumococcal and rotavirus vaccines are 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.
While GAVI has contributed significantly to international efforts to increase immunization coverage throughout the world, and is seen as an important multilateral partner by the U.S. government, discussions about the future level of U.S. support for GAVI continue. In addition, questions remain about whether the U.S. will consider participating in the IFFIm or AMC, GAVI’s principal innovative financing mechanisms, which some see as channels for generating additional resources. These questions are made all the more challenging given the current fiscal environment in the U.S., one of significant budgetary constraint and potential spending-scale backs. As such, it will be important to also assess ways in which U.S. bilateral support for immunization programs and its support for GAVI can most effectively be leveraged together to achieve impact on the ground. Looking forward, U.S. decisions on these issues will have important implications for the partnership, given the U.S. role as a key donor to the Alliance.
GAVI Alliance website: www.gavialliance.org.
International Finance Facility-Immunization website: http://www.iff-immunisation.org/index.html.
Vaccine AMC website: www.vaccineamc.org.
State Department. See: http://www.state.gov/secretary/rm/2010/07/144668.htm.
"GAVI takes steps to address funding woes." Lancet 377:453. Feb 7, 2011.
GHI Strategy Document. See: http://www.pepfar.gov/documents/organization/136504.pdf.
State Department. Quadrennial Diplomacy and Development Review (QDDR). See: http://www.state.gov/s/dmr/qddr/.
Presidential Directive on Development. See: http://www.whitehouse.gov/the-press-office/2010/09/22/fact-sheet-us-global-development-policy.
GAVI Pledging Conference website: http://www.gavialliance.org/about/pledging_conference/resource_event/index.php.
GAVI Governance website: http://www.gavialliance.org/about/governance/boards/index.php.
CEPA. Second GAVI Evaluation Report. Sept 2010.
GAVI Alliance. GAVI Alliance Strategy and Business Plan 2011-2015.
GAVI Alliance. GAVI Guidelines of Country Proposals for June 2011 Round.
GAVI Alliance. GAVI co-financing policy. See: http://www.gavialliance.org/vision/programme_policies/cofinancing_policy/index.php.
GAVI Alliance. Facts and Figures. See: http://www.gavialliance.org/media_centre/facts/index.php.
GAVI Alliance. GAVI 2010 Progress Report.
CRS. Health In Developing Countries: The U.S. Response. RL30793, Feb 2001.
USAID. See: http://www.usaid.gov/press/speeches/2011/sp110215.html.
USAID. Day of the Child: 250 Million Kids to Receive Life-Saving Immunization. USAID IMPACT Blog, June 14, 2011. http://blog.usaid.gov/2011/06/day-of-the-child-250-million-kids-to-receive-life-saving-immunization/
KFF. Budget Tracker. See: http://www.kff.org/globalhealth/8045.cfm.
Leo, B. Can Donors be Flexible Within Restrictive Budget Systems? Options for Innovative Financing Mechanisms. Center for Global Development Working Paper 226, October 2010.