• Introduction

    Gavi Annual Progress Report 2017

    Welcome to Gavi’s Annual Progress Report for 2017, the second in a series of five covering our current strategic period. This report highlights some very encouraging results, but also identifies challenges that we need to tackle if we are to continue to make progress.

    Browse this online version for a comprehensive analysis of how our Alliance is progressing towards achieving our mission and strategic goals, as well as a selection of case studies on our work to reach the unreached with life-saving vaccines.

     

    INTRODUCTIONS: GAVI’S CEO AND BOARD CHAIR


    There is a need for an even greater collective commitment, increased focus on strengthening routine immunisation systems, and continued innovation and learning.

     

    Dr Seth Berkley, CEO

    In 2017 we supported the vaccination of 65 million children – 3 million more than in 2016 – and we are well on track to achieve our mission target of immunising an additional 300 million children between 2016 and 2020. The breadth of protection has also increased, from 37% to 41%, with more countries offering a wider range of vaccines as part of their routine immunisation programmes than ever before.

    This progress has been made despite the supply challenges we are continuing to experience for some vaccines, particularly inactivated polio vaccine (IPV) and human papillomavirus (HPV) vaccine. Supply shortages of these two vaccines, driven by a dramatic increase in demand, were one of the main reasons why in 2017 only 35 of the 50 planned introductions were possible.

    Immunisation continues to be the most universal, cost-effective health intervention. Since our inception in 2000, the Vaccine Alliance has made huge progress in expanding access even further. Our work has helped to nearly halve the number of children in Gavi-supported countries who miss out on basic immunisation – from 28 million in 2000 to just over 16 million today. This has been achieved despite a 15% increase in the number of children surviving beyond 12 months in Gavi-supported countries since 2000.

    We have seen a welcome improvement in coverage with the third dose of diphtheria-tetanus-pertussis-containing vaccines (DTP3), such as pentavalent, in this strategic period, with a 1 percentage point increase over the 2015 baseline. While this is a start, it is not as much as we would have liked – being below our targeted rate of increase. It highlights the need to accelerate progress further with an even greater collective commitment, increased focus on strengthening routine immunisation systems, and continued innovation and learning.

    This is particularly true in countries and areas that are suffering from fragility. Irrespective of the cause – be it conflict, economic decline or the results of climate-related pressures – people living in areas deemed to be fragile are most in need of the protection immunisation offers, but are inherently difficult to reach.

    In such settings, immunisation campaigns often play an important role in rapidly protecting large numbers of vulnerable people from disease. But for many countries, reliance on repeated campaigns can be a contributor to the problem rather than a long-term solution. Too much focus on expensive mass immunisation campaigns, which often come in response to an outbreak, takes health workers away from routine services and detracts from where the real focus should be – on strengthening routine immunisation services and building strong primary healthcare systems. This is one reason why we have not seen measles vaccine coverage increase since 2015. Yellow fever is another case in point: while effort and resources are used to tackle outbreaks through campaigns, routine coverage has remained at below pre-2009 levels for the last five years.

    However, while the issue of coverage remains critical, it should not detract from the progress we have made in other areas. Gavi’s market shaping efforts, for example, have continued to deliver by promoting competition and improving the health of vaccine markets. As a result, in 2017 we saw the cost of fully immunising a child with pentavalent, pneumococcal and rotavirus vaccines fall to US$ 16.63, a reduction of 12% from 2016. In another testament to the continued success of the Gavi model, 8 countries transitioned out of our financial support by the end of the year, bringing the total to 16. This means that we are firmly on course to reach our target of 20 transitioned countries by 2020.

    All this stands us in good stead for our mid-term review in Abu Dhabi in December 2018, where we will report on our progress to our donors. However, as we get closer to 2020 and start thinking about our next strategic period, it is vital that we continue to focus on the challenges highlighted in this report. Because the 2021–2025 period, or “Gavi 5.0”, is likely to present a whole new set of challenges, getting coverage on an upward trajectory again is a number one priority. With renewed focus from countries and partners, we can make sure that no child is left behind.


    To keep immunisation levels high post-transition, we will continue our engagement with transitioning countries and provide them with the support they need to succeed.

     

    Dr Ngozi Okonjo-Iweala, Gavi Board Chair

    One of the year’s recurring themes was “collaboration”. Throughout 2017, Gavi found new ways to work with partners to overcome challenges, both old and new. For an alliance such as ours, that is just how it should be.

