• Introduction

    Highlights of the Vaccine Alliance's 2016 Progress Report

    Welcome to Gavi’s new Annual Progress Report, the first of five covering our 2016–2020 strategic period.

    Browse this online version for a comprehensive analysis of how our Alliance is performing against
    its mission and strategic goals, as well as
    a dedicated section on the wider impact of immunisation on global health
    and development.

    “The 2016 Annual Progress Report
    is a new way of reporting for Gavi.”


    Dr Seth Berkley,
    Chief Executive Officer (CEO)

     

    INTRODUCTIONS: GAVI’S CEO AND BOARD CHAIR


    ...global forces, such as climate change, human migration, conflict and urbanisation, continue to impact and challenge our mission and threaten global health security in the process.

     

    Dr Seth Berkley, CEO

    Welcome to Gavi’s 2016 Annual Progress Report, a new kind of report and the first of five covering our new strategic period. This report differs from previous versions in its approach, not only reporting back on our key performance indicators (KPIs) but also providing a global context for the important work we are doing here at Gavi. This “bigger picture” will become increasingly important in the rapidly changing world, as global forces, such as climate change, human migration, conflict and urbanisation, continue to impact and challenge our mission and threaten global health security in the process.

    As you will see, in this first year of our new 2016–2020 strategy such challenges are already making themselves apparent. It will be critical for us to adapt accordingly. Based on lessons learned from monitoring and reporting on our performance in 2016, we have adjusted several indicators to ensure they provide more meaningful information. For example, with household survey data only available every three to five years, we cannot reliably update our indicators for poverty and gender equity each year. Instead these indicators will be updated at the mid-term (May 2018) and end of our strategy (2020). We will adopt a similar approach to monitoring hepatitis B prevalence through our disease dashboard, where identifying trends over time is more useful than recording annual variations.

    Gavi is also rethinking its institutional capacity indicator to better assess whether countries are improving management of their immunisation systems. Of course, to build as comprehensive picture as possible of the impact of our investments in immunisation, we cannot just rely on our formal indicators. Gavi will continue to draw on a wide range of intermediate indicators and other sources, such as country performance data and evaluations.

    All this emphasises the need for our new initiatives to strengthen health systems.

    Until we do this and start to see stronger data, and more of it, we should not take the apparent stagnation of global immunisation coverage, and countries that appear to be performing very well, at face value. If we want to raise coverage we’ll need to continually expand the net to include those children that are currently not being counted. Another initial set-back is that we have not met our targets on vaccine introductions and have experienced serious supply issues for both yellow fever and inactivated poliovirus vaccines (IPV), partly because demand was so high.

    However, none of this should detract from the great progress we have made in 2016. Last year saw the introduction of new initiatives to help with the global strategies to reduce the risk of outbreaks of both measles and yellow fever. In the case of the latter, this was despite vaccine supply issues and in the face of the largest yellow fever outbreak in decades, ultimately helping to bring an end to that outbreak in Angola and the Democratic Republic of the Congo.

    Last year I also met with Prime Minister Narenda Modi and was given personal reassurances of the Government of India’s commitment towards immunisation and the introduction of pneumococcal, rotavirus and measles-rubella vaccines, commitments which have since been acted upon. With Gavi’s help, in 2016 for the first time ever, the average price of pneumococcal, rotavirus and pentavalent vaccines fell below US$ 20, an extremely positive milestone.

    The other good news is that 2016 was very much a year for innovation and technology, with the launch of three new private sector initiatives: Innovation for Uptake, Scale and Equity in Immunisation (INFUSE), our cold chain equipment optimisation platform (CCEOP) and the launch of the world’s first nationwide autonomous drone-based medical delivery system in Rwanda. These kinds of developments are precisely what we need to address issues around immunisation delivery and to improve data, both of which will help us achieve our coverage and equity objectives.

    We still have a considerable way to go, and it is important to understand the enormity of the task before us; those children we are not reaching are not just the last to be reached, they are by far the most difficult to reach. However, we are only at the beginning of this strategic period and I am confident that we can meet that challenge and achieve our extremely ambitious targets. Doing so will not only save the lives of individuals, but will help create a better future for many millions more by building the foundations for universal health coverage. And from a global health security perspective, this will only serve to make the world a safer place.


    ...the value of vaccines stretches beyond the prevention of illness and death, bringing wider economic gain to countless individuals, families and communities.

     

    Dr Ngozi Okonjo-Iweala, Gavi Board Chair

    For years to come, 2016 will be remembered by many as a turbulent year, and one posing many challenges for our Alliance.

    It was characterised by global emergencies and huge demographic shifts, with conflicts such as Syria triggering the largest number of displaced people since the Second World War. Fears about global health security once again made the headlines following new outbreaks of infectious diseases, such as the Zika virus. It was also a year when we saw an increased focus on domestic agendas following a sudden geopolitical shift away from globalism towards a more unilateral landscape.

    It was against this backdrop that Gavi embarked upon the most challenging phase of its history to date. Not just in terms of beginning an ambitious new strategy, but also because the entire Gavi model is under the microscope like never before, following the transition of four countries out of Gavi support. Given such trying circumstances, this would not normally be the best time to join an organisation! Yet, during my first year as Board Chair I have been repeatedly impressed by Gavi’s resilience and its ability to adapt and innovate when necessary.

