The U.S. Government & Gavi, the Vaccine Alliance

Key Facts

  • Gavi, the Vaccine Alliance (Gavi) is an independent public-private partnership and multilateral funding mechanism that aims to expand global access to and use of vaccines, particularly among vulnerable children. 
  • Since its launch in 2000, Gavi has disbursed over $18 billion to support immunization efforts in low- and middle-income countries, not including funding for COVAX.  
  • 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. Cumulative U.S. contributions through June 30, 2022 comprised 13% of all funding received by Gavi (almost $3.1 billion out of more than $23 billion), and U.S. contributions have grown over time, reaching an annual level of $290 million in recent years. 
  • Additionally, the U.S. is the leading donor to COVAX, a multilateral effort to equitably procure and distribute COVID-19 vaccines globally which is co-led and administered by Gavi; in FY 2021, the U.S. provided $4 billion in emergency funding to COVAX. 
  • Despite past progress in expanding access to childhood vaccinations, there is growing evidence that the COVID-19 pandemic has had a detrimental impact on childhood immunization efforts in many countries, presenting new challenges going forward. 

Gavi Overview

Created in 1999 and formally launched in January 2000, Gavi, the Vaccine Alliance (Gavi) is an independent public-private partnership and multilateral funding mechanism that aims to “save lives and protect people’s health by increasing coverage and equitable and sustainable use of vaccines.”1 Gavi’s main activities include supporting low- and middle-income countries’ access to new and underused vaccines for vulnerable children through financial support, technical expertise, and market-shaping efforts, such as negotiating with manufacturers, to help lower the cost of procuring vaccines. Gavi operates in 5-year funding cycles, with a revised strategy and goals for each cycle. Gavi’s current five-year strategy, for the 2021-2025 period, includes four core goals:2

  1. introduce and scale-up vaccines,
  2. strengthen health systems to increase equity in immunization,
  3. improve sustainability of immunization programs, and
  4. ensure healthy markets for vaccines and related products.

This strategy includes a few key shifts, such as emphasis on reducing the number of ‘zero-dose’ children with a goal of reaching no zero-dose children by 2030,3 prioritizing programmatic and financial sustainability of country immunization programs,4 additional support for countries that have phased out of Gavi support or have never been eligible for Gavi support,5 and providing more tailored approaches for Gavi countries to reach under-vaccinated populations, such as those living in remote or conflict settings, by encouraging countries to adopt strategies that reduce potential barriers to vaccination.6 Additionally, each 5-year strategy is accompanied by an updated vaccine investment strategy, which determines the vaccines that will be made available to countries during the strategy period.7

In addition to Gavi’s role in routine childhood immunizations, Gavi is one of the organizations leading COVAX, a multilateral effort to support the equitable development, procurement, and delivery of COVID-19 vaccines globally that began in April 2020. Gavi’s role in COVAX is to facilitate the procurement and delivery of COVID-19 vaccines, with particular emphasis on low- and middle-income countries.8 As of January 2023, COVAX reports that it has shipped over 1.8 billion COVID-19 vaccine doses to 146 countries.9 During its December 2022 meeting, the Gavi Board agreed to explore the possibility of transitioning their COVID-19 vaccination efforts away from an emergency program and into their core programming.10

Organization

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.11 Gavi does not have program offices or staff based in recipient countries but rather relies on country health ministries and World Health Organization (WHO) regional offices to implement programs.12 Gavi is led by a Chief Executive Officer (CEO), currently Seth Berkley.13

The 28-member Gavi Board sets Gavi’s funding policies and strategic direction and monitors program implementation.14 It includes representation from a broad set of public and private stakeholders: donor governments, implementing countries, multilateral and institutional entities (including WHO, the United Nations Children’s Fund (UNICEF), the World Bank, and the Bill & Melinda Gates Foundation), civil society groups, the vaccine industry in industrialized and developing countries, independent private individuals with expertise in critical areas (such as investment, auditing, and fundraising), and, in a non-voting seat, the CEO of Gavi.15 Additionally, several Board committees 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 one of the Donor Countries Governments constituency seats16 and has a seat on the Audit and Finance Committee and the Market-Sensitive Decisions Committee.17