    With more than 60 partners now on board, our partners’ engagement framework (PEF) is delivering new ways of working thanks to its inherently country-centric approach. In its first two years of operation, PEF has funded more than 200 WHO and UNICEF country office staff positions dedicated to immunisation.

    Our new fragility, emergencies and refugee policy is another novel way in which we are working more closely with countries. Introduced in June 2017, this policy enables Gavi to respond more quickly and with greater flexibility than ever before, allowing countries to boost the number of people in fragile settings receiving vaccines.

    This has never been more needed. In 2017, more than 68 million people were displaced from their homes, more than at any time since World War II. Our new policy aims to address this growing problem by, for example, making it possible for countries hosting large numbers of refugees to request additional support to immunise them. Bangladesh became the first country to take advantage of the policy, conducting Gavi-funded vaccination campaigns for Rohingya refugees in Cox’s Bazar in late 2017.

    Collaboration is also key to ensuring the continued success of Gavi’s sustainability model. Of the 16 countries that have transitioned out of Gavi support so far, 6 are showing signs of a downward trend in immunisation coverage. In order to keep immunisation levels high post-transition, we will continue our engagement with transitioning countries and – by working more closely with key partners such as the World Bank, the Global Fund and the Global Financing Facility around health financing and transition – provide them with the support they need to succeed.

    This support also includes establishing mechanisms for peer-to-peer knowledge exchange such as South-to-South partnerships, in-person get-togethers, study tours and an online members’ platform that encourages best practice in immunisation.

    Initiatives such as these will continue to strengthen and broaden our collaborative links with key partners. Our collaborative work with the Global Fund, for example, already covers a wide range of immunisation related-activities, from risk management, advocacy and health system strengthening, through to monitoring and evaluation. Along with WHO and Unitaid, the Global Fund is also a major partner in our joint effort to pilot a new malaria vaccine. Large-scale trials are due to start in late 2018.

    With positive impacts on education, global health security and civil registration, immunisation provides a gateway to universal health coverage. As our Alliance continues to play an increasingly central role in global health we expect to increase the level of collaboration with an ever-wider range of actors and partners as we work together towards our shared goals.


     

    The Gavi model at work

    Gavi, the Vaccine Alliance is a public-private partnership dedicated to creating equal access to vaccines for people in the world’s poorest countries.

    We bring together all the main actors in global immunisation around our shared mission. All partners contribute to the Gavi business model, and all are accountable for its performance.

    By leveraging economies of scale, Gavi is able to create more stable markets for vaccines and drive down vaccine prices. Sustained, low pricing for vaccines means that more countries are able to maintain and grow their immunisation programmes after our financial support stops.

    Gavi's business model →  

     
  • Measuring our performance


    mission and strategic goals

    The Vaccine Alliance’s 2016–2020 mission is to save children’s lives and protect people’s health by increasing equitable use of vaccines in lower-income countries.

    Five mission indicators reflect our overall aspiration for the 2016–2020 period. We aim to help countries to immunise 300 million children in this period, thereby saving 5–6 million lives in the long term. This is expected to contribute to a 10% reduction in child mortality rates in Gavi-supported countries, and avert 250 million years lost due to disability and death.

    2016–2020 strategy overview →  

    Sustainability is another important ambition for the Alliance. We strive to ensure that all recommended vaccine programmes are maintained by countries after our financial support stops.

    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 systems.a People immunised through campaigns and supplementary immunisation activities are not included.

    2017 performance

    Countries immunised 65 million children – often with more than one Gavi-supported vaccine – in 2017. This is 3 million more than in 2016 and brings the total number of children immunised with our support in the current strategic period to 127 million. We are on track to help countries immunise 300 million children between 2016 and 2020.

    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)

    2017: 65m

    127m  

    2015: n/a2020 target: 300m

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

    Future deaths prevented

    What we measure

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

    2017 performance

    Developing countries prevented approximately 1.3 million future deaths in 2017, up from 1.2 million 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 prevented

    (millions)

    2017: 1.3m

    2.5m  

    2015: n/a2020 target: 5-6m

    Source: Vaccine Impact Modelling Consortium

    Under-five mortality rate

    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.

    2017 performance

    Under-five mortality fell from 62 to 60 deaths per 1,000 live births between 2015 and 2016, putting us on track to reach our target of 56 deaths per 1,000 live births by the end of 2020. 2017 estimates will be available in late 2018.

    Under-five mortality rate

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

    2016:2017 data available Q4 2018

    60/1,000  

    2015: 62/1,0002020 target: 56/1,000

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

    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.