    For example, the first four transitioning countries – Bhutan, Honduras, Mongolia and Sri Lanka – faced a long and complex journey to cross the finish line. It was only because of Gavi support that they got there. Now, some other countries that are due to follow the same path face challenges and risk sliding backwards. During this time, Gavi’s technical support as well as our assistance with vaccine supply and health system strengthening is even more vital.

    This emphasises the importance of Gavi’s shift towards a more country-centric approach, which will play a major role in this current strategic period.

    The focus of our new integrated set of tools and frameworks is to listen to the needs of countries so we can best support their immunisation programmes, while simultaneously tracking progress and minimising any risk. It is an approach which has proved very popular, as I discovered first-hand in Ethiopia during the Ministerial Conference on Immunization in Africa, last year.

    At Addis Ababa, ministers talked about their commitment to transitioning out of Gavi support, and spoke of the importance of building political will to get there. Their enthusiasm and support ultimately led to the Addis Declaration on Immunization, an historic agreement, since endorsed by African leaders, which prioritises immunisation at the continental level.

    To see this commitment backed by sustainable financing, it will be critical to emphasise how the value of vaccines stretches beyond the prevention of illness and death, bringing wider economic gain to countless individuals, families and communities. We have long known that immunisation is one of the most cost-effective ways of improving living standards, health and economies, but last year a research study published in the journal Health Affairs provided a number that quantifies the actual return on investment: US$ 16 return for every dollar invested in immunisation.

    Findings such as this will not only help secure political commitment, they also help us to build support from the private sector, and not just in terms of funding. Last year, the way businesses support Gavi experienced a sea change, placing greater emphasis on operational partnerships aimed at leveraging business and industry expertise. The kind of technical knowledge and experience that this approach brings will play an ever more important role during this strategic period in closing those equity gaps.

    Finally, I’d like to cite one last example of Gavi’s ability to adapt and innovate. It is highlighted in this report and regards an issue that I care very deeply about: gender and equality. Historically, women and girls often face additional barriers to accessing basic health services; this means they can suffer infectious diseases in very different ways compared to men and boys. Zika is just one example of this. My heart goes out to the hundreds of thousands of pregnant women in Zika-infested countries, who have had to face the agonising experience of not knowing the fate of their unborn child.

    So, last year when it became clear that we would face new challenges in reaching our targets to protect girls against cervical cancer with the human papillomavirus (HPV) vaccine, it was great to see Gavi change from a demonstration project-based approach towards encouraging national introductions of this important vaccine. This is just one of the many reasons why I am so very proud to be a part of the Gavi family and am excited about the positive work we are doing.


     

    The Gavi model at work

    Gavi, the Vaccine Alliance is a global partnership bringing together public and private sectors around the shared goal of creating equal access to vaccines for all children.

    As a public-private partnership, our Alliance represents all the key stakeholders in global immunisation: implementing and donor governments, the World Health Organization, UNICEF, the World Bank, the Bill & Melinda Gates Foundation, civil society, the vaccine industry, research agencies and private companies.

    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 developing countries do not miss out on life-saving vaccines.

    Gavi's business model → 

     
  • Measuring our performance


    mission and strategic goals

    Gavi’s mission is to save children’s lives and protect people’s health by increasing equitable use of vaccines in lower-income countries.

    Our work towards achieving this mission is guided by a five-year strategy, underpinned by four strategic goals and a set of key performance indicators. The current strategy, which came into force in January 2016, runs until the end of 2020.

    2016–2020 strategy overview →  

    Our five mission indicators measure our impact on numbers of immunised children, future deaths prevented, under-five mortality rates and years lost due to disability or death in the countries we support. We also track whether vaccine programmes are successfully maintained in countries after our financial support stops – a reflection of our strategy’s increasing emphasis on ensuring sustainability of immunisation.

    Mission indicators

    Children immunised

    What we measure

    The number of children immunised with the last recommended dose of a Gavi-supported vaccine delivered through routine systemsa. People immunised through campaigns and supplementary immunisation activities are not included.

    2016 performance

    Countries immunised 62 million children – often with more than one Gavi-supported vaccine – in 2016. This brings the total number of children immunised with our support since we were founded to 640 million. We are on track to help countries immunise 300 million children in the 2016–2020 period.

    a – To ensure that we do not double-count children who receive more than one vaccine, we only take into account the Gavi-supported vaccine with the highest coverage level in each country.

    Number of children immunised

    (millions)

    62m  

    2015: 63m2020 target: 300m

    Source: WHO/UNICEF Estimates of National Immunization Coverage, 2017; United Nations Population Division; World Population Prospects

    Future deaths averted

    What we measure

    The number of future deaths prevented as a result of vaccination with Gavi-funded vaccines in the countries we support.

    2016 performance

    Developing countries prevented approximately 1.2 million future deaths in 2016 thanks to Gavi-supported vaccines. This puts us well on track to help countries to avert 5-6 million future deaths in the 2016-2020 period.

    Number of future deaths averted

    (millions)

    1.2m  

    2015: n/a2020 target: 5-6m

    Source: WHO/UNICEF Estimates of National Immunization Coverage, 2017; Gavi, the Vaccine Alliance Operational Demand Forecast; United Nations Population Division; World Population Prospects

    Reduced child mortality

    What we measure

    The average probability of a child born in any of the Gavi-supported countries dying before they reach the age of five.

