In March 2008, Gavi contracted JSI Research & Training Institute, Inc. (JSI) to evaluate its injection safety support (INS) window. The evaluation, which was overseen by Gavi's Injection Safety Support Steering Committee, focused on the experience of 58 countries that were awarded INS support during the Gavi's first three years: 15 countries in 2002, 22 countries in 2003, and 21 countries in 2004.


The objectives of the evaluation were to:

  • describe the decision-making process regarding the replacement of Gavi INS support;
  • assess how and to what extent countries have replaced Gavi support during the first year (or more) after Gavi INS support ended;
  • determine how countries have replaced Gavi INS support in a sustainable manner;
  • assess the effect of the Gavi INS support on the broader health sector at the country level;
  • determine how cash funds have supported the implementation of country INS plans of action.


The evaluation utilised both quantitative and qualitative methods to determine whether and how participating countries sustained the supply and use of auto-disposable syringes (AD) syringes after the end of INS support.

The quantitative analysis relied on publicly available data, as well as data provided by the Gavi Secretariat, to ascertain program performance before, during and after Gavi support.

The qualitative analysis relied on information collected during telephone interviews with National Immunization Program (NIP) managers in the subject countries and WHO/UNICEF immunisation focal points.


Gavi's INS support has improved injection safety practices and almost all recipient countries have found ways to replace and sustain the use of AD syringes and safety boxes.


  • All but two of the 46 commodity-recipient countries were able to replace and sustain the use of AD syringes and safety boxes after the end of their Gavi INS support.
  • By mid 2008, 54 percent of the countries were fully financing their commodities with government support, 15 percent were using a combination of government and donor funding, and the remaining 26 percent were donor dependent.
  • West African countries performed better on the financial sustainability indicator than countries in other regions/subregions, possibly because of advocacy by WHO and UNICEF focal points and significant budget support from the European Union for vaccines and essential supplies.
  • Seventy-four percent of the countries receiving commodities and almost all (34 out of the 35) of the government- and/or partially donor-funded countries had a budget line item for the procurement of AD syringes and safety boxes at the time of the evaluation.
  • All 12 countries that received Gavi cash support continued to use AD syringes and safety boxes in their immunisation programs in the years following Gavi INS assistance.
  • Gavi INS support had a positive impact on injection safety practices in the broader health services. Thirty of the 57 countries (53 percent) that responded to this set of questions fully or partially introduced AD syringes and safety boxes to medical services and programmes beyond immunisation, e.g., curative care, HIV/AIDS programmes, family planning.
  • Introduction of AD syringes and safety boxes increased the health care waste management (HCWM) burden on countries.
  • The INS evaluation team found that AD syringe use is considerably higher in Gavi countries than in non-Gavi, lower-middle-income countries.
  • An analysis of UNICEF Supply Division data supported the finding that non-Gavi-funded procurement of AD syringes and safety boxes (i.e., procurement by countries and others through UNICEF) increased after 2004. However, the trend in supply of AD syringes for BCG vaccines, which are unique to Gavi INS, provided evidence that INS support was not only fully replaced, but that the volumes supplied through UNICEF actually increased after INS support ended.


  • Evaluation of Gavi's injection safety support


Last updated: 11 Dec 2019

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