    2017 performance

    Countries averted approximately 55 million DALYs in 2017 thanks to our support, compared with 50 million in 2016. We are on course to achieve our target of 250 million DALYs averted by 2020.

    2017: 55m

    105m  

    2015: n/a2020 target: 250m

    Source: Vaccine Impact Modelling Consortium

    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.

    2017 performance

    All transitioned countries continued to deliver all their recommended routine vaccination programmes throughout 2017.

    100%  

    2015: n/a2016-2020 target: 100%

    Source: WHO/UNICEF Estimates of National Immunization Coverage

    Four strategic goals and a set of key performance indicators help us track our progress.

    • 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

      Improve 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
     

    2017 at a glance

    ▶ Average coverage of Gavi-funded vaccines in the countries we support climbed to 41%, up from 37% in 2016.

    ▶ Coverage with a full course of pentavalent vaccine across Gavi-supported countries has stalled at 80% – some way from our 2020 target of 84%.

    ▶ On average, 84% of districts across Gavi-supported countries met the benchmark for equitable immunisation coverage, putting us on track to achieve our target.

     

    ▶ We only achieved 35 of the 50 introductions scheduled to take place in 2017, largely due to supply shortages.

    ▶ 2017 saw the WHO prequalification of a new, more effective typhoid vaccine, allowing Gavi to open a funding window to support it.

     

    Reaching the unreached

    All children – regardless of whether they are girls or boys, where they live or how poor they are – are entitled to be vaccinated against deadly and debilitating diseases. To help ensure that children everywhere have access to this fundamental right to health, our Alliance continues to support the delivery of 13 life-saving vaccines in the world’s poorest countries, including some of the most fragile.

    Since Gavi was founded in 2000, we have supported nearly 400 vaccine introductions and campaigns and helped to increase average routine immunisation coverage rates by more than 20 percentage points across the countries we support.

    However, this average figure masks inequities in coverage between countries. In non-fragile Gavi-supported countries, coverage has steadily increased, putting it on a par with the global average. Meanwhile, coverage across the 18 Gavi-supported countries that were classified as fragile in 2017 has remained flat over the past seven years.

    This is not to say that no progress has been made: given population growth and the enormous challenges fragile countries face, maintaining coverage levels is already an impressive achievement. But we recognise that we need to work harder to overcome the obstacles to reaching every child in all countries – poor infrastructure, lack of frontline health workers, weak management and social, cultural and gender-related barriers – in order to achieve our goals.

    Our objectives

    Our ambitions for the 2016–2020 period include not only extending the reach of routine immunisation programmes but also increasing the number of vaccines each child receives. On the latter, we are progressing well.

    Despite some delays due to supply shortages, between January 2016 and December 2017 we supported 80 introductions and campaigns; at least 150 more are expected by the end of 2020.

    In recent years, an increasing proportion of our support has been allocated to immunisation campaigns. While these are essential in order to vaccinate those who are missing out on routine immunisations, there is a risk that frequent and insufficiently planned campaigns take much-needed resources away from routine programmes. We are working with countries to improve the quality of campaigns through more careful planning and systematic assessments to ensure that the expansion and strengthening of routine immunisation programmes is not compromised.

    While increasing coverage and equitable uptake of all vaccines across the countries we support remains our key objective, we also aim to:

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

    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 pentavalent vaccine, which protects against diphtheria, tetanus, pertussis (DTP), hepatitis B and Hib, 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 receive 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.

    2017 performance

    Average coverage of the first dose of measles vaccine in Gavi-supported countries has plateaued at 78%. While third-dose pentavalent vaccine coverage increased between 2015 and 2016, it stalled over the past year – leaving us moderately off track to reach our 2020 target. This trend is particularly evident in fragile countries, where coverage has remained at just 62% since 2010.

    Because of population growth, flatlining coverage rates still mean that countries are immunising more children than ever before. The total number of children who received a third dose of DTP-containing vaccine, such as pentavalent, in Gavi-supported countries increased from 62 million in 2016 to close to 64 million in 2017.

    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 the last dose of three vaccines specific to certain regions.a  

    2017 performance

    Coverage for these nine vaccines averaged 41% in 2017, an increase of 4 percentage points compared with 2016. However, progress was below target in 2017 – largely due to delayed vaccine introductions caused by supply shortages – and we are slightly off track to reach our 2020 target of 62%.

    2016–2020 strategy overview →  

    a – In 2017, this indicator only tracked six vaccines. HPV vaccine was not included due to lack of data.

