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What are the main lessons that Gavi
learnt from its 2011–2015 strategy?
Seth: Much of this last period was about tackling the two largest killers of children, pneumonia and diarrhoea.
Between 2011 and 2015 we took vaccines that protect against each of these diseases to scale, exceeding our target number of launches. One or more of pneumococcal, rotavirus and pentavalent vaccines were added to routine schedules in 14 more countries than expected. Particularly encouraging was the 2015 completion of India’s national roll-out of pentavalent vaccine.
In addition, access to routine immunisation in Gavi-supported countries has been boosted, thanks largely to our market shaping activities. The average weighted cost of immunising a child with pentavalent, pneumococcal and rotavirus vaccines has fallen by 43% since the beginning of
the strategic period. Indeed, it is now possible to fully immunise a child with all vaccines
by WHO for the same
price it once cost for just these three. That’s amazing progress.
What can we take from this as we move from Gavi 3.0 to Gavi 4.0?
Seth: While we did well on launches, we didn’t get the coverage we were hoping for. This was partly the result of delays in getting started, but also because of the challenges posed by reaching children in high-risk areas. Too many are still missing out.
That is not to say that we didn’t make progress; we now have the highest immunisation coverage in history. But if we are to reach the fifth child, we really need to focus on both coverage and equity, in particular by continuing to build on health systems as the base of the primary health pyramid. That is what Gavi 4.0 is all about.
What does this mean for the future and the
challenges that lie ahead?
Seth: A key part of what the Vaccine Alliance has been doing, by helping countries strengthen their immunisation programmes, is boosting capacity. This is enabling health systems to handle more complex vaccines, such as inactivated poliovirus vaccine (IPV)
and meningitis vaccines, and it also makes systems better able to respond to disease outbreaks. This kind of preparedness is likely
to become increasingly more important and relevant to Gavi as climate change, increases in urbanisation and population density, and the growing problem of drug resistance shift the behaviour
of infectious disease and challenge our ability to prevent it.
During the 2011–2015 strategic period, there has already been much more engagement than expected
in relation to outbreaks, notably with Ebola, but also cholera, measles and yellow fever. Lessons learnt from the innovative financing mechanisms that Gavi has used
in the past have been applied to drive innovation with Ebola vaccines. Building higher vaccine coverage will also play an important role in outbreak preparedness, both by preventing disease and ensuring the systems are in place to react quickly. This is why our Board approved a new measles
strategy in 2015, which puts strengthening routine immunisation at the centre of a more comprehensive approach to tackling this highly infectious disease. Strong systems and high routine coverage will become increasingly
important in the face of growing global health security threats.
How important is strong political leadership to Gavi’s long-term success?
Ngozi: Children are the lifeblood of every country and
so protecting their health needs to be a priority for all governments. Health ministers already know this, but moving forward, Gavi’s challenge is to engage other political leaders, such as finance ministers, to convince them to make prevention of childhood disease a national priority.
To ensure there is sustainable funding for immunisation, there must be a line item for vaccines in every national budget. As a former finance minister I know that we can do this by making the case for the economic merits of immunisation. We must explain that vaccines
are not just affordable but an investment, returning US$ 16 in immediate healthcare savings for every dollar spent on them. By making this case and explaining the role vaccines have to play in helping governments reach their economic and development targets, we can put immunisation on every country’s agenda.
What signs are there that countries are taking ownership of their immunisation programmes?
Ngozi: All countries ultimately want to be able to support themselves, and Gavi’s innovative model is unique in making this possible – it is one of the reasons why I
was drawn to it. In 2015, our business model proved its value as four countries transitioned entirely out of Gavi support. With close to 20 other countries set to follow
in the next five years, this marks a new phase in the
history of the Vaccine Alliance – and there are lots of
signs that countries are ready to take ownership of their immunisation programmes.
Over the last five years, we have seen 14 countries take on the funding of at least one of their Gavi-supported programmes. In addition, countries are contributing more towards their vaccine programmes, delivering 47% more in co-financing by the end of the 2011–2015 strategic period than was projected in 2010.
What do these changes mean for the Gavi model in the long term?
Ngozi: It means that Gavi will be working itself out of a job in many countries as they take over the management of their vaccine programmes in a sustainable manner. This will enable Gavi to concentrate on the remaining fragile states, which, by their very nature, pose even greater challenges.
As we move forward, we will also see an increasingly country-centric approach. The introduction of the partners’ engagement framework (PEF), which encompasses our core partners, including WHO and UNICEF, will ensure that our support is more suited to
the needs of individual countries through a Gavi-funded permanent country presence.
Drawing on the individual strengths of its members, Gavi pools country demand, guarantees long-term, predictable funding and brings down prices, helping to ensure that generations of children in poor countries do not miss out on life-saving vaccines.