Funding

From its launch through June 30, 2022, Gavi received more than $23 billion in financing, not including funding for COVAX (see Table 1).18 More than 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 were the United Kingdom, the U.S., and Norway, while the largest private donor (and largest donor overall) was the Gates Foundation. The remainder (23%) of Gavi’s funding came from the proceeds of two unique innovative financing mechanisms – the International Finance Facility-Immunisation (IFFIm) and the Pneumococcal Advance Market Commitment (AMC). The IFFIm was created in 2006 and uses donor funding commitments to back the issuance of special bonds in capital markets, essentially providing “up-front” financing to Gavi. The AMC began in 2010 and supports accelerated access to pneumococcal vaccines through up-front funding commitments from donors. The U.S. does not support either of these mechanisms, due to restrictions on making commitments to multi-year appropriations.19

Table 1: Funding Received by Gavi, 2000 – 2022 (not including COVAX)
Funding Source Funding
in U.S. $ millions
% of Total
Funding
TOTAL 23,749 100.0
Donor Government Contributions 13,388 56.4
   United Kingdom 3,281 13.8
   United States 3,070 12.9
   Norway 2,143 9.0
   Germany 1,100 4.6
   Canada 828 3.5
   Sweden 633 2.7
   Netherlands 598 2.5
   Others 1,736 73
Private Contributions 4,862 20.5
   Bill & Melinda Gates Foundation 4,602 19.4
   Others 260 1.1
Innovative Financing Mechanisms 5,500 23.2
   International Finance Facility-Immunisation (IFFIm) 41,87 17.6
   Pneumococcal Advance Market Commitment (AMC) 1,313 5.5
NOTES: Reflects total cash received (proceeds), as of 30 June 2022. Does not include contributions to the COVAX AMC. Totals may not sum due to rounding.
SOURCE:  Gavi, “Cash Receipts 30 June 2022,” https://www.gavi.org/news-resources/document-library/cash-receipts.

In addition to financing Gavi’s regular activities, donors have pledged additional resources to support the Gavi COVAX Advance Market Commitment (COVAX AMC), a financial mechanism within COVAX that supports low- and middle-income countries through procurement and distribution of COVID-19 vaccines; to date, donor governments and private philanthropy have pledged $12.4 billion to the COVAX AMC for vaccine procurement, delivery, and logistics.20

Country Eligibility and Support

Eligibility

Only low- and middle-income countries with a Gross National Income (GNI) per capita below or equal to $1,730 on average over the last three years are eligible for Gavi support.21 In 2022, 54 countries were eligible for Gavi support;22 these included 23 of the 25 U.S. priority countries for maternal and child health assistance.23

Recipient countries’ governments are expected to share responsibility for funding their national immunization efforts through Gavi’s co-financing requirements (introduced in 2008), determined according to country income level and transition status. As countries develop economically, they are expected to contribute a greater share of the funding required for immunization programs.24 Countries below the threshold (average of $1,730 GNI per capita over the past three years) and classified as low-income by the World Bank are initial self-financing countries, while countries below the threshold and classified as lower-middle income by the World Bank are in preparatory transition.25 Initial self-financing countries are responsible for co-financing the equivalent of $0.20 per dose each year. Countries in preparatory transition gradually increase their co-financing contribution each year.26 When a country’s income rises above the GNI per capita threshold, 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.27 As of 2022, 19 countries have transitioned out of Gavi financial support.28

Additionally, as part of its 2021-2025 strategy, the Gavi Board approved limited support for countries that have transitioned out of Gavi eligibility and for middle-income countries that have never been eligible for Gavi support.29 Recognizing that many formerly and never Gavi-eligible countries experience low coverage rates and have yet to make key vaccine introductions,30 an initial investment of $281 million is expected to provide limited support for 19 former and 26 never Gavi-eligible countries for political advocacy related to immunization, technical assistance, and targeted assistance to reach under-vaccinated communities and, in the long-term, to support an innovative financing facility for procurement.31 As of July 2022, four former Gavi-eligible countries have been selected to apply for support to help mitigate declining vaccine coverage rates: Angola, Bolivia, Honduras, and Indonesia.32

Separate from Gavi’s regular activities, countries that meet eligibility requirements can participate in the COVAX AMC, which helps to support countries in the procurement and delivery of COVID-19 vaccines. To be eligible to participate, countries must have been classified as low-income or lower-middle income according to the World Bank,33 or be eligible for support from the International Development Association (IDA).34 Countries that do not meet these requirements can still participate in COVAX, however as fully self-financing participants.35