    KPI  

    3 Equity: geographic distribution

    What we measure

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

    2017 performance

    The proportion of districts in Gavi-supported countries in which third-dose pentavalent vaccine coverage is equal to or above 80% increased from 80% in 2016 to 84% in 2017. We are on track to achieve our 2020 target of 89%.

    4 Equity: wealth distribution

    What we measure

    Average difference in coverage with a third dose of pentavalent vaccine between the poorest fifth of the population and the richest 20% across the Gavi-supported countries where recent data is available.

    2017 performance

    The average difference between immunisation coverage in the richest and poorest quintiles in Gavi-supported countries was 19% in 2017. The lack of movement on this indicator since 2015 means that we are not on track to reach our 2020 target of 16%. Due to the low availability of recent data, however, measuring progress in this area remains a challenge.

    5 Equity: maternal education

    What we measure

    Average difference in coverage between children of non-educated mothers or other female caregivers, and those whose mothers have at least completed secondary school. We use three doses of pentavalent vaccine as the basis for this indicator, which includes all Gavi-supported countries where recent survey data is available.

    2017 performance

    The average difference between coverage of the third dose of pentavalent vaccine among children of educated and non-educated mothers in Gavi-supported countries has stalled at 19% over the last few years. Gavi is currently not on course to meet its 2020 target for this indicator, although the lack of availability of recent data poses challenges for accurately tracking this indicator.

    KPI  

    KPI  

    KPI  

    Looking ahead
    • The Vaccine Alliance is on track to help countries to immunise 300 million additional children in the 2016–2020 period, and to contribute to a significant increase in the number of vaccines each child receives.

      However, stagnating coverage rates for routine immunisation remain a trend that the Alliance is working hard to reverse. The high frequency of vaccine-preventable disease outbreaks is also of concern and often a sign of persistent weaknesses in routine immunisation systems, particularly in the poorest and most fragile countries. We are working with a wide range of partners to help countries address this, but we recognise that this is a long-term process.

    • We are increasingly adopting more flexible, tailored approaches to meet the specific needs of fragile countries, where routine immunisation services are struggling to reach everyone with life-saving vaccines. This will require more innovative solutions and even greater levels of collaboration across the public and private sectors.

      We are also looking at supporting new, life-saving vaccines. Our next vaccine investment strategy, due to be finalised by the end of 2018, will identify new vaccines and immunisation products for inclusion in our portfolio going forward, prioritising products that will maximise our impact.

    • In 2016, we took the decision to support the piloting of a malaria vaccine, with large-scale trials starting in 2018. Given the high mortality rates for malaria – especially among young children – the vaccine could have a significant impact if it is used in combination with other interventions, including spraying and bednets.

      Making sure that people everywhere are fully protected with all the vaccines they need is vital to prevent disease outbreaks, protect global health security and safeguard the lives of all children – now and in the future.

     
  • The health systems goal


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

    2017 at a glance

    ▶ Coverage with the first dose of pentavalent vaccine in Gavi-supported countries has flatlined over the past couple of years – an indication that some systems are still weak.

    ▶ The proportion of Gavi-supported countries that meet our benchmarks for integrated service delivery increased from 34% in 2016 to 44% in 2017.

     

    ▶ Countries were approved for support for 66,000 pieces of state-of-the-art, environmentally-friendly refrigerators and freezers through our innovative cold chain equipment platform.

    ▶ Gavi-supported countries received an average score of 68% for effective vaccine management, up from 67% in 2016.

     

    A platform for health

    Currently, 80% of all children in the world’s poorest countries are immunised with a full course of basic vaccines, and even more are reached through vaccination campaigns. No other health intervention touches as many lives, particularly during the first year of life.

    Immunising millions of children, especially those who live in some of the most fragile and remote regions of the world, is a complex undertaking. Communities need to be informed about the benefits of immunisation, vaccines have to be kept cool on their long journey from depot to clinic, health workers and supply chain managers require training, and immunisation data needs to be collected and analysed. While all of these components must be in place to reach children with vaccines, they also serve as a platform for other health services.

    Reaching the final “fifth child” – the one in every five children in the poorest countries who is still missing out on basic immunisation – is often the most difficult. He or she tends to live in a fragile country plagued by conflict or natural disaster or in an isolated rural area beyond the reach of health workers. Others may be “hidden” in urban slums or born into communities where there is little awareness of the benefits of vaccines.

    Strengthening health systems is critical to reaching the “fifth child” and achieving one of the main goals of our 2016–2020 strategy: greater immunisation coverage and equity.