The vaccine goal: Accelerate the uptake and use of underused and new vaccines by strengthening country decision-making and introduction
The health systems goal: Contribute to strengthening the capacity of integrated health systems to deliver immunisation
The financing goal: Increase the predictability of global financing and improve the sustainability of national financing for immunisation
The market shaping goal: Ensure appropriate and affordable vaccines for developing countries
See graphic in more detail in the full report
Our third strategic period came to an end in December 2015. Check each graph and its analysis to see how we have performed against our three mission goals.
Read more in the full report →
Average child mortality in Gavi-supported countries fell from 76 to a projected 63 deaths per 1,000 live births between 2010 and 2015, an unprecedented rate of reduction of 3.6% per year. The acceleration in the number of new vaccine introductions in recent years, as well as the increased coverage with existing vaccines, has contributed to the substantial reduction in under-five mortality rates.
In Gavi-eligible countries (per 1,000 live births)
Sources: The United Nations Inter-agency Group for Child Mortality Estimation, United Nations Population Division; World Population Prospects
By helping countries to avert more than 4 million future deaths between the start of 2011 and the end of 2015, Gavi exceeded its target of 3.9 million for the five-year period. In addition, Gavi-funded measles vaccine campaigns conducted between 2013 and 2015 are estimated to have averted more than 300,000 future deaths. Since Gavi was set up in 2000, we have contributed to averting more than 8 million future deaths in developing countries.
Source: Joint impact modelling by Gavi, the Vaccine Alliance and the Bill & Melinda Gates Foundation
By the end of 2015, 277 million children had been immunised with Gavi-supported vaccines relative to the end of 2010. This means that the Vaccine Alliance surpassed its target of immunising an additional 243 million children during the 2011–2015 period across all our routine vaccine programmes. Since our inception in 2000, we have supported countries in immunising close to 580 million children.
Source: WHO/UNICEF Estimates of National Immunization Coverage, United Nations Population Division; World Population Prospects
We completed the 2011–2015 period by surpassing our targets for country introductions of pentavalent, pneumococcal and rotavirus vaccines. However, coverage rates for all three vaccines fell short of our goals. These are expected to catch up in the coming years as the most populated developing countries plan to introduce one or both of pneumococcal and rotavirus vaccines. Most encouragingly, India, which accounts for almost one third of Gavi’s birth cohort, completed its nationwide introduction of pentavalent vaccine in 2015.
By supporting more than 200 vaccine introductions in five years, we have helped countries boost their ability to deliver more vaccines. Gavi provides support for almost all the vaccines universally recommended by WHO in the first two years of a child’s life, as well as HPV vaccine which is delivered in adolescence.
At the start of the strategic period, we were funding an average of one vaccine programme in each Gavi- supported country; five years later, this figure has almost quadrupled.
In 2015, Gavi also drew lessons from country introductions of two critical vaccines in its portfolio: the human papillomavirus (HPV) and measles-rubella vaccines. Our new measles and rubella strategy reinvigorated efforts to control these two infectious diseases, mainly through strengthened routine immunisation coverage. As we move into the new strategic period, we will not only support country introductions of these vaccines but also ensure they are rooted in stronger national immunisation systems.
Source: Gavi, the Vaccine Alliance, 2016; United Nations Population Division, Department of Economic & Social Affairs; World Population Prospects
Countries continued to recognise the importance of pneumococcal vaccine in preventing one of the main child killer diseases – pneumonia. In 2015, another eight countries introduced the vaccine into their routine immunisation schedule, raising the total number of introductions for the 2011–2015 strategic period to 51, above the target of 45.
A total of 54 countries have introduced pneumococcal vaccine with our support since it was added to our vaccine portfolio. Included in the group of countries that introduced in 2015 were Bangladesh, which simultaneously introduced pneumococcal and inactivated polio vaccine, and Nepal, which continued with its programme to roll out the vaccine even in the aftermath of a devastating earthquake.
WHO estimates that to date over 76 million children have been protected against pneumococcal disease with Gavi support. Only 15 of those countries eligible for Gavi funding have yet to apply for pneumococcal vaccine support.
The vaccine’s high rate of introduction matches the successful roll-out of the pentavalent vaccine and has pushed coverage levels to 35% in 2015 – but still five percentage points short of our five-year target.
However, in some countries that have introduced both the pneumococcal and pentavalent vaccines, coverage rates for the full three doses of pneumococcal vaccine lag behind rates for three doses of pentavalent vaccine – despite their matched schedules. This trend is reflected in Gavi’s failure to meet its annual pneumococcal coverage targets for the 2011–2015 period, which is attributed to supply issues in the early years of the programme and delayed introductions in countries with large populations, such as Bangladesh and Nigeria.