Country Support

Gavi provides financing to country programs through different types of support. Eligible countries may request Gavi support in the following main areas:

  • Vaccine support (including support for vaccine introduction, targeted campaigns, and routine campaigns),
  • Health systems strengthening support (including improving countries’ data systems, supply chains, and community engagement, among other priority areas),
  • Cold Chain Equipment Optimization Platform (CCEOP) support (support for purchasing and deploying modern cold chain technology),
  • Equity Accelerator Fund (EAF) support (support for reaching zero-dose children and missed communities), and
  • Targeted country assistance (support for country-specific needs to improve vaccine introductions and routine campaigns, through the work of partner organizations such as WHO, UNICEF, U.S. Centers for Disease Control and Prevention, and the World Bank).36

Each support type, excluding vaccine support, has accompanying funding ceilings representing the maximum available funding each country can apply for during the 2021-2025 period. These ceilings are formulated based on a country’s number of zero-dose children, under-immunized children, birth cohort, and GNI per capita.

Additionally, Gavi has provided country support through emergency response funding, including: support for Ebola vaccination,37 allowing for up to $200 million in reprogrammed Gavi support for COVID-19 response in Gavi-eligible countries,38 and other support for the COVID-19 response including the creation of COVAX (to help expand access to COVID-19 vaccines in lower-income countries) and the COVID-19 Vaccine Delivery Partnership (CoVDP, which aims to improve COVID-19 vaccine coverage in COVAX AMC-eligible countries, with a particular emphasis on countries that were below 10% coverage in January 2022).39 CoVDP is set to phase out its operations in June 2023 as the partnership was not set up to be a permanent structure.40

Since its launch in 2000, Gavi has disbursed over $18 billion to support country immunization programs (not including funding for COVAX).41,42 Over the past three years, 2019-2022, more than $7.4 billion has been disbursed, most of which has been for vaccine support (62%), followed by health systems strengthening (14%) (see Table 2). 43

Table 2: Gavi Country Support (Disbursements), by Type, 2019 – 2022
Type of Support Funding
in U.S. $ millions
TOTAL 7,401.9
Vaccine support* 4.563.9
Health systems strengthening 1,070.7
Operational costs for immunization campaigns 420.2
Partners’ Engagement Framework (PEF)** 739.5
Other programs 607.6
NOTES: Reflects Gavi-reported disbursements by year paid in 2019-2022.
* Vaccine support includes: COVID-19 vaccines, Ebola vaccine, human papillomavirus virus (HPV) vaccine, inactivated polio virus (IPV) vaccine, Japanese encephalitis vaccine, malaria vaccine, measles-rubella vaccine, meningococcal A vaccine, oral cholera vaccine, pentavalent vaccine, pneumococcal conjugate vaccine, rotavirus vaccine, typhoid conjugate vaccine, tetanus-diphtheria vaccine, yellow fever vaccine, and others.44 Vaccine support also includes support for injection safety devices and co-financing waivers.
** The partners’ engagement framework (PEF) allows Gavi to provide funding to partners to support priority countries’ immunization programs by clarifying the role of each partner and enforcing accountability. Foundational support under this framework is long-term funding to eligible partners (WHO, UNICEF, the World Bank, the Centers for Disease Control (CDC), and the Civil Society Organization (CSO) Constituency) to support staff working at global and regional levels.45 Programs included under the PEF include targeted country assistance46 and strategic focus areas.47
*** Other programs include the Cold Chain Equipment Optimization Platform (CCEOP), the Equity Accelerator Fund (EAF), among others.Totals may not sum due to rounding. COVAX funding not included.
SOURCES: KFF analysis of data provided by Gavi on disbursements by program area and year. KFF personal communication with Gavi, Feb. 10, 2023.

