The U.S. & Gavi, the Vaccine Alliance - Kaiser Family Foundation

Key Facts

Gavi, the Vaccine 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.”
Since its launch in 2000 through 2018, Gavi has committed $16 billion in support of immunization efforts in 76 low- and middle-income countries. Gavi kicked off its next replenishment round in December 2018, which will culminate in 2020 before Gavi’s next five-year funding cycle begins.
The U.S. government (U.S.) has supported Gavi since its creation through direct financial contributions, participation in Gavi’s governance, and technical assistance.
The U.S. is one of Gavi’s top government donors. U.S. contributions through 2018 comprised 12% of all donations received by Gavi ($1.9 billion out of $16.4 billion).
U.S. contributions to Gavi have grown almost every year since 2001, reaching a high of $290 million in 2018.

Gavi Overview

Gavi, the Vaccine 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.” Created in 1999, Gavi was formally launched in January 2000.

Goals

Gavi’s current five-year strategy, for the 2016-2020 period, includes four core goals:

accelerate equitable uptake and coverage of vaccines;
increase effectiveness and efficiency of immunization delivery as an integrated part of strengthened health systems;
improve sustainability of national immunization programs; and
shape markets for vaccines and other immunization products.

Organization

Secretariat and Partners

Gavi’s Secretariat, with its main headquarters in Geneva, and an office in Washington, D.C., carries out the day-to-day operations of the partnership. A team of Country Responsible Officers, based in the Geneva offices, oversees agreements with countries and works with country governments to implement programs. Gavi is led by a Chief Executive Officer (CEO), currently Seth Berkley. The partnership does not have program offices or staff based in recipient countries.

Gavi’s partners include: donors such as the U.S. government (discussed further below); institutions such as the World Health Organization (WHO) and the Bill & Melinda Gates Foundation; developing country governments; multilateral organizations, such as the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), and the World Bank; and civil society groups.

Governance

The 28-member Gavi Board, with representation from a broad set of public and private stakeholders (see Table 1), sets Gavi’s funding policies and strategic direction. A subset of Board members also comprise the Executive Committee, which can meet to decide on time-sensitive matters between Board sessions. Additionally, several Board committees, such as the Audit and Finance Committee and the Programme and Policy Committee, guide and advise the Board and the CEO on Gavi activities under their purview. The U.S. government is represented on Gavi’s Board as an alternate board member for the Donor Countries Governments constituency seat; it also holds a seat on the following Board committees: Audit and Finance; Market Sensitive Decisions; and Programme and Policy.

Constituency	# of Seats
Institutional (UNICEF, WHO, World Bank, Gates Foundation)	4
Donor Countries Governments	5
Developing Countries Governments	5
Research & Technical Health Institutes	1
Industrialized Countries Vaccine Industry	1
Developing Countries Vaccine Industry	1
Civil Society Organizations	1
Unaffiliated*	9
CEO of Gavi, the Vaccine Alliance (non-voting)	1
NOTES: * The unaffiliated seat is for independent private individuals with expertise in critical areas, such as investment, auditing, and fundraising.

Funding

Through September 2018, the partnership had received over $16 billion in financing (see Table 2). Three-quarters (77%) of Gavi’s funding comes from direct donations provided by donor governments and private organizations and individuals. The top three government donors are the United Kingdom, the U.S., and Norway, while the largest private donor (and largest donor overall) is the Gates Foundation. The remainder (23%) of Gavi’s funding comes from the proceeds of two unique innovative financing mechanisms – the International Finance Facility-Immunisation (IFFIm) and the Advance Market Commitment (AMC). The U.S. does not support these mechanisms, due to restrictions on making commitments to multi-year appropriations.

Gavi marked the mid-point of its current funding cycle with a midterm review meeting in December 2018 that also kicked off a replenishment effort, which aims to generate additional donor support for Gavi’s next five-year funding period 2021-2025.

