The U.S. and Gavi, the Vaccine Alliance
- 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.”1
- 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 August 2019, 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 ($2.2 billion out of $18 billion).
- U.S. contributions to Gavi have grown almost every year since 2001, reaching a high of $290 million in FY 2018 and FY 2019.
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.”2 Created in 1999, Gavi was formally launched in January 2000.
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.3
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.4 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); 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.
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.5 A subset of Board members also comprise the Executive Committee, which can meet to decide on time-sensitive matters between Board sessions.6 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 a board member for one of the Donor Countries Governments constituency seats; it also holds a seat on the following Board committees: Audit and Finance; Market Sensitive Decisions; and Programme and Policy.
|Table 1: Members of the Gavi Board|
# 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|
|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.
SOURCES: Gavi. “Governing Gavi.” http://www.gavialliance.org/about/governance/.
Through June 2019, the partnership had received almost $18 billion in financing (see Table 2).7 Three-quarters (79%) 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 (21%) 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.8
Gavi marked the mid-point of its current funding cycle with a midterm review meeting in December 2018,9 and officially kicked off its replenishment effort with a launch meeting in August 2019. The replenishment effort aims to generate donor support for Gavi’s next five-year funding period (2021-2025), for which the organization says it will need $7.4 billion.10
|Table 2: Contributions to Gavi, 2000 – June 2019|
in U.S. $ millions
|% of Total
|Donor Government Contributions||10,183.8||56.6|
|Bill & Melinda Gates Foundation||3,739.4||20.8|
|Innovative Financing Mechanisms||3,848.7||21.4|
|International Finance Facility-Immunisation (IFFIm)||2,625.7||14.6|
|Advance Market Commitment (AMC)||1,223.0||6.8|
|NOTES: Reflects total cash received (proceeds), through 30 June 2019.
SOURCE: Gavi. “Cash received by Gavi, proceeds as of 30 June 2019”. https://www.gavi.org/investing/funding/donor-contributions-pledges/cash-receipts/.
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.11
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.12 Six donors support the AMC; in order of commitment amount, they are: Italy, the United Kingdom, Canada, Russia, Norway, and the Gates Foundation.13
Country Eligibility and Support
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. 58 countries are currently eligible;14 these include 24 of the 25 U.S. priority countries for maternal and child health assistance.15
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.16 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.17 Since 2015, fifteen countries have transitioned out of Gavi financial support, with a total of 19 expected by 2020.18
Gavi provides financing to country programs through different types of support. Eligible countries may apply for funding provided through one of Gavi’s several “funding windows”, 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 has also provided country support through emergency response funding, including support for Ebola vaccination in the Democratic Republic of Congo in the context of the Ebola outbreak that began there in 2018.19
Overall, from 2000 through November 2018, Gavi has disbursed over $13 billion in support to 76 low- and middle-income countries through more than ten funding windows (see Table 3). Most Gavi support (79%) has been provided through the new and underused vaccines funding window, followed by health systems strengthening (11%).20
|Table 3: Gavi Country Support, by Type, 2000 – November 2018|
Type of Support
in U.S. $ millions
|New and underused vaccines*||9619.2|
|Health systems strengthening||1508.2|
|Emergency response support||951.9|
|Operational costs for immunization campaigns||541.5|
|Immunization services support||350.3|
|Vaccine introduction grants||180.5|
|Injection safety support||113.4|
|Cold chain equipment optimization platform||50.3|
|Civil society organizations||30.4|
|NOTES: Reflects Gavi-reported disbursements by year paid, from 2000 through November 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.
SOURCES: Gavi. “Disbursements by Country”. http://www.gavi.org/country/all-countries-commitments-and-disbursements/.
According to Gavi, its support has led to improved child health and immunization indicators in countries that have received it. For example, Gavi reports since its inception in 2000, the organization has contributed to the immunization of over 760 million people in supported countries, saving an estimated 13 million lives.21 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).22
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 2001.23 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.
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 2019 (Figure 1).24 The current Administration requested $250 million for FY 2020.25 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.
The U.S. government has made two multi-year pledges of support to Gavi in the past. 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.