    2016 performance

    Under-five mortality was projected at 64 deaths per 1,000 live births in 2016, the same proportion as in 2015. Final 2016 estimates will be available in late 2017.

    Under-five mortality rate

    In Gavi-eligible countries (per 1,000 live births)

    64b /1,000 live births  

    2015: 64/1,0002020 target: 58/1,000

    Sources: The United Nations Inter-agency Group for Child Mortality Estimation; United Nations Population Division; World Population Prospects

    b – Projection.

    Future disability-adjusted life years averted

    What we measure

    The number of future disability-adjusted life years (DALYs) averted as a result of vaccination with Gavi-supported vaccines. DALYs measure the number of healthy years lost due to disability or premature death.

    2016 performance

    Countries averted approximately 50 million DALYs in 2016 thanks to our support. We are on course to achieve our target of 250 million DALYs averted by 2020.

    50m  

    2015: n/a2020 target: 250m

    Source: WHO/UNICEF Estimates of National Immunization Coverage, 2017; Gavi, the Vaccine Alliance Operational Demand Forecast; United Nations Population Division; World Population Prospects

    Vaccines sustained after Gavi support ends

    What we measure

    The percentage of countries that continue to deliver all recommended vaccines included in their routine programmes after they transition out of Gavi financing. This indicator covers all vaccines recommended by national authorities for routine immunisation, not only those supported by Gavi.

    2016 performance

    All transitioned countries continued to deliver each of their recommended routine vaccination programmes throughout 2016.

    100%  

    2015: n/a2016-2020 target: 100%

    Source: WHO/UNICEF Estimates of National Immunization Coverage, 2017

    We focus on four strategic goals to achieve our mission:

    • The vaccine goal

      accelerate equitable uptake and coverage of vaccines

    • The health systems goal

      increase the effectiveness and efficiency of immunisation delivery as an integrated part of strengthened health systems

    • The sustainability goal

      improving sustainability of national immunisation programmes

    • The market shaping goal

      shape markets for vaccines and other immunisation products

     
  • The vaccine goal


    accelerate equitable uptake
    and coverage of vaccines

    2016 at a glance

    ▶ There were significant improvements in coverage for pentavalent, rotavirus, pneumococcal and inactivated polio vaccines.

    ▶ Delayed introductions, largely because of supply shortages, meant that we only achieved 45 of the 72 introductions expected in 2016.

    ▶ Routine coverage with a full course of diphtheria-tetanus-pertussis-containing vaccine (such as pentavalent) and a first dose of measles vaccine in Gavi-supported countries failed to rise for the third consecutive year.

     

    ▶ For the second year in a row, just 16% of Gavi-supported countries met our benchmark for equitable immunisation coverage across all districts.

    ▶ We continued to evolve our approach to delivering measles, meningitis A, human papillomavirus (HPV) and yellow fever vaccine support.

    ▶ Ghana and the Sudan became the first Gavi-supported countries to introduce meningitis A vaccine into their routine immunisation programmes – an important step towards ensuring long-term protection.

     

    Protecting every child through routine immunisation

    Every child, including those living in hard-to-reach places like urban slums and remote rural locations, should be protected by vaccines – regardless of poverty, geography, gender and other possible obstacles.

    To ensure that all children in developing countries receive the level of protection they need, our Alliance subsidises countries’ access to 12 life-saving vaccines via routine immunisation programmes, preventive campaigns and, in emergencies, global stockpiles.

    Making sure that vaccines are part of basic healthcare systems everywhere is vital to prevent disease outbreaks and help safeguard the lives of children born today and those in generations to come.

    An evolving goal

    During the 2016–2020 strategic period, we will be supporting countries to conduct more vaccine introductions and campaigns than ever. The majority of Gavi-supported countries have already introduced pentavalent, pneumococcal and rotavirus vaccines into their routine systems. Now their attention is turning towards vaccines protecting against human papillomavirus (HPV), yellow fever, meningitis A and rubella.

    Continuing to help countries expand their national immunisation programmes in terms of the number of diseases prevented is a key objective going forward. At the same time, we remain strongly committed to helping countries reduce gaps in immunisation coverage.

    Acutely aware that we fell short of our targets for immunisation coverage and equity in the previous strategic period, we have set new ambitious goals for increasing the equitable uptake and coverage of all vaccines. We aim to:

    • increase coverage and equity of immunisation;
    • support countries to introduce and scale up vaccines against new and important diseases; and
    • respond flexibly to meet the needs of children in fragile countries.

    Previously, we used a set of performance indicators to track immunisation coverage for our three main vaccines: pentavalent, pneumococcal and rotavirus. In this period, we are widening our scope to measure coverage for all WHO-recommended vaccines in every country we support.

    We also track the reach of routine immunisation, as well as gauge the impact of key barriers to equitable coverage. This will help us identify where the under-immunised live and how we can best ensure that all children receive the vaccines they need.

    2016-2020 strategy: vaccine goal →  

    Performance indicators: vaccine goal

    1 Routine immunisation coverage

    What we measure

    Percentage of children reached with the third dose of a vaccine containing antigens against diphtheria, tetanus and pertussis (DTP), such as pentavalent, and the first dose of measles vaccine in Gavi-supported countries.

    Pentavalent vaccine is given in three doses, all within the first six months of a child’s life. Children are given the first dose of a measles-containing vaccine before their first birthday. Universally present in the routine schedules of Gavi-supported countries, coverage estimates for these two vaccines provide a reliable indicator of the proportion of children with access to basic immunisation services.