    Our objectives

    One of the main aims of our health system and immunisation strengthening (HSIS) framework, launched in 2016, is to identify and address bottlenecks to sustainable, high and equitable immunisation coverage.

    When a country applies for new health system strengthening (HSS) support, we work together with national health authorities and in-country partners to ensure that the application includes a three- to five-year overview of all types of Gavi support: vaccine support, HSS support (including cold chain equipment) and technical assistance.

    This helps to ensure that planned interventions are complementary and align with national health plans. It also means that health system strengthening activities can be better targeted and tailored to reach the children who are still missing out on vaccination.

    The majority of our HSS funding is directed towards “strategic focus areas”, or SFAs. These are the areas that we consider most likely to have a sustainable impact on coverage and equity, and where Vaccine Alliance partners have a comparative advantage.

    By the end of 2017, we had introduced four SFAs: data; supply chain; sustainability; and in-country leadership, management and coordination of immunisation programmes. During the year, the Alliance started to move forward with demand generation as a potential fifth SFA.

    Our 2016−2020 objectives reflect the critical importance of integrated immunisation programmes, investments that are key 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 average score achieved by Gavi-supported countries that have completed WHO’s effective vaccine management (EVM) assessment. 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 features assessed are vaccine management, storage capacity, human resources and information systems.

    2017 performance

    Gavi-supported countries achieved an average EVM score of 68% in 2017, up from 67% 2016. A target for this indicator will be developed in late 2018. Nevertheless, it is clear that countries and partners have made important strides towards implementing our supply chain strategy:

    • By the end of 2017, 34 countries had been approved for funding for more than 66,000 new, energy-efficient refrigerators and freezers under our cold chain equipment optimisation platform (CCEOP). We aim to have upgraded cold chain equipment in 40−50 countries by the end of 2020.
    • Supply chain leaders in 15 Gavi-supported countries met competency requirements, having completed the STEP leadership development programme to build management skills and competencies. By 2020 we hope to have qualified leaders in 35 countries.
    • 54 countries have conducted at least two supply chain management EVM assessments, 35 of which demonstrated improvements. Our aim is for all Gavi-supported countries to have implemented supply chain management plans by 2020.
    • At least 31 countries are using various information systems to monitor their stock and manage their cold chain inventories. Our 2020 target is 30–40 countries.
    • System design analyses were initiated in 11 countries; 7 were already implementing their findings to improve the efficiency of their supply chains. Our goal is for 10 countries to have completed this process by 2020.
     

    KPI  

    Data quality

    What we measure

    Proportion of Gavi-supported countries with a 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.

    2017 performance

    47% of countries reported administrative coverage data within 10 percentage points of survey coverage, the same proportion as in 2016. This means that we are moderately off track to achieve our 2020 target of 53%.

    2016–2020 strategy overview →  

    KPI  

    Coverage with a first dose of pentavalent vaccine and drop-out rate between the first and third dose

    What we measure

    Coverage with a first dose of pentavalent vaccine and the drop-out rate between the first and third dose 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.

    2017 performance

    Coverage with a first dose of pentavalent vaccine in Gavi-supported countries has remained flat at 86% since 2015, and we are not on track to reach our 2020 target of 90%.

    The drop-out rate was 7%, the same level as in 2016. We are just on course to achieve our target for this indicator.

    2016–2020 strategy overview →  

    KPI  

    Integrated health service delivery

    What we measure

    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.

    2017 performance

    44% of Gavi-supported countries met the benchmark for integrated service delivery, an increase of 10 percentage points compared with the year before. In 2017 alone, close to 64 million children in Gavi-supported countries received three doses of a DTP-containing vaccine, such as pentavalent. This translates into more than 190 million points of contact between these children and the primary health system, all of which provide an opportunity to reach both them and their families with other essential health interventions.

    Our work rests very much on the premise that immunisation offers a platform for the delivery of other healthcare services. For instance, vitamin A supplementation has been successfully linked with vaccination campaigns and routine immunisation services in many countries.

    Deworming is also often delivered together with vaccination. In 2012, more than 78 million preschool children received deworming treatment at the same time as their vaccinations or vitamin A supplementation – corresponding to almost 25% of the children in need of treatment. Likewise, bednets tend to be distributed in tandem with the first dose of pentavalent, DTP or Bacille Calmette Guerin (BCG) vaccine, or the first or second dose of measles vaccine.

    2016–2020 strategy overview →  

    KPI  

    Civil society engagement

    What we measure

    Percentage of countries we support that meet 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 (CSOs) in national immunisation 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.