Funding Source	Contributions in U.S. $ millions	% of Total Contributions
TOTAL	$16,424.3	100.0%
Donor Government Contributions	9,043.2	55.1
United Kingdom	2,462.1	15.0
United States	1,889.5*	11.5
Norway	1,574.2	9.6
Germany	562.2	3.4
Canada	517.8	3.2
Sweden	498.8	3.0
Netherlands	464.9	2.8
Others	1,082.7	6.6
Private Contributions	3,637.3	22.1
Bill & Melinda Gates Foundation	3,434.4	20.8
Others	212.9	1.3
Innovative Financing Mechanisms	3,743.7	22.8
International Finance Facility-Immunisation (IFFIm)	2,575.7	15.7
Advance Market Commitment (AMC)	1,168.0	7.1
NOTES: Reflects total cash received (proceeds), through 30 September 2018. * As of late Sept. 2018, the U.S. contribution for 2018, for which Congress provided $290 million, was not yet included in these totals.

International Finance Facility-Immunisation. Created in 2006, IFFIm uses donor funding commitments to back the issuance of special bonds in capital markets, essentially providing “up-front” financing to Gavi. Donor support for IFFIm comes from country governments, with the largest donors being the United Kingdom, France, Italy, Australia, Norway, and Spain.

Advance Market Commitment. The AMC, which began operating in 2010, supports accelerated access to pneumococcal vaccines. Donors provide up-front funding commitments to support vaccine purchases, which helps speed the introduction and use of the vaccines in Gavi-supported countries. Six donors support the AMC; in order of commitment amount, they are: Canada, Italy, Norway, Russia, the United Kingdom, and the Gates Foundation.

Country Eligibility and Support

Eligibility

Only low- and middle-income countries with a Gross National Income (GNI) per capita below or equal to $1,580, and that meet benchmarks for commitment to vaccine delivery and, depending on the vaccine, burden of disease are eligible for Gavi support. 47 countries are currently eligible; these include 20 U.S. priority countries for maternal and child health assistance.

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, they are expected to contribute a greater share of the funding required for immunization programs. When a country’s income rises above the GNI per capita threshold ($1,580), it moves into a 5-year “accelerated transition” period of increasing domestic financing share, after which the country is expected to fully fund its own immunization programs. Since 2015, sixteen countries have transitioned out of Gavi financial support, with a total of 20 expected by 2020.

Country Support

Eligible countries may apply for funding provided through one of Gavi’s several “funding windows” (types of support), which include support provided in the form of new and underused vaccines assistance (i.e., helping countries to introduce and expand the use of new and underused vaccines in their national immunization programs) as well as support for complementary activities, such as developing vaccine delivery systems, health systems strengthening, and supporting the development of civil society. Gavi also provided support to countries in the wake of the 2014-2015 West Africa Ebola epidemic, to help them recover and rebuild national immunization programs, and has supported the deployment of an Ebola vaccine in response to the outbreak in the Democratic Republic of Congo in 2018.

Type of Support (“Funding Window”)	Funding in U.S. $ millions	# of Countries Receiving Support
New and underused vaccines*	8,880.7	75
Health systems strengthening	1,305.5	56
Operational costs for immunization campaigns	471.3	63
Immunization services support	352.0	63
Vaccine introduction grants	171.5	72
Injection safety support	113.4	75
Cold chain equipment optimization platform	41.8	12
Civil society organizations	30.6	10
Ebola recovery plan	12.7	3
Graduation grants	10.6	15
HPV demonstration cash support	5.3	26
Product switch grants	2.5	4
TOTAL	$11,397.8	76
NOTES: Reflects Gavi-reported disbursements by year paid, from 2000 through March 2018. * New and underused vaccines include: Hepatitis B, Haemophilus influenzae type b (Hib), humanpapilloma virus (HPV), pentavalent, tetravalent, yellow fever, pneumococcal, rotavirus, meningitis A, Japanese encephalitis, inactivated polio virus (IPV), and measles.

Overall, from 2000 through March 2018, Gavi has disbursed over $11 billion in support to 76 low- and middle-income countries through more than ten funding windows (see Table 3). Most Gavi support (78%) has been provided through the new and underused vaccines funding window, followed by health systems strengthening (12%).

