One of the cornerstones of Gavi’s development model is that support to countries is time-limited and catalytic, and that this support diminishes and ultimately ends as their economies grow.
“Gavi-supported countries are allocating an ever-greater proportion of their domestic resources to vaccination. Of the 20 countries due to transition out of Alliance support by 2020, 16 are already fully self-financing their vaccine programmes.”
Mid-Term Review report, page 8
A key characteristic of Gavi’s development model is that support is time-limited and catalytic. Gavi’s support is based on countries’ ability to pay and puts them on a trajectory towards financial sustainability. Co-financing obligations rise as gross national income (GNI) grows. Once a country’s GNI reaches a specific threshold, Gavi’s support starts to phase out over a five-year period. At the end of this process, countries are fully self-financing their vaccines.
Gavi’s sustainability model thus reflects the maturity of countries’ health systems along the development continuum. Lower-income countries, which are eligible for Gavi support, often have weak foundations for their health and immunisation systems. These include poorly functioning supply chains, an inadequately-trained health workforce and weak governance, and tend to be coupled with acute fiscal constraints.
As countries achieve higher levels of development, their systems grow stronger. However, gaps in institutional capacity in key areas often remain. While such countries frequently possess growing domestic resources, the processes that should ensure such resources are efficiently used are inadequate. This also hampers their ability to identify and prioritise the most impactful and cost-effective interventions.
There is often a positive correlation between a country’s economic development and progress in immunisation programmes and financing. However, these gains are vulnerable to risks, and there are sometimes missed opportunities for broader impact and efficiencies. As countries and their needs evolve, the types of engagement and support offered by Gavi adapt accordingly. (see Figure 1).
Figure 1: Gavi’s sustainability model
ELIGIBILITY, CO-FINANCING AND SUSTAINABILITY POLICY
Gavi’s policy for eligibility, co-financing, and sustainability reflects these evolving needs and guides the institutional framework for transitioning countries out of the Alliance’s support. It serves as the key mechanism for domestic resource mobilisation and sustainability, and recognises that:
- domestic financing is key, but not enough;
- programmatic sustainability requires critical national capacities;
- sequencing interventions correctly and addressing systemic bottlenecks early on is essential;
- support should be adapted to each country’s needs and reflect its transition status.
Figure 2: Gavi’s transition model
Gavi’s co-financing policy provides the mechanism for countries to increase domestic investments in vaccine financing, adding to their broader investments in service delivery and immunisation systems. It creates national ownership and helps to build procurement capacity while Gavi’s financial support is being phased out.
The co-financing policy has spurred record levels of domestic resource mobilisation for vaccines. Since its introduction in 2008, country contributions towards Gavi-supported vaccines have increased more than 14 times (see figure 3).
Figure 3: Country contributions
Explore Gavi co-financing data by country:
Between 2008 and 2017, country co-financing and self-financing as a proportion of total Gavi funding for routine vaccine programmes climbed from 0% to 35%. Country self-financing and India’s co-financing contributions (see figure 4) are two of the main drivers behind this increase.
Reflecting the policy’s wider impact, the rise in country co-financing contributions discussed above is paralleled by an overall increase in domestic financing for non-Gavi vaccines (“traditional vaccines”) as well. This shows that rather than simply reallocating government financing, the co-financing policy has helped to catalyse a broader increase in overall domestic resources available for immunisation and vaccines.
TRANSITIONING COUNTRIES OUT OF GAVI SUPPORT
Of the 16 countries that have transitioned out of Gavi support, 8 have already been fully self-financing their vaccines for more than year (see figure 5). Importantly, over the same period, they have also managed to maintain or increase coverage (see figure 6). However, both Indonesia and the Republic of Moldova report coverage rates below 90%, despite a steady increase in the number of children reached with three doses of pentavalent vaccine.
In all of these countries, domestic resources for vaccines increased significantly between 2010 and 2017.
While most of the countries that have transitioned out of Gavi support are maintaining high immunisation coverage rates, some have gaps in programmatic capacities. These include regulatory matters, procurement, supply chain and data systems, as well as gaps in the number of new vaccines introduced.
In response, in 2017, the Board agreed to systematic engagement with countries post-transition to ensure their progress does not slip. This new approach aims to mitigate serious programmatic risks in post-transition countries by providing catalytic support to mitigate serious programmatic risk; for example, support to address anti-vaccine movements or strengthening vaccine procurement capacities.
To reduce the risk that countries transition without critical vaccines in their routine programmes, Gavi now allows governments to apply for new vaccine support at any stage during the transitioning process. As a result, most countries are now transitioning with three out of four critical vaccines (pentavalent, rotavirus, pneumococcal and human papillomavirus) already included in their routine programmes (see table 1).
A small sub-set of transitioned countries have introduced less than three vaccines. In most cases, this is due to strategic decisions, such as relying on local manufacturers (e.g. Cuba and Indonesia) or deciding that other vaccines are not cost-effective in the country’s specific epidemiological context (eg Sri Lanka). Nevertheless, this situation is continually evolving. For example, Indonesia is now conducting pilot programmes for pneumococcal and human papillomavirus vaccines to guide a decision on potential national introductions.
Table 1: Vaccine introductions of countries transitioning and transitioned from Gavi support
Four other countries transitioning in this period – Angola, the Congo, Papua New Guinea and Timor-Leste – share more systemic issues, mainly linked to post-conflict challenges. All entered Gavi’s final transition phase following rapid economic growth driven by high commodity prices. Each still has relatively low immunisation rates that are not improving. This means that they are faced with the task of transitioning out of Gavi support while they still need to develop their health systems capacities and develop their institutions. They also face the risk that their economies remain vulnerable to short-term downturns. These challenges require a longer timeframe to have the right institutions and systems in place, as well as the enhancement of leadership and programme skills (see Table 2).
Recognising the need for special measures, the Board has identified Angola, Congo Republic, Papua New Guinea and Timor-Leste as “high-risk”, and has requested specific country strategies. Consistent with the Alliance’s overall shift towards country-tailored programmes, customised plans are now in place for Angola, Papua New Guinea and Timor-Leste, as well as Nigeria.
In these high-risk countries, Gavi is providing longer-term support for each of these countries to help strengthen service delivery in districts with low coverage rates. This includes increasing the capacity of the Expanded Programme for Immunization (EPI) and health workers, as well as modernising supply chains. In November 2018, the Board decided to classify Congo as Gavi-eligible again, as a result of its GNI per capita falling below Gavi’s eligibility threshold.
 Includes pentavalent, pneumococcal, rotavirus, measles-rubella, human papillomavirus, yellow fever and meningitis A vaccine programmes
 This excludes Cuba, which has not introduced any vaccines with Gavi support.