    2016 performance

    Coverage of the third dose of pentavalent and the first dose of measles vaccine in Gavi-supported countries has stalled over the past three years at 80% and 78%, respectively – some way below our 2020 targets. On the upside, coverage of a second dose of measles vaccine across Gavi-supported countries increased by 7 percentage points between 2015 and 2016, from 43% to 50%.

    2016–2020 strategy overview →  

    KPI  

    2 Breadth of protection

    What we measure

    Percentage of children reached with the last dose of seven vaccines recommended across all Gavi-supported countries and of three vaccines specific to certain regions.

    2016 performance

    Average coverage for these 10 vaccines amounted to 37%, an increase of 7 percentage points compared with the year before. Countries have made significant headway in improving coverage of several vaccines. This includes Haemophilus influenzae type b (part of the pentavalent vaccine), which rose by 11 percentage points between 2015 and 2016.

    However, progress towards our target was affected by delays in vaccine introductions, especially for inactivated polio vaccine (IPV) but also human papillomavirus (HPV) and rotavirus vaccines. Introductions of IPV were delayed in 18 countries, rotavirus vaccine in 4 countries and HPV vaccine in 3.

    2016–2020 strategy overview →  

    KPI  

    Equity in vaccine coverage

    3 Geography 4 Poverty status 5Education of mothers/
    female caregivers

    Geography – what we measure

    The percentage of countries we support in which coverage with a third dose of pentavalent vaccine is equal to or greater than 80% across all districts. As part of an increased effort to ensure accurate subnational data are available for measuring equity, WHO and UNICEF have started to report geographically disaggregated coverage data on an annual basis.

    2016 performance

    16% of Gavi-supported countries reported pentavalent vaccine coverage (third dose) of at least 80% in all districts, the same proportion as in 2015. This mirrors the stagnation in national coverage estimates for pentavalent vaccine.

    Poverty status – what we measure

    The percentage of Gavi-supported countries in which coverage with a third dose of pentavalent vaccine among the poorest fifth of the population lies within 10 percentage points of the coverage among the richest 20%.

    Education of mothers/female caregivers – what we measure

    The percentage of Gavi-supported countries in which there is a less than 10 percentage point difference in immunisation coverage between children of non-educated mothers and those whose mothers have at least completed secondary school. We use three doses of pentavalent vaccine as the basis for this indicator.

    The poverty status and female education indicators are based on survey data. Due to limited availability of this data, and the implications this has for interpreting trends over time and across Gavi-supported countries, we are not presenting these indicators in this report. We continue to use equity data to drive our coverage and equity work in countries, and will report on individual countries where appropriate. We will give a full update of these indictors at the mid-term (2018) and end of our current strategy period (2020).

    KPI  

    Looking ahead
    • In this strategic period, we have ambitious goals to increase equitable uptake and coverage of all vaccines in every country we support. We will aim to do this by supporting more vaccine introductions and campaigns than ever before, and by helping countries to strengthen their routine immunisation systems.

      Extending existing vaccination programmes to reach more children within countries will account for just over half of the projected rise in immunisation coverage across all Gavi-supported vaccines by 2020.

    • New country introductions will drive the remaining 47%. We will also look at supporting new vaccines. In June 2016, we approved support for the piloting of a malaria vaccine. While its efficacy is lower than hoped, early estimates suggest a significant impact if the vaccine is combined with other interventions, including spraying and bednets.

      Health and humanitarian challenges will continue to shape the future of our support. These include an increasing number of fragile states, and failures to expand access to

    • immunisation in some Gavi-supported countries. More and more people are becoming displaced as a result of conflict and climate change, causing spill-over effects in neighbouring countries. Among these is the spread of infectious disease.

      Robust immunisation systems with high and equitable coverage have the potential to lessen all of these clear and present dangers. Strong childhood immunisation programmes in all countries will make the world a better and safer place for everyone.

     
  • The health systems goal


    increase the effectiveness and efficiency
    of immunisation delivery as an integrated
    part of strengthened health systems

    2016 at a glance

    ▶ 90% of countries’ applications for HSS support were recommended for approval on first review, having demonstrated a clear commitment to improving coverage and equity.

    ▶ The difference in coverage rates between the first and third dose of pentavalent vaccine in Gavi-supported countries has remained unchanged over the past few years – an indication that some delivery systems are still weak.

     

    ▶ 18 countries applied for support for more modern, energy-efficient cold chain equipment through our innovative platform.

    ▶ The proportion of Gavi-supported countries that meet our benchmarks for data quality increased from 43% in 2015 to 49% in 2016.

     

    Building a foundation for universal access to healthcare

    Since 2000, basic immunisation coverage in Gavi-supported countries has risen from 59% to 80%, despite a large population increase. In the last few years, however, progress has stalled, and health systems in the poorest countries are still not reaching an estimated one in five children with a full course of basic vaccines.

    These remaining pockets of underimmunised children are often the hardest to find. They tend to live either unregistered with health clinics in urban slums or in remote rural areas where they are beyond the reach of health workers. Others are born into marginalised communities where parents may be unaware of the benefits of vaccination.

    Vaccinating a child in the clinic is just the final destination of a complex journey that spans a sequence of essential steps – from training supply chain managers and health workers to maintaining the cold chain, collecting data and raising awareness of the benefits of vaccination in local communities.