With our new 2016–2020 mission focused on increasing coverage and equity, Vaccine Alliance partners are working to both drive up and maintain pneumococcal coverage rates. Efforts are concentrated on ensuring that vaccine supply remains stable, that adequate support is available for those yet to introduce and that programmes, once established, are sustainable over the long term.
Read updates on all Gavi-supported vaccines in the full version →
Source: Gavi, the Vaccine Alliance, 2015
Pneumococcal vaccine, 3rd dose
Source: WHO/UNICEF Estimates of National Immunization Coverage, 2016
The year 2015 brought welcome progress towards our pentavalent coverage target; by December, Uttar Pradesh’s roll-out of the five-in-one vaccine meant that by December all states in India had introduced the vaccine. While we still fell 9% short of our 77% goal, pentavalent’s roll-out in India – home to the world’s largest birth cohort with 26 million newborns each year – is expected to significantly increase coverage rates by the end of 2016.
The Alliance exceeded its pentavalent introduction target – reaching all 73 Gavi-supported countries by the end of 2014, 12 months ahead of schedule and 15 years after setting out to ensure all poor countries have access to DTP, hepatitis B and Hib vaccines.
Hepatitis B infection causes hundreds of thousands of deaths every year through acute and chronic illnesses, including liver cancer and cirrhosis, while the Hib bacterium causes meningitis, pneumonia and septicaemia.
The pentavalent success story reflects the power of our public- private sector model. While WHO and UNICEF help countries make informed decisions about when and how to introduce the vaccine, UNICEF‘s Supply Division works to meet demand for 200 million doses each year. With the number of suppliers rising from just one in 2000 to seven in 2016, production capacity has increased tenfold, and the average weighted price of pentavalent has fallen by 44% over the current strategic period.
Pentavalent vaccine, 3rd dose
Three new rotavirus introductions in 2015 ensured that we surpassed our 2011–2015 target of 33 introductions by a healthy margin of four. However, the Vaccine Alliance finished the strategic period 11 percentage points short of its annual coverage targets, mainly because of supply constraints experienced up until 2014.
2015 saw few new applications for Gavi’s rotavirus vaccine support. These were limited by factors such as countries not being eligible for support (because of their low DTP3 coverage rate or by being close to transitioning out of Gavi support) and countries prioritising other vaccines in their immunisation schedules.
However, projected introductions from several highly-populated countries will boost coverage rates after 2018. The Democratic Republic of the Congo, India, Nigeria and Pakistan, which together account for almost half of the children born in Gavi-supported countries, are all expected to introduce rotavirus vaccine. Tajikistan’s on-schedule introduction of rotavirus vaccine set 2015 off to a good start. Several introductions had been delayed in 2014 because countries’ immunisation systems were not suf ciently equipped or prepared.
Gavi encourages countries to integrate immunisation with other cost-effective interventions for preventing and treating diarrhoea. These include breastfeeding, adequate nutrition, handwashing with soap, safe drinking water and sanitation, and treatment with oral rehydration solution, antibiotics and zinc.
Rotavirus vaccine, 3rd dose
Dr Dafrossa Cyrily Lyimo has managed Tanzania’s Immunisation and Vaccine Development Programme since 2009. She began her career in medicine almost 30 years ago as a general practitioner in a municipal hospital before moving into healthcare management. We talked to Dr Dafrossa about her country’s achievements in vaccination and her vision for the future.
Gavi: What is the situation in Tanzania with regard to vaccination coverage?
Dr Dafrossa Cyrily Lyimo (DCL): Generally, it’s good. In 2015 we had 98% country coverage for the third dose of pentavalent vaccine. Coverage with this vaccine has increased across all districts.
What was a key turning point for the national immunisation programme?
DCL: 2001–2002, when Tanzania started receiving support from Gavi, as well as our increased government co-financing.
What are your most notable successes?
DCL: They include the dual introduction of the pneumococcal and rotavirus vaccines in 2013, improved routine immunisation coverage, and Tanzania being certi ed polio free by the African regional Polio Certi cation Committee. In 2012, we were among the countries registered as having eliminated neonatal tetanus.
What were the biggest challenges?
DCL: Tanzania is a huge country, so a major challenge has been achieving a balance between sustainability and reaching the maximum number of children. The fact that we have a number of hard-to-reach areas with nomadic populations doesn’t help. We’ve also faced a shortage of transportation to distribute vaccines and supplies, human resource limitations and sector-wide barriers. This has led to low and uctuating coverage in some districts. Having insufficient funds to implement what we need also makes things difficult.
You have been successful when it comes to achieving high national coverage. Why do you think that is?
DCL: I’d say it was down to government commitment and the involvement of key partners like Gavi, WHO, UNICEF, the Clinton Health Access Initiative and the Maternal and Child Survival Program. Strong leadership of the programme at national and subnational levels helped, as did a clear strategy, detailed planning and adequate cold chain capacity and infrastructure.