Results48

According to Gavi, its support has led to improved child health and immunization indicators in countries that have received it, and coverage rates for certain vaccines are generally high in Gavi countries. For example, one estimate of the average vaccine coverage across the multiple key Gavi-supported vaccines, including the human papillomavirus (HPV) vaccine, inactivated polio vaccine, and pentavalent vaccine, among others, was 51% in 2021, up from 47% in 2019.49 Gavi also reports that since its inception in 2000, the organization has contributed to the immunization of over 981 million children in supported countries, saving more than 16 million lives. Additionally, Gavi reports that its influence in vaccine market shaping has helped lower the cost of the pentavalent vaccine (the vaccine providing protection against diphtheria, tetanus, pertussis, hepatitis B, and Hib) from a weighted average price per dose of $1.68 in 2015 to $0.86 in 2020.50

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 2001.51 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 a high of $290 million in recent years (Figure 1). The current administration has requested level funding for the U.S. contribution to Gavi in FY 2023.52 Congress provides funding for U.S. contributions to Gavi through the Global Health Programs account at the U.S. Agency for International Development (USAID), specifically within the maternal and child health budget line.

Additionally, in response to the COVID-19 pandemic, the U.S. has provided $4 billion in FY 2021 emergency funding to Gavi COVID-19 vaccine procurement and delivery support under COVAX,53 making the U.S. the largest donor to COVAX in terms of total amounts pledged for vaccine procurement (32%, or $4 billion, of $12.4 billion total to date).54 The U.S. is also the largest donor of delivered COVID-19 vaccine doses;55 see the KFF tracker for the latest information on U.S. international COVID-19 vaccine donations.

Governance Activities

A U.S. government representative (from USAID) occupies an alternate seat on the Gavi Board that represents the donor countries governments constituency’s U.S./Australia/Japan/Republic of Korea group. The U.S. government is also represented on the Gavi Board’s Audit and Finance Committee and Market Sensitive Decisions 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.56

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.57 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 maternal and child health (MCH) efforts, also receive support from Gavi.58 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 helping global immunization delivery programs and improving child health in developing countries. As the pandemic continues, its impact on ongoing immunization efforts, including those supported by Gavi, remains a concern. Key policy issues for U.S. engagement with Gavi going forward include:

  • Future of COVAX and global COVID-19 Vaccine Access. The Access to COVID-19 Tools and Accelerator (ACT-A), for which COVAX is the leading entity of its vaccines pillar, recently announced that it will transition its COVID-19 work, with a focus on long-term control.59 According to the transition plan, COVAX will continue its work on various activities, including research and development, procurement, operations, delivery support, and others, with some of these efforts operating at reduced levels, transitioning into partner processes (i.e., being absorbed into Gavi’s or another partner’s standard programs), or moving to standby status in case of need for reactivation. Additionally, a recent proposal by the Gavi board could phase out COVAX and incorporate COVID-19 vaccination into Gavi’s existing immunization efforts.60 However, despite these developments, there is still a gap in reaching global populations with COVID-19 vaccines, including both the primary series and boosters, especially variant-targeting boosters.61 Questions remain around how the U.S. will support the global COVID-19 response going forward, including whether the U.S. will provide additional contributions to COVAX and/or Gavi for pandemic response, and the extent to which the U.S. will engage with and shape the process of COVAX transition.
  • Addressing pandemic-related disruptions in routine immunization programs. Despite past progress in expanding access to childhood vaccinations, there is growing evidence that the COVID-19 pandemic has had a detrimental impact on such efforts in many countries. Mitigating and reversing this impact presents a significant challenge going forward.
  • Possible future growth in Gavi’s funding requirements. Gavi’s strategic plan calls for furthering vaccine coverage and expanding the number of vaccines in its portfolio – including the new RTS,S malaria vaccine, which is being made available to Gavi-eligible countries in sub-Saharan Africa62 – while addressing further vaccine deployment for outbreaks such as Ebola, including supporting vaccine trials for strains with no licensed vaccine currently available. Additionally, Gavi has recently released a plan to support the diversification of regional manufacturers, with a particular emphasis on increasing manufacturing capacity in Africa.63 This plan includes a potential financing mechanism, similar to the COVAX AMC, that would help mitigate the high costs of market entry for manufacturers. Supporting these efforts to expand vaccine coverage and regional manufacturing will require additional resources, raising questions about whether and how much the U.S. might consider increasing its core contributions to the organization in future years.
Endnotes
  1. Gavi, “About our Alliance,” webpage, https://www.gavi.org/our-alliance/about.