    All of these activities have to be in place if vaccines are to be delivered at the right time and in the right quantity even to the poorest and hardest-to-reach communities. Importantly, they also provide a platform for delivering and prioritising other essential health services to children and their families.

    Improving coverage and equity, one of the central tenets of our 2016-2020 strategy, requires new and enhanced strategies to reach these children, including a revised approach to strengthening health systems.

    An evolving goal

    Gavi’s health system and immunisation strengthening (HSIS) framework, launched in early 2016, is designed to target bottlenecks to high and equitable immunisation coverage.

    Our new approach ensures that our different types of support, including health system strengthening (HSS) and technical assistance from Alliance partners, complement each other and align with national health plans. HSIS also shifts decision-making processes closer to countries.

    The bulk of our investment in health system strengthening is now directed towards “strategic focus areas” or SFAs. These are areas which we believe are most likely to yield sustainable improvements in coverage and equity, and where Gavi has a comparative advantage.

    By the end of 2016, three SFAs had been introduced: data, supply chain; and in-country leadership, management and coordination of immunisation programmes. We had also started to explore demand promotion and community engagement as a potential fourth SFA.

    Our 2016−2020 objectives reflect this shift in focus, and place greater emphasis on integrated immunisation programmes, investments in areas that are critical to improving coverage and equity, and enhanced partner collaboration. They are:

    • to contribute to providing integrated and comprehensive immunisation programmes including fixed, outreach and supplementary components;
    • to support improvements in supply chains, health information systems, demand generation and gender-sensitive approaches; and
    • to strengthen engagement of civil society, private sector and other partners in immunisation.

    2016-2020 strategy: health systems goal →  

    Performance indicators: health systems goal

    Supply chain performance

    What we measure

    The percentage of Gavi-supported countries meeting WHO’s effective vaccine management (EVM) benchmarks.

    This indicator helps countries to evaluate their immunisation supply chain performance over time against best practice standards, as well as to identify and respond to shortcomings. Among the supply chain features assessed are vaccine control, storage capacity, vaccine management, human resources and information systems.

    2016 performance

    19% of Gavi-supported countries met the 80% EVM benchmark, slightly below the 2016 target of 20%. There were, however, encouraging signs that our supply chain strategy was beginning to make a difference:

    • Supply chain leaders in 10 Gavi-supported countries met competency requirements. By 2020 we hope to have suitably qualified leaders in 35 countries.
    • 47 countries have conducted two supply chain management EVM assessments, 32 of which demonstrated improvements. Our aim is for all Gavi-supported countries to have implemented supply chain management plans by 2020.
    • 17 countries have expressed interest in improving information systems to oversee their supply chain and measure performance, and at least 11 have improved visibility in parts of the supply chain. Our 2020 target is 30–40 countries.
    • System design analyses were initiated in 10 countries; 7 were already implementing their findings to improve the efficiency of their supply chains. By 2020 our goal is for 10 countries to have completed this process.
    • A total of 18 countries had submitted requests for funding under our cold chain equipment optimisation platform. We aim to have upgraded cold chain equipment in 40−50 countries by the end of 2020.
     

    KPI  

    Data quality

    What we measure

    The proportion of Gavi-supported countries with less than 10 percentage point difference between different estimates of immunisation coverage.

    This indicator reflects the degree of consistency between available estimates of immunisation coverage. “Administrative coverage” refers to estimates based on national-level data reported annually by the country itself. “Survey coverage” refers to estimates based on data collected as part of household surveys, such as the demographic health survey, which is usually carried out every three to five years.

    2016 performance

    In 2016, 49% of countries reported administrative coverage data within 10 percentage points of survey estimates. This represents an increase of 6 percentage points compared with 2015, and puts us on track to achieve our 2020 target of 53%.

    2016–2020 strategy overview →  

    KPI  

    Coverage with a first dose of pentavalent vaccine and percentage point difference between the first and third dose

    What we measure

    Coverage with the first dose of pentavalent vaccine and the percentage point difference between first- and third-dose coverage in countries we support.

    Taken together, these two measures provide a good indication of the ability of the health system to deliver immunisation services. High first-dose coverage coupled with low rates of drop-out from the first to the third dose suggests a strong health system, capable of reaching and fully immunising children with the required number of doses. A weaker delivery system may succeed in reaching a child with the first dose but not the third.

    2016 performance

    Coverage with a first dose of pentavalent vaccine in Gavi-supported countries stayed at at 87% for the third consecutive year. The difference between coverage with the first and third dose increased from 6 to 7 percentage points.

    As our new support model, with its focus on innovation, community demand and immunisation supply chains, comes into its own we hope to see rising rates of coverage with all required doses of basic vaccines.

    2016–2020 strategy overview →  

    KPI  

    Integrated health service delivery

    What we measure

    The percentage of countries we support meeting our benchmark for integrated delivery of antenatal care and immunisation services. A country meets this benchmark if coverage levels for four interventions – antenatal care and administration of neonatal tetanus, pentavalent and measles vaccines – are within 10 percentage points of each other, and all above 70%.

    This indicator reflects the level of integration between immunisation and other interventions delivered through the routine system. If these complementary services are achieving similar levels of coverage, it generally follows that the linkages and coordination between them are strong.