To what extent has strong political support, in particular the personal commitment of former President Kikwete, played a role in Tanzania’s immunisation success story?
DCL: Former President Kikwete has played a number of key roles.
He hosted the opening ceremony of the Gavi Partners’ Forum in 2012. He committed his government to procuring traditional vaccines and co- nancing Gavi vaccines, and he launched the One Plan for Reproductive and Child Services that contributed to improving maternal and child health. Under his leadership, Tanzania was able to reduce child mortality, helped to a large extent by immunisation.
While national coverage is high, certain communities such as Maasai tribes are hard to reach. How is Tanzania addressing this?
DCL: We work to understand the background of nomads to make sure we reach them and offer immunisation services. This involves developing an effective strategy, delivering specific communication messages and holding regular primary healthcare meetings.
How can Gavi help Tanzania ensure vaccines reach every child everywhere?
DCL: Gavi can help us collect suf cient data and create a way to get to hard-to-reach communities. They can support linking civil registration with immunisation. And they can help develop innovations that enable unique identification and the mapping of the movements of our nomadic population.
Where do you hope Tanzania will be in ve years’ time with regard to coverage and equity?
DCL: I hope we’ll have sustained our high coverage while improving our performance among the hard-to-reach population and in lower- performing districts. Speci cally, we’re hoping to attain the global measles-rubella elimination goal and contribute to a world free of poliomyelitis.
Why do you do what you do?
DCL: First and foremost, I love children. I’m a mother of four. In the early 1960s, my parents managed to make sure I was vaccinated. I’d like all children born in Tanzania to enjoy the same protection. Also I once worked as a clinician in a paediatric ward and, at that time, children were dying daily from vaccine-preventable diseases like diarrhoea, pneumonia, diphtheria, measles and tetanus. Vaccines were available but access was a challenge. Now I have the opportunity to help, I’m inspired to do everything I can to ensure children have access to powerful vaccines and other preventative services.
Gavi and its partners have made significant headway in increasing access to routine vaccinations in many developing countries, including some in which conditions are especially challenging. Since 2010, basic immunisation coverage across Gavi-supported countries has increased from 78% to 81%, despite a large population increase.
An unprecedented level of access means that more children are being vaccinated than ever before. In 2015 alone, more than 65 million children were immunised with Gavi- supported vaccines.
Because the remaining pockets of unimmunised children tend to be those that are hardest to reach, coverage improvements slowed during the 2011–2015 period, and we failed to reach our five-year targets for improving coverage and equity.
Almost one in five children in Gavi-supported countries is still not receiving a full course of the most basic package of vaccines.
A “business as usual” approach will not be sufficient
to reach these children. In 2015, we started laying the foundation for our new strategy’s focus on improving coverage and equity. A new model for health system and immunisation strengthening support, to be implemented from 2016 onwards, will direct investment to where it is needed most – the poorest and hardest-to-reach communities and populations.
Read more detail on Gavi's Health Systems Goal →
Coverage with three doses of a diphtheria-tetanus- pertussis-containing vaccine (DTP3) is a standard measure of the strength of national immunisation programmes. In 2015, coverage with DTP3-containing vaccines – including the pentavalent vaccine – reached 81% in Gavi-supported countries. While we did not meet our target of 84% coverage across the 73 countries, our 2016–2020 strategy will focus on further improving immunisation coverage and making it more equitable.
Source: WHO/UNICEF Estimates of Immunization Coverage, 2016
Poverty is a critical factor in determining whether or not a child is immunised. Equity in immunisation can therefore be measured by comparing DTP3 coverage for the poorest 20% of the population with that for the richest 20%. The percentage of Gavi-supported countries meeting the minimum equity benchmark increased from 51% in 2010 to 58% in 2015, 4 percentage points below the target.
Source: DHS and MICS; other surveys that use comparable methods may be used where no DHS or MICS is conducted
Tracking the percentage of children who receive the first but not the third dose of DTP-containing vaccines reflects the number of children who failed to complete the full vaccination series. In 2015, the difference between DTP1 and DTP3 coverage in Gavi-supported countries fell to 6 percentage points, in line with our 2015 target. This shows that countries are increasingly able to deliver a full course of the vaccine.
Children are usually immunised against measles at nine months of age – later than DTP3 but still within the first year of life. Coverage with the first dose of measles vaccine, which Gavi does not currently support financially, thus measures the ability of health services to vaccinate children beyond early infancy. While DTP3 coverage has increased in recent years, routine coverage with the first dose of measles vaccine has stalled at 78%. Gavi has not set a specific target for measles vaccine coverage.