A U.S. government representative (from USAID) currently occupies a 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, Market Sensitive Decisions committee, and Programme and Policy Committee.26
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.27 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.28 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 given ongoing fiscal constraints in the U.S. federal budget and in light of the Gavi replenishment effort that kicked off in August 2019 and which will culminate with a donor pledging conference in 2020 to support Gavi’s next five year funding cycle;
- 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 further 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.
Gavi Website, “Gavi’s Mission”. http://www.gavialliance.org/about/mission/.
Gavi Website, “Gavi’s Mission”. http://www.gavialliance.org/about/mission/.
Gavi Website. “Phase IV (2016-2020)”. http://www.gavi.org/About/Strategy/Phase-IV-2016-20/.
Gavi Website. “Seth Berkley”. http://www.gavi.org/about/governance/secretariat/seth-berkley/.
Gavi Website. “Governing Gavi.” http://www.gavialliance.org/about/governance/.
Gavi Website. “Executive committee”. http://www.gavi.org/about/governance/gavi-board/committees/executive-committee/
Gavi Website. “Key figures: donor contributions and pledges”. http://www.gavi.org/funding/donor-contributions-pledges/.
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. September 2011. http://kff.org/global-health-policy/report/innovative-financing-mechanisms-for-global-health-overview/.
Gavi Website. “Gavi Mid-Term Review, Abu Dhabi high level conference, 10-11 December 2018”. https://www.gavi.org/investing/funding/resource-mobilisation-process/gavi-mid-term-review-meeting-december-2018/.
Branswell H. ‘Global vaccine coalition unveils ambitious plan to immunize 300 million children.’ STAT, August 29, 2019. https://www.statnews.com/2019/08/29/gavi-vaccine-alliance-ambitious-plan/.
International Finance Facility for Immunisation Website. “Donors”. http://www.iffim.org/donors/.
Gavi Website. “Pneumococcal AMC”. http://www.gavi.org/funding/pneumococcal-amc/.
Gavi Website. “How the pneumococcal AMC works”. http://www.gavi.org/funding/pneumococcal-amc/how-the-pneumococcal-amc-works/.
Gavi Website. “Countries eligible for support”. http://www.gavi.org/support/sustainability/countries-eligible-for-support/.
USAID. “Maternal and Child Health Priority Countries.” https://www.usaid.gov/global-health/health-areas/maternal-and-child-health/priority-countries.
Gavi Website. “Graduation policy”. http://www.gavi.org/about/governance/programme-policies/eligibility-and-transition/.
Gavi Website. “Transitioning out of Gavi support”. https://www.gavi.org/support/sustainability/transition/.
Gavi Progress Report 2017. https://www.gavi.org/progress-report/.
Gavi Website. “Gavi boosts funding for Ebola outbreak response”. https://www.gavi.org/library/news/press-releases/2019/gavi-boosts-funding-for-ebola-outbreak-response/
KFF analysis of Gavi disbursement data: “Disbursements by Country”. http://www.gavi.org/country/all-countries-commitments-and-disbursements/
Gavi “Facts and figures.’ https://www.gavi.org/about/mission/facts-and-figures/; Branswell H. ‘Global vaccine coalition unveils ambitious plan to immunize 300 million children.’ STAT, August 29, 2019. https://www.statnews.com/2019/08/29/gavi-vaccine-alliance-ambitious-plan/.
Gavi Strategy and Business Plan 2011-2015. http://www.gavi.org/library/gavi-documents/strategy/gavi-alliance-strategy-and-business-plan-2011-2015/.
Congressional Research Service. Health in Developing Countries: The U.S. Response. RL30793, Feb 2001.
U.S. contribution amounts as reported by Gavi “Cash received by Gavi, proceeds as of 30 June 2019”. https://www.gavi.org/investing/funding/donor-contributions-pledges/cash-receipts/; KFF analysis of FY2019 final omnibus spending bill.
KFF analysis of White House FY2020 Budget request. https://www.kff.org/news-summary/white-house-releases-fy20-budget-request/.
Gavi ‘Governing Gavi.’ https://www.gavi.org/about/governance/.
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.
KFF analysis of Gavi recipient countries and USAID maternal and child health priority countries. https://www.usaid.gov/what-we-do/global-health/maternal-and-child-health/priority-countries.