    2016 performance

    26% of Gavi-supported countries met the benchmark for integrated service delivery – the same proportion as in 2015. The lack of movement on this indicator is likely due to several factors, including the fact that direct support for integrated service delivery is a recent development for the Alliance, and results will take several years to materialise.

    Everything we do to improve immunisation coverage and equity is done with a view to integrating service delivery and using immunisation as a platform for the delivery of essential health services. In 2016 alone, 62 million children in Gavi-supported countries received three doses of a DTP-containing vaccine. This equates to more than 185 million points of contact between these children and the primary health system, providing an opportunity to reach both them and their families with other health interventions and information.

    2016–2020 strategy overview →  

    KPI  

    Civil society engagement

    What we measure

    The percentage of countries we support meeting our benchmarks for civil society engagement in national immunisation programmes to improve coverage and equity.

    We use three criteria to assess the level of civil society engagement:

    • inclusion of civil society organisations in national immunisation plans with plans with clearly stated activities;
    • defined allocations in the EPI budget for CSO plans and activities (or justification given as to why these are not included); and
    • documented evidence that CSO plans have been completed and/or are being implemented.

    2016 performance

    Four of the 10 countries for which data are available meet all of the three criteria. CSOs feature in the national immunisation plans of seven of these countries, seven have clear budget allocations for CSO plans and activities, and six show evidence of CSO plans being implemented. A target for this indicator will be developed after one full year of reporting.

    2016–2020 strategy overview →  

    KPI  

    Looking ahead
    • Immunisation is one of the cornerstones of health systems, and a key component of universal health coverage. Yet children do not immunise themselves. Delivering vaccines requires a well-oiled machine of trained staff, efficient supply chains, equipped health clinics, functioning information systems, sufficient resources, and parents and communities who are aware of the benefits of immunisation.

      Going forward, we will continue to find innovative solutions, drive the use of data and new technology, and work nimbly across the public and private sectors.

    • This will help improve access not only to vaccines, but to other health services as well. Importantly, our support to HSS will help countries prevent and manage outbreaks of infectious diseases.

      We will continue to build on our more country-centric support model to provide exible solutions that help each country tackle its specific barriers to immunisation.

    • It will also help us to manage risks more effectively.

      Immunisation, at its most basic level, currently reaches 86% of the world’s children. It is the only intervention that has the potential to bring the vast majority of families into contact with a country’s health system five or more times during the first year of a child’s life. If we expand this reach even further, we have a solid platform in place for universal health coverage.

     
  • The sustainability goal


    improve sustainability of national
    immunisation programmes

    2016 at a glance

    ▶ 14 countries fully self-financed 21 vaccine programmes originally introduced with Gavi support.

    ▶ Self-financing represented 15% of all country co-financing of vaccine programmes (roughly US$ 20 million).

    ▶ Countries contributed a total of US$ 133 million to the cost of their vaccines, the highest amount to date.

     

    ▶ All countries that had failed to pay their 2015 commitments on time paid their arrears in 2016.

    ▶ Four countries transitioned out of Gavi support.

    2016-2020 strategy: sustainability goal →  

    Supporting countries to become self-sufficient

    Empowering countries to take ownership of their vaccine programmes lies at the heart of the Alliance’s vision. When we partner with a country, it is on the understanding that it also commits resources to developing its own immunisation programme. This begins with all countries self-funding a portion of the cost of the vaccines introduced with our support.

    We adjust the level of our support according to a country’s ability to contribute towards the cost of its vaccines. As its income grows, so does its vaccine co-financing obligation. At a certain pre-defined income level, we start to phase out our financial support, usually over a five-year period, until the country is fully self-financing. This process is called “transitioning”.

    In the 2016–2020 period, 20 countries are expected to start fully self-financing their vaccines. Of these, four transitioned in 2016.

    An evolving goal

    Financial sustainability has been a key principle for Gavi from the start. Over time, our model has evolved to also incorporate programmatic sustainability.

    Our aim now is to make certain that all immunisation programmes established with Gavi support are sufficiently strong and resourced to continue delivering life-saving vaccines after a country transitions.

    Our new approach sets a long-term sustainability goal for all our investments in each of the countries we support. To achieve this goal, we apply a series of investment principles that guide the way in which a country programme is designed and implemented.

    This vision lies behind our three new sustainability objectives for the 2016−2020 period. These are:

    • to boost national and subnational political commitment to immunisation;
    • to help enable national human and financial resources to be allocated to immunisation appropriately by legislative and budgetary means; and
    • to prepare countries to sustain immunisation performance after they transition.
     
    Performance indicators: sustainability goal

    1 Countries on track to successful transition

    What we measure

    The percentage of countries in the accelerated transition phase that are on track for a successful transition. A country is on track if:

    • it shows substantial progress in implementing its transition plan (that is, at least 75% of milestones and activities, such as having a functional national regulatory agency, have been completed on time);
    • its coverage with the third dose of diphtheria-tetanus-pertussis vaccine (DTP3) has increased over the last three years (if the country has already reached DTP3 coverage of at least 90%, it should have sustained this level for three years); and
    • it is meeting its co-financing obligations and did not default on its payments in the previous year.

    2016 performance

    79% of countries in the accelerated transition phase were on track for successful transition. Many countries made impressive strides in preparing for their transition out of Gavi support.

    In total, 14 countries fully self-financed 21 vaccine programmes originally introduced with Gavi support. This equates to approximately US$ 20 million, or around 15% of the total value of vaccine co-financing in 2016, and provides proof that our sustainability model is working.