Dr Osama Mere was born in Damascus and graduated from medical college at Damascus University in 1990. For five years, he served as head of Child Health and the national manager of the Extended Programme for Immunization (EPI) in Syria. In 2015, he became the acting country representative in Yemen for WHO. We talked to him about how Gavi has adapted its health system strengthening to ensure vaccines are still being delivered despite Yemen’s ongoing conflict.
Gavi: What are the main challenges of delivering vaccines in a conflict zone like Yemen, Dr Mere?
Dr Osama Mere (OM): The main issue is how to get vaccines into the country. The only way is through the UN flight via Djibouti, which needs the consent of the Arab Coalition. Fortunately, they let vaccines through.
Inside Yemen, the challenge is to distribute the vaccines across the country. In three or four districts. This is very difficult because of the ongoing conflict. But, in spite of this, we’re able to get vaccines into places like Taiz City, which is under virtual siege.
What support do you receive from the Vaccine Alliance in Yemen?
OM: Gavi helps us overcome the main challenge, which is the cost of vaccines. In 2015, the problem was the government had no funds. The
cost of transporting the vaccines to the children that need them, things
like transportation and wages, has also increased. Gavi helped us cover this.
How was Gavi’s health system strengthening support (HSS) adjusted to address the unique challenges of working in Yemen?
OM: Without HSS, it would have been very difficult to cope with the situation. It was the only fund available to us. Gavi has been extremely flexible. They’ve accepted that we need to act, do outreach and distribute the vaccines.
Could you describe how Gavi HSS support is used in Yemen today and what are the results?
OM: In 2015, we had 67% coverage with DTP3, with outreach activities supported mainly by Gavi, our main financier. Instead of our normal four rounds of outreach, we did five. Outreach activities were carried out like a campaign. We rented around 1,000 cars and sent them out into the field for five days with people trained using Gavi funds.
In every round of outreach, working from eight to five o’clock, we managed 6,000 or more immunisations, even covering remote villages and reaching places where there was no electricity and we had to use generators and solar power. So, that’s five rounds of outreach and 30,000 immunisation sessions. A big achievement in spite of everything.
Our people were also able to offer advice on nutrition, childhood illnesses and reproductive health.
Could you highlight any innovative approaches you’ve used in Yemen to reach communities on the frontlines?
OM: The Expanded Programme for Immunization (EPI) Task Force, the main body managing and leading immunisation activities during the crisis, was closely monitoring areas that required special care. They approached the local authorities and communities, who were very efficient in increasing accessibility.
How important is political support to the success of immunisation in Yemen?
OM: All the authorities on both sides have been very supportive. The de-facto vice-minister was attending most of the weekly meetings of the EPI Task Force in addition to the representatives of WHO and UNICEF. The whole country has worked to facilitate the delivery of vaccination services. But it has to be said that this hasn’t translated into anyone actually paying for vaccines. We’ve had to rely on Gavi and the UN for that.
What challenges does your organisation continue to face in maintaining and increasing immunisation coverage in Yemen?
OM: What we need to do is revitalise health facilities, especially vaccine departments. We must maintain the quality of immunisation services by training new staff – basic training and effective vaccine management – and making sure they’re supervised. We also have to guarantee the distribution and supply of vaccines into the country and distribute them properly.
But the main issue is to stick to five continuous rounds of outreach every year, based on very detailed micro-plans
What are the strengths of the Gavi model and how has this helped the Alliance work in Yemen?
OM: The key things are that the funding is available at the local level for use by the Minister of Health for Yemen and there’s flexibility in how it’s used. It all comes down to Gavi’s willingness to be flexible, which has been much appreciated in Yemen. It’s good that the HSS makes sure funds are used well and monitors activity correctly.
Ultimately, what would you say has been your biggest achievement?
OM: Sustaining routine immunisation coverage in Yemen in 2015 in spite of the armed conflict and the political unrest. All the new vaccines offered by Gavi were introduced in Yemen, including pentavalent, pneumococcal, rotavirus, measles-rubella and inactivated polio vaccine.
Our long-term vision for immunisation has always been one of self-sufficiency. Since its inception in 2000, Gavi support has been geared towards increasing countries’ own investment in their immunisation programmes. Our funding model thus encourages national ownership and helps to ensure that programmes are sustainable after our financial support ends. By the end of 2015, just seven years after countries made their first co-financing contributions towards Gavi-supported vaccines, our funding model is coming into its own.
Countries are making great strides in taking over the full
cost of their vaccines, demonstrating their commitment
to investing in immunisation and the value of the Vaccine Alliance’s assistance to countries as they prepare to transition out of Gavi support. 2015 was a litmus test for Gavi’s funding model and shows what can be expected in the years to come.
Four countries – Bhutan, Honduras, Mongolia and Sri Lanka – have started to fully self-finance their vaccines introduced with Gavi support, while close to 20 others are preparing to transition by 2020.