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  2. Gavi, “Gavi, the Vaccine Alliance strategy 2021-2025,” undated, https://www.gavi.org/sites/default/files/board/minutes/2019/Gavi%20strategy%202021-2025%20one-pager.pdf; Gavi, “Gavi’s strategy,” webpage, https://www.gavi.org/our-alliance/strategy.

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  3. Gavi, “Gavi’s strategy,” webpage, https://www.gavi.org/our-alliance/strategy; Gavi, “Gavi 5.0: The Alliance’s 2021-25 Strategy,” Report to the Board, June 2019, https://www.gavi.org/sites/default/files/board/minutes/2019/06%20-%20Gavi%205.0_The%20Alliances%202021-2025%20Strategy.pdf.; Gavi, “Reaching Zero-dose Children,” webpage, updated Nov. 4, 2021, https://www.gavi.org/our-alliance/strategy/phase-5-2021-2025/equity-goal/zero-dose-children-missed-communities.

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  4. Gavi, “Gavi’s strategy,” webpage, https://www.gavi.org/our-alliance/strategy; Gavi, “Gavi 5.0: The Alliance’s 2021-25 Strategy,” Report to the Board, June 2019, https://www.gavi.org/sites/default/files/board/minutes/2019/06%20-%20Gavi%205.0_The%20Alliances%202021-2025%20Strategy.pdf

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  5. Gavi, “Gavi 5.0: The Alliance’s 2021-25 Strategy,” Report to the Board, June 2019, https://www.gavi.org/sites/default/files/board/minutes/2019/06%20-%20Gavi%205.0_The%20Alliances%202021-2025%20Strategy.pdf.

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  6. Gavi, “Prevent, Protect, Prosper: The Gavi Investment Opportunity 2021-2025,” Replenishment Launch presentation, Aug. 30, 2019, https://www.slideshare.net/Gavi-Vaccine-Alliance/the-gavi-investment-opportunity-20212025.

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  7. Gavi, “History of Vaccine Investment Strategy,” webpage, https://www.gavi.org/our-alliance/strategy/history-of-vaccine-investment-strategy.

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  8. WHO, “What is the ACT-Accelerator?,” webpage, https://www.who.int/initiatives/act-accelerator/about.

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  9. UNICEF, “COVID-19 Market Dashboard,” https://www.unicef.org/supply/covid-19-market-dashboard. Accessed 17 January 2023.

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  10. Gavi, “Review of Decisions, Board Meeting 7-8 December 2022, Geneva, Switzerland,” https://www.gavi.org/sites/default/files/board/minutes/2022/7-8-dec/Board-2022-Mtg-03-Review-of-Decisions.pdf. Accessed 17 January 2023.

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  11. Gavi, “Gavi Secretariat,” webpage, https://www.gavi.org/operating-model/gavi-secretariat.

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  12. Gavi, “Operating model,” webpage, https://www.gavi.org/our-alliance/operating-model.

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  13. Gavi, “Dr. Seth Berkley, Gavi CEO,” webpage, https://www.gavi.org/operating-model/gavi-secretariat/seth-berkley.

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  14. Gavi, “Gavi, the Vaccine Alliance Board,” webpage, https://www.gavi.org/our-alliance/governance/gavi-board.

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  15. Gavi, “Board composition,” webpage, https://www.gavi.org/governance/gavi-board/composition.

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  16. Gavi, “Board members,” webpage, https://www.gavi.org/governance/gavi-board/members.

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  17. Gavi, “Audit and Finance Committee,” webpage, https://www.gavi.org/governance/gavi-board/committees/audit-finance-committee; Gavi, “Market Sensitive Decisions Committee,” webpage, https://www.gavi.org/governance/gavi-board/committees/market-sensitive-decisions-committee.

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  18. Gavi, “Cash Receipts 30 June 2022,” https://www.gavi.org/news-resources/document-library/cash-receipts.

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  19. For further information about restrictions on U.S. support for these innovative financing mechanisms, see KFF, Innovative Financing Mechanisms for Global Health: Overview and Considerations for U.S. Government Participation, Sept. 2011.

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  20. In addition to direct contributions provided to the COVAX AMC by donor governments and private donors, funds have been made available to the COVAX AMC through the IFFIm and unallocated Pneumococcal AMC funds. Gavi, “COVAX AMC Donors Table,” Nov. 9, 2021, https://www.gavi.org/sites/default/files/covid/covax/COVAX-AMC-Donors-Table.pdf.