    The four countries that transitioned in early 2016 (Bhutan, Honduras, Mongolia and Sri Lanka) are now fully financing the vaccines they introduced with Gavi support. In 2016, these countries continued to show an outstanding commitment to immunisation. Mongolia was able to self-finance its 2016 introduction of pneumococcal vaccine, taking advantage of the lower price offered through our Advanced Market Commitment.

    Honduras and Sri Lanka both drew on our catalytic support for routine immunisation with the human papillomavirus (HPV) vaccine. Gavi only contributed 50% of the cost of the vaccine during the first year of introduction. Both countries had access to the reduced price negotiated by Gavi.

    Building on this success, another four countries – Guyana, Indonesia, Kiribati and the Republic of Moldova – stopped receiving Gavi vaccine support at the end of 2016 and will transition fully in 2017. Guyana contributed more towards its vaccine costs than required – testament to its determination to become self-sufficient.

    Although Indonesia is transitioning successfully, the country faces significant challenges. Coverage remains low and HPV, pneumococcal and rotavirus vaccines are not yet part of the national immunisation programme. In 2016, Indonesia was approved for catalytic support to introduce the measles-rubella vaccine nationwide.

    2016–2020 strategy overview →  

    KPI  

    2 Co-financing

    What we measure

    The percentage of countries that fulfill their co-financing commitments by the end of the year, or who pay their arrears in full within 12 months.

    Where necessary, we adapt our deadlines to countries with a different fiscal cycle, such as Kenya and Pakistan.

    2016 performance

    All countries with co-financing obligations fulfilled their commitments within the 12-month window, a clear sign that they are fully committed to co-financing. All 10 countries that defaulted on their payments in 2015 had cleared their arrears by the end of 2016.

    Overall, 2016 proved to be our most successful year ever in terms of co-financing. Countries co- or self-financed 184 programmes introduced with our support – an 11% increase from 2015. In addition, the amount of co-financing contributions received by December 2016 was up 25% on the figure for December 2015.

    Only six countries defaulted on their 2016 obligations:

    • The Democratic Republic of the Congo ended the year in default, although its vaccine funding has increased consistently since 2014 following Gavi’s adoption of a more country-tailored approach.
    • Ghana struggled with severe budget restraints and economic hardship, a particularly worrying development as it was about to enter the accelerated transition phase.
    • Madagascar was only able to pay around half of its co-financing requirements.
    • Due to health budget constraints, the Niger could not mobilise sufficient domestic resources on time.
    • Two fragile states failed to make their payments before the end of the year: South Sudan, which was embroiled in a civil war, and Yemen. The latter received an extension of the waiver granted by our Board in late 2016 for its co-financing requirements.
     
    KPI

    Source: Gavi, the Vaccine Alliance, 2016.

    3 Country investments in routine immunisation

    What we measure

    The percentage of countries that have increased their investment in routine immunisation per child, relative to 2015.

    This indicator covers every vaccine in a country’s national programme, not just those supported by Gavi. It also includes expenditure on related 85% products beyond vaccines, such as injection supplies.

    2016 performance

    Results for this indicator will be available in November 2017.

    KPI  

    4 Institutional capacity

    What we measure

    The percentage of Gavi-supported countries that meet our minimum criteria for national decision-making, programme management and monitoring.

    Strong institutional capacity is vital if a country is to become programmatically and financially sustainable. This indicator assesses the performance and effectiveness of key immunisation management bodies such as the Expanded Programme on Immunization (EPI) and national immunisation technical advisory groups (NITAGs).

    2016 performance

    Initial data highlighted the need for Gavi to revisit the way in which the indicator is measured to better capture countries’ progress. The revised indicator results will be available in October 2017.

    Results available:
    OCTOBER 2017
     

    Looking ahead
    • We are entering a period in which our transition model will be tested as it never has been before.

      Between 2017 and 2020, another 12 countries are set to transition: Angola, Armenia, Azerbaijan, Bolivia, the Congo, Cuba, Georgia, Nicaragua, Papua New Guinea, Timor-Leste, Uzbekistan and Vietnam.

      Most of the countries that are on track for successful transition have a number of characteristics in common, principally strong political commitment to immunisation and resilient health systems.

    • However, others will transition without having introduced some of the key life-saving vaccines, and many face low levels of immunisation coverage and equity. Of these, five are at risk of not being fully ready to transition, or transitioning with low coverage rates. This group includes Angola and the Congo, who have both repeatedly defaulted on their co-financing payments.

    • We will continue to strengthen our engagement with at-risk transitioning countries. Although they will still be expected to take over full financing of their existing programmes, there may well be a case for maintaining our involvement after they transition to build on the progress they have already made.

      Whatever happens, we will continue to find new ways to improve how we work, so that we can help all countries sustain their achievements well into the future.

     
  • The market shaping goal


    shape markets for vaccines and other
    immunisation products

    2016 at a glance

    ▶ By the end of 2016, nine markets had sufficient and uninterrupted supply. This is 82% of our 2020 target.

    ▶ The weighted average price per course of pentavalent, pneumococcal and rotavirus vaccines was US$ 19, down 5% from 2015.

    2016-2020 strategy: market shaping goal →  

    ▶ Three products with improved characteristics became available to countries we support: an oral cholera vaccine with an improved vial opening system, a human papillomavirus (HPV) vaccine approved to be used outside of the cold chain for a limited period and a pentavalent vaccine with a smaller vial size.