Predictable, long-term donor support is another cornerstone of the Gavi funding model, giving countries the confidence to introduce new vaccines. By providing visibility of future demand, we enable manufacturers to better plan their production and supply vaccines at more affordable prices to developing countries. Greater immunisation coverage leads to healthier, more productive populations and increases economic prosperity. This, in turn, means that countries are better able to take over the full financing of their immunisation programmes.
More information on the Financing Goal →
Donor pledges (US$ billions)
Co-financing amounts (US$ millions)
Total cost to fully immunise a child with pentavalent, pneumococcal and rotavirus vaccines (selected vaccine package price, US$)
Number of country introductions of new and underused vaccines (pentavalent, pneumococcal, rotavirus)
Population-weighted average GNI per capita for Gavi-supported countries (US$)
Annual birth cohort of countries transitioning and transitioned from Gavi support (millions)
2015 was our most successful year to date in terms of co- financing, a culmination of remarkable progress by countries across the 2011–2015 strategic period. By the end of the year, 14 countries had taken over full financing of 20 vaccine programmes previously supported by Gavi. Four of these countries – Bhutan, Honduras, Mongolia and Sri Lanka – were poised to transition out of Gavi support by 1 January 2016. In total, countries contributed US$ 113 million to the cost of Gavi-supported programmes in 2015 – a more than threefold increase since 2010.
Despite growing co-financing requirements, more countries made their contributions on time in 2015: 85% made timely payments, compared with 75% in 2014. This translates into a 40% reduction in the number of defaulting countries, from 17 in 2014 to 10 in 2015. These achievements reflect both countries’ commitment to investing in vaccines and the value of the support and follow-up provided by Gavi and its partners during the transition period. Despite this progress, we did not achieve our ambitious target of 100% timely co-financing payments.
As shown to the right, countries are stepping up their total spend on vaccines, in which Gavi co-financing plays a part. The total amount spent on vaccines per child in Gavi-supported countries increased by 47% between 2013 and 2014, from US$ 4.30 to US$ 6.30. The 2015 figure will be available in October 2016.
More on all Gavi-supported programmes in the full version →
Average expenditure per child (US$)
Source: WHO/UNICEF Joint Reporting Form; Gavi Annual Progress Reports; Gavi’s Adjusted Demand Forecast; UNPD data.
Percentage of countries
Source: UNICEF Supply Division and the PAHO Revolving Fund.
By the end of the year Gavi had secured full funding for the 2011–2015 strategic period, with all pledges successfully delivered – an exceptional feat for a multilateral development agency.
By the end of 2015, cumulative funds received by Gavi since its inception in 2000 totalled US$ 12 billion.
This includes contributions from national donor governments, the European Commission, the Bill & Melinda Gates Foundation and the private sector.
Most pledges in this period were in the form of multi- year commitments. Long-term funding means that developing countries can confidently plan their vaccine programmes and manufacturers, given assured, visible demand, are better able to invest in production, as well as reduce vaccine prices. A strong capital base also gives Gavi the flexibility to respond to urgent needs, such as the global roll-out of inactivated polio vaccine and the devastating Ebola epidemic.
Donors can support Gavi both directly and through funding mechanisms such as the International Finance Facility for Immunisation (IFFIm), the Advance Market Commitment (AMC) and the Gavi Matching Fund.
In 2015, total donor funding in the form of direct contributions and proceeds from these three innovative finance mechanisms amounted to US$ 1.7 billion.
Source: Gavi, the Vaccine Alliance, 2016.
In 2015, we received close to US$ 1 billion in direct contributions from 14 donor governments: Australiaa, Canada, France, Germany, India, Ireland, Japan, Luxembourg, the Netherlands, Norway, the Republic of Korea, Sweden, the United Kingdom (UK) and the United States of America (USA).
The cumulative value of direct contributions received from national governments and the European Commission since Gavi was set up in 2000 amounts to US$ 6.1 billion.
a Australia’s contribution was paid in 2014.
Minister Yolani Batres became the Secretary of State at Honduras’s Bureau of Health in January 2014. Since then, controlling, eliminating and eradicating vaccine-preventable diseases and introducing new vaccines have been key priorities for her. We talked to Dr Batres, who is also a Gavi Board member, about her country’s transition out of Gavi support and what the future holds.
Gavi: Could you describe the situation in Honduras today, Dr Batres?
Dr Yolani Batres (YB): Honduras has improved economically. Now we’re being looked at in the same way as Mexico, Brazil, Colombia and Argentina. These countries have greater resources than us, so in one way we’re at a disadvantage.
In terms of vaccination, our coverage is above 95% and we’re happy. It tells us our workers are doing the best for our children.
How does Honduras look at the rest of the world?