Results

According to Gavi, its support has led to improved child health and immunization indicators in countries that have received it. For example, Gavi reports that in supported countries between 2010 and 2016, child mortality declined by an average of 3.6% per year, 280 million more children were immunized, and over 4 million children’s lives were saved due to Gavi support. WHO has also estimated that over Gavi’s first decade, its funding helped reverse previously stagnating or declining coverage rates of childhood vaccinations in low-income countries, increasing average vaccine coverage from 66% to 79% during this period (2000-2010).

U.S. Engagement with Gavi

The U.S. government 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. provided its first contribution in 2001. Currently, the U.S. supports Gavi through financial contributions, participation in Gavi’s governance, and providing technical assistance. It also supports other global immunization activities that, while separate, support the work of Gavi.

Financial Support

U.S. financial support to Gavi has grown over time and includes direct contributions to Gavi but, thus far, has not included support for Gavi’s innovative financing mechanisms. The U.S. has contributed to Gavi every year since 2001, with U.S. contributions increasing from $48 million in 2001 to $290 million in 2018 (Figure 1). The current Administration requested $250 million for FY 2019.

Figure 1: U.S. Contributions to Gavi, 2001-2018

Congress provides funding for U.S. contributions to Gavi through the Global Health and Child Survival account at the U.S. Agency for International Development (USAID), specifically within the maternal and child health budget line.

Multi-Year Pledges

The U.S. government has made two multi-year pledges of support to Gavi. The first pledge was made in June 2011 for $450 million over three years, a pledge which was met through U.S. contributions in 2012 through 2014. A second pledge was made in January 2015 for $1 billion over four years. Congress met this pledge with its Gavi appropriations between FY 2015 and FY 2018.

Governance Activities

A U.S. government representative (from USAID) currently occupies an alternate seat on the Gavi Board that represents the donor countries governments constituency’s U.S./Australia/Republic of Korea/Japan group. The U.S. government is also represented on the Gavi Board’s Audit and Finance Committee, Market Sensitive Decisions committee, and Programme and Policy Committee.

Technical Support

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 U.S. agencies. For example, Gavi’s accelerated introduction programs for the pneumococcal and rotavirus vaccines have been conducted with technical support from the Centers for Disease Control and Prevention (CDC) and USAID, along with other partners.

Other U.S. Immunization Activities

Support of Gavi is one component of a broader set of global immunization activities of the U.S. government. In addition to multilateral funding for the U.S. contribution to Gavi, the U.S. provides bilateral (country-to-country) support for immunization through USAID, CDC, and other agencies. The two types of assistance – multilateral and bilateral – are intended to be complementary, with funding for Gavi supporting the introduction of new and underused vaccines into routine immunization systems globally, and bilateral aid supporting countries’ immunization system improvements in order to help them deliver Gavi-financed and other vaccines. Indeed, many of the countries in which the U.S. carries out its global health programs, including bilateral global immunization activities that are part of U.S. global MCH efforts, also receive support from Gavi. See the KFF fact sheets on U.S. global MCH efforts and U.S. global polio efforts.

Key Issues for the U.S.

The U.S. government has consistently supported Gavi since its inception in 2000 as a means of supporting global immunization programs and improving child health in developing countries. Key policy issues for U.S. engagement with Gavi going forward include:

future U.S. contributions to Gavi, especially in light of Gavi replenishment efforts (kicked off in December 2018 and culminating in 2020) and in the context of ongoing fiscal constraints in the U.S. federal budget and potential cuts to U.S. foreign assistance;
potential future growth in Gavi’s funding requirements as immunization coverage is further expanded and, potentially, more vaccines are introduced into the Gavi portfolio and as Gavi supports vaccine deployment for outbreaks, such as Ebola;^,
deciding the governance and technical assistance roles the U.S. will play in engaging with Gavi in coming years; and
ensuring U.S. immunization investments, both multilateral (through Gavi) and bilateral, are leveraged effectively to contribute to the achievement of global immunization goals.

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