    ▶ Two vaccine markets were assessed to have moderate to high market health – our target for 2020 is six.

     

    Shaping markets to support increased immunisation

    The Alliance exists to support countries’ efforts to introduce new vaccines and immunise as many children as possible. Through the comparative advantage of Alliance partners, we are in a unique position to shape markets for the benefit of the countries we work with.

    Healthy markets allow manufacturers to produce the right vaccines and immunisation products in quantities and at prices that are appropriate and sustainable. This enables developing countries to access suitable products at prices they can afford, even after they transition out of Alliance support. Donors are also able to maximise their investments.

    By the end of 2015, we had met or exceeded our key market shaping goals for the 2011–2015 strategic period. We had been able to identify and attract new manufacturers with suitable products in several markets – pentavalent vaccine, for instance.

    The cost per child to fully immunise with pentavalent, pneumococcal and rotavirus vaccines had decreased, while our product offering had increased with eight new products.

    Throughout the five-year strategy, we improved transparency and information sharing.

    Despite good progress, challenges remained. For example, the vaccine market landscape evolved significantly from 2011. At the same time, Gavi’s vaccine portfolio doubled from 6 to 12 vaccines.a 

    These developments, coupled with the current Gavi strategy that strongly focuses on improving coverage and equity, have guided the development of a new supply and procurement strategy for the 2016–2020 period. This takes a more holistic view of healthy markets, applies a longer-term approach to market shaping and clearly defines our role in product innovation.

    a – Gavi has committed to funding a stockpile for a 13th vaccine, Ebola, once it has been licensed and recommended by WHO.

    Performance indicators: market shaping goal

    1 Sufficient and uninterrupted supply

    What we measure

    Number of Gavi vaccine markets with sufficient and uninterrupted supply of appropriate vaccines.

    2016 performance

    At the end of 2016, 9 of the vaccine markets in which we work had sufficient and uninterrupted supply. This is 82% of our 2020 target, which is 11 markets.

    Supply levels for the inactivated polio vaccine (IPV) and yellow fever vaccine remained lower than they should be. IPV programmes have been delayed or interrupted. Shortages of yellow fever vaccine meant it was not possible to fully meet increases in demand for vaccination campaigns without interfering with routine immunisation programmes.

    Our support in helping a second oral cholera vaccine (OCV) become available to UNICEF was a significant step forward. Supply is now sufficient to meet demand.

    KPI  

    2 Cost of fully vaccinating a child with pentavalent, pneumococcal and rotavirus vaccines

    What we measure

    Change in the weighted average vaccine price per child to fully vaccinate him or her with pentavalent, pneumococcal and rotavirus vaccines.

    2016 performance

    In 2016, the weighted average price per course of pentavalent, pneumococcal and rotavirus vaccines was US$ 19, down 5% from 2015. This reduction follows a 43% drop between 2010 and 2015, and marks the first time we broke the US$ 20 barrier.

    The decrease in cost was driven by an 8% reduction in the weighted average price for the pentavalent vaccine and the effects of the exchange rate on the cost of the rotavirus vaccine.

    Because this indicator is unchanged from the 2011–2015 period, we will be able to monitor trends in price reduction over a continuous period of 10 years to 2020.

    KPI  

    3 Innovation

    What we measure

    The number of vaccine products with improved characteristics procured as compared to the baseline year.

    This indicator uses straightforward, objective criteria, published by WHO, the Alliance partner responsible for technical guidance on vaccines. The indicator includes all antigens supported by Gavi.

    2016 performance

    In 2016, three products with improved characteristics became available to countries we support. Our 2020 target is 10. These included a new presentation of OCV with an improved vial opening system, an HPV vaccine approved to be used outside of the cold chain for a limited period and a pentavalent vaccine with a smaller vial size.

    KPI  

    4 Healthy market dynamics

    What we measure

    the number of Gavi vaccine markets with moderate or high healthy market dynamics. We rate this in terms of:

    • high
    • moderate
    • low
    • no healthy market dynamics.

    2016 performance

    Of the vaccine markets in which Gavi operates, two (the pentavalent and HPV vaccine markets) enjoyed moderate to high market dynamics in 2016. The supply of vaccines met country demand and presentation preference and the markets showed moderate supply security. By 2020, we aim to have six healthy vaccine markets.

    KPI  

    Looking ahead
    • To deliver on our 2016–2020 goal of healthy markets, it is important to recognise that each market is unique and evolves at a different pace depending on a range of factors. This requires moving beyond assessing supply, cost and innovation as separate objectives to improving the overall “health” of each vaccine market.

      Suitable product innovation is key to better meet the needs of the countries we support and to improve coverage and equity.

    • Over the current strategic period, our Alliance will develop common principles to guide our approach to product innovation. We will take into account not only the cost of these innovations but also the potential impact on our coverage and equity goals.

      In everything we do, we will take a longer-term view of markets. This includes equipping countries that transition out of our support to sustain their immunisation programmes as well as to become strategic customers in the vaccine market.

    • We will share our knowledge to help countries make well-informed decisions about which vaccines to introduce and procure.

      We have already helped to transform several vaccine markets – including the market for pentavalent vaccine. Over time, we will aim to have a positive impact on more markets, stretching well beyond the countries we support.

     
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