    2017 performance

    12 (57%) of the 21 Gavi-supported countries for which data is available met all of the three criteria, up from 40% in 2016. A target for this indicator will be developed in late 2018.

    2016–2020 strategy overview →  

    KPI  

    Looking ahead
    • Since Gavi’s inception in 2000, basic immunisation coverage rates in the world's poorest countries have increased by over 20 percentage points. More people than ever before are being reached with life-saving vaccines.

      However, not all countries are reaping the full benefits of immunisation; some are lagging behind. Fragile countries – those that are conflict-ridden or hit by natural catastrophes – in particular are struggling to build sufficiently strong immunisation systems to protect their populations against fatal diseases.

    • Going forward, we will continue to find flexible, tailor-made solutions to help each country, especially those that are fragile, to improve their systems so everybody can benefit from life-saving vaccines.

      We will work across the public and private sectors to address barriers to, and bottlenecks in, immunisation programmes, be they outdated supply chains, insufficient or low-quality data and technology or gaps in the leadership, management and coordination of immunisation programmes.

    • Immunisation is one of the cornerstones of primary healthcare, and provides a gateway to universal health coverage. It is the only intervention that brings the vast majority of families into regular contact with health services, especially during the important first year of a child’s life. This alone makes the immunisation system key to delivering primary healthcare services to all.

     
  • The sustainability goal


    improve sustainability of national
    immunisation programmes
     

    2017 at a glance

    ▶ Another 8 countries transitioned out of Gavi's financial support, bringing the total to 16.

    ▶ Countries contributed a total of US$ 136 million towards the cost of Gavi-supported vaccine programmes.

     

    ▶ Countries fully self-financed 27 vaccine programmes originally introduced with Gavi support – up from 21 in 2016.

    ▶ Transitioned and transitioning countries invested US$ 48 million in vaccine programmes formerly supported by Gavi, up from US$ 20 million in 2016.

    2016-2020 strategy: sustainability goal →  

    Empowering countries to take ownership

    Sustainability is at the core of the Gavi model. From the outset of our support, we work with all countries to help them take ownership of their immunisation financing and strengthen their systems so that they can eventually transition out of our financial support.

    Every country we partner with is required to contribute to the cost of vaccines introduced with our support. As countries’ economies grow, their co-financing obligations increase and we begin to reduce the amount of financial support we provide. The process by which a country gradually takes on the full cost of all its Gavi-supported vaccines is called “transitioning” and usually takes five years to complete. By the end of this period, countries are expected to be fully self-financing all their vaccine programmes.

    Between 2016 and 2020, 20 countries are expected to transition out of Gavi support. Sixteen of these – Angola, Armenia, Azerbaijan, Bhutan, the Congo, Cuba, Georgia, Guyana, Honduras, Indonesia, Kiribati, Mongolia, the Plurinational State of Bolivia, the Republic of Moldova, Sri Lanka and Timor-Leste – had already done so by the end of 2017.

    Our objectives

    As a pioneer of sustainability, we are constantly learning from our experience and using that to refine our model. Today, our approach to sustainability extends far beyond just vaccine financing. To us, sustainability means that countries can successfully expand and sustain their national immunisation programmes with high and equitable coverage after they transition out of our support. They should also have sufficiently robust systems and well-functioning decision-making processes in place to facilitate future vaccine introductions, also to serve as a platform for other primary healthcare interventions.

    Our specific objectives for this goal 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.

    These objectives are reflected in each country’s transition plan, as well as in the long-term programmatic and financial sustainability goals we set for our investments. They shape how programmes are designed and carried out from the beginning of our support. Sustainability has been identified as one of Gavi’s strategic focus areas for the 2016–2020 period.

    Performance indicators: sustainability goal

    1 Countries on track to successful transition

    What we measure

    Percentage of countries in the accelerated transition phase that are on track to transition successfully. A country is on track if:

    • at least 75% of predefined transition activities (such as a having a functional national regulatory agency) have been completed on time;
    • DTP3 coverage has increased over the last three years (if a country has already achieved at least 90% DTP3 coverage, this level should have been sustained for three years); and
    • it is meeting its co-financing obligations and did not default on payments in the previous year.

    2017 performance

    By the end of the year, 53% of countries in the accelerated transition phase were on track to transition successfully. The seven countries that were off track all failed to meet the immunisation coverage criteria and included five countries that transitioned out of Gavi support on 31 December 2017. We are addressing these challenges through a combination of tailored country approaches, post-transition engagement and transition grants.