YB: Honduras is outward-looking. If we see something good that another country is doing, especially in the area of health, we always want to imitate it.
How long has Honduras worked with Gavi?
YB: Since 2004.
How would you describe the relationship with Gavi?
YB: Gavi respects our politics, programmes and laws. We’ve worked shoulder to shoulder and learned a lot. Now we have transitioned from Gavi but have the possibility to maintain the prices of vaccines so we can protect our people. We also want the chance to buy new vaccines at Gavi prices.
In transitioning, what were the challenges specific to Honduras?
YB: Our challenge was to achieve the highest possible level of coverage and maintain it. We also had to negotiate with Gavi to maintain current prices for vaccines and have the possibility to introduce new ones.
What factors made it possible for Honduras to transition?
YB: It’s a tough process. We’ve succeeded because of strict planning and very good programming. We also passed a law in 2013 guaranteeing that all children have free access to vaccines. But we have to remember that, as a developing country, we have limited finances.
Now that Honduras has transitioned successfully, what advice would you give to countries that are about to start the same process?
YB: Any country’s aim has to be to achieve financial sustainability. You can only do this by involving your ministry of finance as early as possible. Include them in discussions and make sure they understand the part they need to play. This is key.
Insisting the Ministry of Health does the necessary planning years, and not months, before transitioning is also essential. Transition can be a very long and challenging process.
What does the immediate future look like for Honduras? What work has to be done right away?
YB: The future looks good. What we have to do immediately is try to maintain vaccine prices not just for five years but for longer. We also need to keep Honduras in a position to be able to afford new vaccines.
And what is your long-term vision for Honduras?
YB: I want to maintain coverage above 95% in all cities, districts and rural areas and continue to use vaccines against preventable diseases.
How would you suggest that other transitioning countries work with Gavi?
YB: As I said, stick to a planned, programmed process. Negotiate with your ministries of health and finance. Reach out to people at the highest possible levels. For instance, we have a great relationship with our President Hernández. He’s very switched on and wants even more vaccines, for things like dengue and malaria.
Now that Honduras has transitioned successfully, what relationship does your country have with Gavi?
YB: It’s very good, for me personally and my country. Gavi listens, and respects our needs, culture, laws and ideas.
Why do you do what you do?
YB: I like working in health prevention, on preventable diseases. As a doctor, I think vaccines are the only tools you really have control of, that you can give to a person and be sure they’ll prevent disease.
Also, I had polio when I was 11 years old. This makes me very aware of what can happen when you live in a rural area and don’t have access to vaccines. I want to make sure this doesn’t happen to other children. And I want to bring awareness of how hard life can be in a country like Honduras to people in richer countries.
Most of all, though, I want to build on the good things we’ve done and give my country even better possibilities to grow.
How would you describe the character of Honduras in one word?
In order to reach all children with life-saving vaccines, vaccine markets need to be made to work better for lower-income countries. This means putting in place mechanisms that allow manufacturers to plan production based on known demand, donors to maximise their investments and, most importantly, developing countries to buy suitable vaccines at prices they can afford and to eventually transition out of Gavi support.
In 2015, Gavi achieved its market shaping goals for appropriate prices and improved supply security for many life-saving vaccines. However, supply shortages remain, particularly for yellow fever, cholera and inactivated polio vaccines.
Collaboration between Alliance partners and vaccine manufacturers led to the launch, in January 2016, of an advance purchase commitment for Ebola vaccine. Thanks to this commitment, 300,000 doses of the vaccine will be available from mid-2016 for use in clinical trials and emergencies.
During 2015, plans to expand Gavi’s market shaping work took a step closer to fruition. In the next five-year strategic period, 2016–2020, our market shaping goals will extend beyond vaccines to include other immunisation-related products, such as cold chain equipment.
Read more detail on Gavi's Market Shaping Goal →
Efforts by Vaccine Alliance partners to foster healthy vaccine markets have led to increased competition and a more diversified manufacturing base. In 2001, there were only 5 Gavi vaccine suppliers; by the end of 2015, 16 manufacturers were producing prequalified vaccines suited to the needs of Gavi-supported countries.
Gavi currently measures supply security using an indicator based on the number of products that manufacturers offer in response to tenders for the vaccines we support. Between 2010 and 2015 the value of this increased from 54% to 104% of the target, meaning that we not only met our 2015 objective but surpassed it.
Another way in which we quantify supply security is
by tracking the number of vaccines that fail to meet shipment plans agreed with UNICEF. Three inactivated polio vaccines were temporarily not available to meet shipments in 2015, along with four pentavalent vaccines and one yellow fever vaccine.
Number of products offered as % of 5-year target
Source: UNICEF Supply Division.