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  21. Gavi support types include health system strengthening, vaccine, cold chain, and targeted country assistance. Gavi, “Eligibility,” webpage, https://www.gavi.org/types-support/sustainability/eligibility.

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  22. Gavi, “Eligibility,” webpage, https://www.gavi.org/types-support/sustainability/eligibility.

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  23. USAID, “Priority Countries,” webpage, https://www.usaid.gov/global-health/health-areas/maternal-and-child-health/priority-countries.

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  24. Gavi, “Gavi, the Vaccine Alliance, Co-Financing Policy Version 2.0,” https://www.gavi.org/sites/default/files/document/gavi-co-financing-policypdf.pdf.

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  25. Gavi, “Eligibility and transition policy,” webpage, https://www.gavi.org/programmes-impact/programmatic-policies/eligibility-and-transitioning-policy.

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  26. Countries in the first year of the preparatory transition phase co-finance the equivalent of $0.20 per dose, the same as initial self-financing countries. For each subsequent year, countries in preparatory transition co-finance a 15% increase of the total fraction paid in the prior year. The preparatory transition phase does have a set duration amount. Gavi, “Gavi Application Process Guidelines,” Nov. 2022, https://www.gavi.org/sites/default/files/support/ApplicationProcess_Guidelines.pdf.

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  27. Countries in the first year of the accelerated transition phase co-finance the equivalent of the prior year’s total fraction plus 15%, the same as countries in preparatory transition. For each year after, the amount per dose increases linearly until the country is fully financing each vaccine after the fifth year and end of Gavi support. Gavi, “Gavi Application Process Guidelines,” Nov. 2022, https://www.gavi.org/sites/default/files/support/ApplicationProcess_Guidelines.pdf.

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  28. Gavi, “Eligibility,” webpage, https://www.gavi.org/types-support/sustainability/eligibility.

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  29. This would include countries with GNI per capita below $4,000, as well as upper-middle income countries, as defined by the World Bank. Gavi, “Gavi’s approach to engagement with former and never-eligible Middle Income Countries (MICs),” Board presentation, Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20MICs%20-%20Presentation.pdf.

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  30. Center for Global Development (CGD), “New Gavi Modalities for a Changing World,” June 24, 2019, https://www.cgdev.org/publication/new-gavi-modalities-changing-world.

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  31. Gavi, “Gavi’s approach to engagement with former and never-eligible Middle Income Countries (MICs),” Board presentation, Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20MICs%20-%20Presentation.pdf; Gavi, “GAVI’S APPROACH TO ENGAGEMENT WITH FORMER AND NEVER-ELIGIBLE MIDDLE-INCOME COUNTRIES (MICS),” Report to the Board, Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20Gavi%27s%20approach%20to%20engagement%20with%20former%20and%20never-eligible%20MICs.pdf.; Gavi, “Annex C: Summary of support proposed under the MICs Approach,” Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20Annex%20C%20-%20Summary%20of%20support%20proposed%20under%20the%20MICs%20Approach.pdf; Gavi, “Annex B: Paragraphs referenced in decision points for the MICs Approach,” Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20Annex%20B%20-%20Paragraphs%20referenced%20in%20decision%20points%20for%20the%20MICs.pdf; Gavi, “List of countries and economies eligible for support under the MICs Approach as of 1 July 2022.” https://www.gavi.org/sites/default/files/programmes-impact/support/Countries-and-economies-eligible-for-support-under-Gavi-MICs-Approach.pdf.

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  32. Gavi, “Gavi’s approach to engaging with middle-income countries,” webpage, https://www.gavi.org/types-support/sustainability/gavi-mics-approach.

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  33. The World Bank, “World Bank Country and Lending Groups,” webpage, https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.

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  34. IDA is “the part of the World Bank that helps the world’s poorest countries. Established in 1960, IDA aims to reduce poverty by providing zero to low-interest loans (called ‘credits’) and grants for programs that boost economic growth, reduce inequalities, and improve people’s living conditions.” IDA, “What Is IDA?,” webpage, https://ida.worldbank.org/en/about. According to IDA, “eligibility for IDA support depends first and foremost on a country’s relative poverty, defined as GNI per capita below an established threshold and updated annually. IDA also supports some countries, including several small island economies, that are above the operational cutoff but lack the creditworthiness needed to borrow from” the World Bank’s the International Bank for Reconstruction and Development (IBRD). IDA, “Borrowing Countries,” webpage, https://ida.worldbank.org/en/about/borrowing-countries.