    In total, 15 transitioning and transitioned countries fully self-financed 27 vaccine programmes, compared with 14 countries and 21 programmes in 2016. Country contributions towards self-financed programmes in 2017 amounted to US$ 48 million.

    An additional eight countries – Angola, Armenia, Azerbaijan, the Congo, Cuba, Georgia, the Plurinational State of Bolivia and Timor-Leste – transitioned out of our support at the end of 2017, bringing the total to 16 countries. Seven of these countries have already achieved DTP3 coverage rates of 90% or above. However, six transitioned countries saw basic immunisation coverage levels decline between 2016 and 2017.

    2016–2020 strategy overview →  

    KPI  

    2 Co-financing

    What we measure

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

    2017 performance

    All countries met their 2016 co-financing commitments in that year or paid all their arrears in 2017. In addition, 58 out of 63 countries (92%) fulfilled their 2017 obligations in a timely manner.

    Five countries, Cameroon, the Central African Republic, Chad, the Democratic Republic of the Congo and Sierra Leone, defaulted on their 2017 payments. Overall, this is on a par with the co-financing performance in 2016.

    In terms of numbers of co- and self-financed programmes, however, 2017 proved to be the most successful year to date. Countries contributed a total of US$ 136 million towards their 2017 co-financing obligations and collectively co- or self-financed 197 programmes – up from 184 in the year before.

    KPI  

    3 Country investments in routine immunisation

    What we measure

    Percentage of countries that have increased their investment in routine immunisation per child, relative to 2015. This indicator takes into account every vaccine in a country’s national programme, not just those supported by Gavi. It also includes expenditure on related products, such as injection supplies.

    2017 performance

    Just over half of Gavi-supported countries increased their investment in routine immunisation between 2015 and 2016. Data for 2017 will be available in November 2018. The target for 2020 is that immunisation investment per child will have increased in all Gavi-supported countries.

    KPI  

    4 Institutional capacity

    What we measure

    Average score of Gavi-supported countries measured against our criteria for national decision-making, programme management and monitoring. Through this indicator, we assess the performance and effectiveness of bodies that manage immunisation, including the Expanded Programme on Immunization (EPI), interagency coordinating mechanisms and national immunisation technical advisory groups (NITAGs).

    2017 performance

    Gavi-supported countries achieved an average score of 2.4 out of a maximum 4.0 in the institutional capacity assessment. A score of 4.0 means a country is independently sustaining its systems, processes and capacity. Scoring 3.0 reflects a satisfactory government decision-making and coordination function and capacity to manage the EPI programme with technical assistance.

    The relatively low average score reflects the fact that several Gavi-supported countries are still in the process of establishing new systems for planning, managing and monitoring immunisation programmes, or of strengthening existing systems. A target for this indicator will be developed in late 2018.

    KPI  
    Looking ahead
    • Gavi’s pioneering approach to sustainability in immunisation is, for the most part, working well. However, we recognise that some countries continue to face challenges on their road to sustainable transition. Together with our partners, we are making every effort to ensure that all countries can successfully progress towards self-sufficiency.

      Almost half of the 20 countries that have already transitioned or are due to do so by 2020 have only introduced one or two of the four main vaccines in Gavi’s portfolio: pentavalent, pneumococcal, rotavirus and human papillomavirus. In an effort to address this, we have extended the period in which transitioning countries can apply for new vaccine support.

    • Our sustainability model has evolved significantly in other important ways since 2000. In 2017, we took significant steps forward by formalising our engagement with countries that have already transitioned, and by agreeing with some of our key partners – the World Bank, the Global Fund and the Global Financing Facility – to further expand our collaboration around health financing and transition.

      We are also looking at how the Alliance can continue to shape vaccine markets to meet the needs of countries post-transition.

    • Peer-to-peer networking initiatives and South-to-South collaboration are making it increasingly possible for countries to share knowledge and best practices. We are helping to empower countries to truly own their transition and act as mentors within a dynamic, confident community. This will help to safeguard their progress long after our financial support ends.

     
  • The market shaping goal


    shape markets for vaccines and other
    immunisation products
     

    2017 at a glance

    ▶ The weighted average price of fully immunising a child with pentavalent, pneumococcal and rotavirus vaccines fell to US$ 16.63, a 12% drop from 2016.

    ▶ Two new lower-volume vaccine products, which will help reduce the pressure on cold chain systems, were procured.

    2016-2020 strategy: market shaping goal →  

    ▶ Three vaccine markets were assessed as having moderate health, one more than in 2016.