Through its proactive market shaping efforts, Gavi has been successful in reducing vaccine prices for the world’s lowest-income countries. The weighted average price of immunising a child with a full course of pentavalent, pneumococcal and rotavirus vaccines – one of our key performance indicators – fell to US$ 20 in 2015. This represents a decrease of 7% from 2014 and 43% from 2010.
Much of this is due to the reduction in the price of rotavirus vaccine, which has fallen by 70% since 2010, and the decrease in the price of the pentavalent vaccine, which reduced by 44% over the same period. The weighted average price of pneumococcal vaccine dropped by just 3% in the five years to 2015.
elected vaccine package price (US$)
Source: Procurement partner manufacturer offers
One of the world’s poorest countries, Ethiopia receives support from Gavi for seven life-saving vaccines. Liya Woldegiorgis has been coordinator of the Expanded Programme on Immunization (EPI) at the Ethiopian Ministry for Health for the past two years. Her background is in nursing. We talked to Woldegiorgis about the vital role Gavi plays in procuring essential vaccines.
Gavi: What is the situation in Ethiopia today with regard to immunisation?
Liya Woldegiorgis (LW): Our biggest success has been the great improvement in coverage. Political commitment to immunisation from the ministry down to the regions grows all the time. Right now, as per our five- year strategic plan, we’re concentrating on equity and quality. We’re also working on cold chain expansion and capacity-building activities.
Our greatest challenge is increasing immunisation in places like the Somali region, where there’s low coverage and poor quality of service.
How would you describe what Gavi does in Ethiopia?
LW: Gavi has been our largest, most reliable donor for the past 16 years. Apart from creating vital access to immunisation, Gavi plays a significant role in continuing to strengthen our health system.
If you hadn’t had Gavi funding, would you have been able to introduce new vaccines?
LW: The government would have been forced to find another source, which would have been challenging to say the least. Don’t forget, another advantage of working with Gavi is benefiting from the prices they negotiate with manufacturers.
Could you explain the advantages to Ethiopia of being able to introduce new vaccines like pentavalent and human papillomavirus (HPV) with Gavi support?
LW: These vaccines help to reduce mortality and morbidity. In addition, pentavalent, which protects against five diseases in one shot, reduces the overall number of injections that children need. We’ve successfully introduced the HPV vaccine via demonstration projects in Gomma and Ahferom. Over 6,000 girls have benefited.
How has Gavi helped you deal with outbreaks of meningitis in your country?
LW: We’ve been carrying out a preventive meningitis A mass vaccination in phases since 2013, targeting people aged 1–29. With Gavi’s financial and technical support, we’ve reached over 60 million people considered at high risk of being infected.
Could you describe what you do in your role as the EPI manager for Ethiopia?
LW: I managed the development of our five-year plan and now help implement it. I’m involved with and monitor all EPI-related activities like introducing new vaccines, and managing logistics. My other duties include supplemental immunisation activities and overseeing developmental partner work.
How exactly does the procurement of vaccines work in Ethiopia? What are the stages of the process and how are you involved?
LW: With government-purchased vaccines, the Health Minister will take the best cost estimate from a supplier. When the budget is approved, the money is transferred to a contractor’s account. The vaccine arrives and the procurement pharmaceutical supply agency responsible distributes it. For Gavi-supported vaccines, UNICEF is the procurement agency.
How is Gavi helping you meet the vision of the fully immunised child?
LW: Gavi has funded 80% of the cost of the vaccines that we have introduced and they help educate our people about their benefits. Every time a life-saving vaccine is used, the community sees its effect, which increases demand. Gavi was pivotal in helping us meet the UN Millennium Development Goal targets for reducing under-five mortality three years ahead of time.
We understand that Ethiopia is keen to be part of Gavi’s cold chain equipment optimisation platform support. Why is this?
LW: There are many reasons. We’re a large country. We’ve constructed a lot of new facilities – 16,500 health posts, more than 3,500 health centres and almost 400 hospitals. These all need to be fully equipped with modern equipment. Being part of the platform will help improve our service quality and increase coverage. It will improve quality and reduce vaccine stock-outs.
Ethiopia has done an enormous amount of work to vaccinate hard-to-reach groups like the nomadic population. Why do you personally think this is so important?
LW: Immunisation is the most cost-effective public health service. Every child and community has a right to receive vaccines.
How do you see the immediate and long-term future for immunisation in Ethiopia?
LW: Our five-year strategy is all about sustaining the gains – maintaining the coverage we have currently, working towards better quality and creating equity.
What part do you think Gavi will play in this?
LW: Gavi will continue to be a reliable donor that contributes a lot, not just financially but also through technical support and by helping us carry out health system improvements.
LW: For many reasons. When you work with a community, you can personally reach people and see the results over the years. I’m happy to do my bit to create a healthy community. Community-focused activity is really impressive. Seeing healthy children gives me great pleasure and meaning in life.
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