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  35. KFF, COVAX and the United States, Feb. 18, 2021.

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  36. Gavi, “Gavi Application Process Guidelines,” Nov. 2022, https://www.gavi.org/sites/default/files/support/ApplicationProcess_Guidelines.pdf.

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  37. Gavi, “500,000 doses of Ebola vaccine to be made available to countries for outbreak response,” webpage, https://www.gavi.org/news/media-room/500000-doses-ebola-vaccine-be-made-available-countries-outbreak-response.

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  38. Gavi, “Responding to COVID-19,” webpage, https://www.gavi.org/covid19.

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  39. WHO, “COVID-19 Vaccine Delivery Partnership,” webpage, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/covid-19-vaccine-delivery-partnership.

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  40. Devex, “Exclusive: A COVID-19 initiative for vaccine delivery is winding down,” 11 January 2023, https://www.devex.com/news/exclusive-a-covid-19-initiative-for-vaccine-delivery-is-winding-down-104724.

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  41. Gavi, “Annual Progress Report 2021,” https://www.gavi.org/sites/default/files/programmes-impact/our-impact/apr/Gavi-Progress-Report-2021.pdf; International Aid Transparency Initiative, “d-portal,” Accessed 28 Feb. 28, 2023, https://d-portal.org/.

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  42. COVAX funding not included.

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  43. KFF analysis of data provided by Gavi on disbursements by program area and year. KFF personal communication with Gavi, Feb. 10, 2023.

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  44. Gavi, “Vaccine support,” webpage, https://www.gavi.org/programmes-impact/types-support/vaccine-support.

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  45. Gavi, “Partners’ engagement framework,” webpage, https://www.gavi.org/programmes-impact/types-support/pef; Gavi, “Foundational support,” webpage, https://www.gavi.org/types-support/pef/foundational-support.

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  46. Gavi, “Targeted country assistance,” webpage, https://www.gavi.org/types-support/pef/targeted-country-assistance.

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  47. Gavi, “Strategic focus areas,” webpage, https://www.gavi.org/types-support/pef/strategic-focus-areas.

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  48. Gavi, “Our impact,” webpage, https://www.gavi.org/programmes-impact/our-impact; Gavi, “About our alliance,” webpage, https://www.gavi.org/our-alliance/about.

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  49. Breadth of protection is a measure of the average vaccine coverage across the following key Gavi-supported vaccines: last dose of human papillomavirus (HPV) vaccine, second dose of inactivated polio vaccine, third dose of pentavalent vaccine, third dose of pneumococcal conjugate vaccine, first dose of rubella-containing vaccine, last dose of the RotavirusC vaccine, second dose of measles-containing vaccine, yellow fever, meningococcal A, and Japanese encephalitis. Gavi, “Annual Progress Report 2021,” https://www.gavi.org/sites/default/files/programmes-impact/our-impact/apr/Gavi-Progress-Report-2021.pdf.

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  50. Gavi, “Facts and figures,” webpage, https://www.gavi.org/programmes-impact/our-impact/facts-and-figures.

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  51. Congressional Research Service (CRS), Health in Developing Countries: The U.S. Response, RL30793, Feb. 27, 2001, https://www.everycrsreport.com/files/20010227_RL30793_d6a2932fbec1fd24ee44c9af96185d1dbbf2e79e.pdf.

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  52. KFF, White House Releases Full FY 2023 Budget Request, March 29, 2022.

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  53. KFF, Global Funding Across U.S. COVID-19 Supplemental Funding Bills.

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  54. The U.S. announced it would donate 500 million Pfizer doses to COVAX at the G7 Summit in June 2021. However, a portion of these doses were purchased using funds appropriated to Gavi ($2 billion for 300 million Pfizer doses), while the remaining 200 million doses were purchased using $1.5 billion in other emergency funds from the American Rescue Plan Act. To avoid double-counting, Gavi counts the U.S. funding that was contributed to Gavi under its COVAX funding contributions, with only 200 million of the doses – those purchased directly by the U.S. – counted as COVAX vaccine dose donations. KFF personal communication with Gavi, Nov. 12, 2021; White House, “FACT SHEET: President Biden Announces Historic Vaccine Donation: Half a Billion Pfizer Vaccines to the World’s Lowest-Income Nations,” June 10, 2021; Gavi, “COVAX AMC Donors Table,” Apr. 7, 2022, https://www.gavi.org/sites/default/files/covid/covax/COVAX-AMC-Donors-Table.pdf; USAID, “USAID’s COVID-19 Response: Ending The Global Pandemic and Building Back Better,” Oct. 2021,  https://www.usaid.gov/sites/default/files/documents/USAID_COVID_Response_Fact_Sheet_Oct_2021_FINAL.pdf. See also KFF, U.S. International COVID-19 Vaccine Donations Tracker.

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  55. UNICEF, “COVID-19 Market Dashboard,” Accessed Nov. 15, 2022, https://www.unicef.org/supply/covid-19-market-dashboard.

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  56. CRS, Global Vaccination: Trends and the U.S. Role, R45975, Oct. 18, 2019, https://sgp.fas.org/crs/row/R45975.pdf; Center for Strategic & International Studies (CSIS), Sustaining U.S. Support for Gavi: A Critical Global Health Security and Development Partner, Feb. 24, 2020, https://www.csis.org/analysis/sustaining-us-support-gavi-critical-global-health-security-and-development-partner.

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  57. Richard Murray Trostle & Angela K Shen, “Three decades of USAID investments in immunization through the child survival revolution,” In Emerging Microbes & Infections, 3:1, 1-9, DOI: 10.1038/emi.2014.13, published online Feb. 26, 2014.

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  58. These included 23 of the 25 U.S. priority countries for maternal and child health assistance. KFF analysis of Gavi recipient countries and USAID maternal and child health priority countries. Gavi, “Eligibility,” webpage, https://www.gavi.org/types-support/sustainability/eligibility; USAID, “Priority Countries,” webpage, https://www.usaid.gov/global-health/health-areas/maternal-and-child-health/priority-countries.

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  59. WHO, “ACT-Accelerator Transition Plan (1 Oct 2022 to 31 Mar 2023),” https://www.who.int/publications/m/item/act-accelerator-transition-plan-(1-oct-2022-to-31-mar-2023).

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  60. Under this proposal, Gavi would end COVID-19 vaccine support for 37 middle-income countries, however, one-time funding would be provided to these countries to set up national COVID-19 vaccination programs. The 54 Gavi-eligible countries would still qualify for COVID-19 vaccine support through free COVID-19 vaccine doses and subsidized delivery support. The New York Times, “Global Partners May End Broad Covid Vaccination Effort in Developing Countries,” December 6, 2022, https://www.nytimes.com/2022/12/06/health/covid-vaccines-covax-gavi.html; The Washington Post, “Organization leading Covax could end the vaccine-sharing initiative,” December 7, 2022, https://www.washingtonpost.com/world/2022/12/07/gavi-covax-phase-out-coronavirus/.

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  61. Gavi, “Gavi, Moderna update COVAX supply agreement; agree on access to variant-containing vaccines for lower-income countries,” https://www.gavi.org/news/media-room/gavi-moderna-update-covax-supply-agreement-agree-access-variant-containing-vaccines.

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  62. For example, Gavi helped pilot the RTS,S malaria vaccine in several countries (see: https://www.gavi.org/news/media-room/partnership-welcomes-launch-first-malaria-vaccine-pilot) and could be involved in introduction and scaling up of other updated vaccine formulations and/or new combination vaccines. See also WHO, “WHO recommends groundbreaking malaria vaccine for children at risk - Historic RTS,S/AS01 recommendation can reinvigorate the fhight against malaria,” news release, Oct. 6, 2021, https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk; Gavi, “Gavi Board approves funding to support malaria vaccine roll-out in sub-Saharan Africa,” news release, Dec. 2, 2021, https://www.gavi.org/news/media-room/gavi-board-approves-funding-support-malaria-vaccine-roll-out-sub-saharan-africa.

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  63. Gavi, “Gavi sets course to support sustainable vaccine manufacturing in Africa with new action plan in support of African Union’s 2040 vision,” https://www.gavi.org/news/media-room/gavi-sets-course-support-sustainable-vaccine-manufacturing-africa-new-action-plan.

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