    ▶ The Alliance broadened its market shaping activities to include accelerating innovation, supporting country-owned decisions and assessing any unintended consequences of market shaping activities.

     

    Why market shaping matters

    Nurturing healthy vaccine markets is a vital part of the Alliance’s work. The fact that Gavi finances vaccines and other immunisation products for countries representing close to 60% of the world's annual birth cohort puts us in a unique position to shape markets.

    Our market shaping activities are geared towards ensuring that supply meets demand, or more specifically, that manufacturers produce the right vaccines in the right quantities and at the right price to meet the needs of Gavi-supported programmes. We work with industry to help them forecast demand levels, and with countries to ensure they are able to access the vaccines they need at a price they can afford. By shaping markets in this way we can make donor investments go further and maximise our impact.

    In the current strategic period we have broadened the scope of our market shaping activities to respond to evolving country needs. This includes extending our reach beyond vaccines to include immunisation-related products, such as cold chain equipment. Given the growing number of countries that are transitioning out of Gavi support, we are increasingly focusing effort on securing the long-term sustainability of vaccine markets.

    To lay the foundations for sustainable programmes, we also focus on supporting informed country decisions on product procurement and prioritisation. In addition, we are working hard to improve our forecasting methodology, and to assess any unintended consequences of our market shaping work.

    Our objectives

    The main goal of Gavi’s market shaping efforts has always been to make vaccine markets work for the benefit of the poorest countries, ensuring that as many people as possible benefit from the life-saving potential of immunisation. In the early days of the Alliance, our focus was primarily on how to balance demand with supply, while promoting healthy competition to make sure that prices were sufficiently affordable for the countries we support.

    While these ambitions remain at the core of our strategy, we are now taking a more holistic view of healthy markets. This includes working to improve the suitability of both vaccines and other immunisation products for developing country markets.

    The objectives of our market shaping work are:

    • to ensure sufficient and secure supply of quality vaccines;
    • to reduce prices of vaccines and other immunisation products to an appropriate and sustainable level;
    • to incentivise the development of suitable, innovative vaccines and other immunisation products; and
    • to increase the number of healthy vaccine markets.
     
    Performance indicators: market shaping goal

    1 Sufficient and uninterrupted supply

    What we measure

    Number of Gavi vaccine markets where supply of appropriate vaccines is both uninterrupted and sufficient to meet demand.

    2017 performance

    By the end of the year, eight vaccine markets were reported to have sufficient and uninterrupted supply of appropriate vaccines – down from nine markets in 2016.

    Markets meeting the definition of sufficient and uninterrupted supply were: Japanese encephalitis, measles, measles-rubella, meningitis A, oral cholera, pentavalent, pneumococcal and yellow fever. This represents 73% of the 2020 target of 11 markets.

    KPI  

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

    What we measure

    The weighted average vaccine price of fully immunising a child with pentavalent, pneumococcal and rotavirus vaccines.

    2017 performance

    By the end of 2017, the cost of immunising a child with a full course of pentavalent, pneumococcal and rotavirus vaccines averaged US$ 16.63. This represents a reduction of 17% compared with the 2015 baseline figure of US$ 20, and a 12% drop from the 2016 price of US$ 19.

    This progress was largely driven by the reduction in the weighted average price per dose of pentavalent vaccine, which fell to US$ 0.88 in 2017 – a 43% drop from 2016. The lowest price for this vaccine was US$ 0.68 per dose.

    A reduction in the cost of pneumococcal vaccine also contributed; in 2017, two suppliers dropped their prices from US$ 3.30 and US$ 3.40 per dose, respectively, to US$ 3.05 per dose.

    KPI  

    3 Innovation

    What we measure

    Number of vaccines and other related products with improved characteristics procured compared with the baseline year.

    2017 performance

    Since 2015, five new products with improved characteristics have been prequalified by WHO and procured by Gavi, three in 2016 and two more in 2017. Our 2020 target is 10 products.

    The two new products that were procured in 2017 comprised a new and improved presentation for the oral cholera vaccine, and a pneumococcal conjugate vaccine in a multi-dose vial presentation.

    Both of these products will help lighten the load on countries’ cold chains. The new oral cholera vaccine comes in a plastic tube, which takes up 30% less space and weighs 50% less than the previous glass vial product. It is also 25% cheaper. The four-dose presentation of the pneumococcal vaccine also offers a volume reduction benefit.

    KPI  

    4 Healthy market dynamics

    What we measure

    Number of Gavi vaccine markets classified as enjoying high or moderate health. Each vaccine market is rated as having high, moderate, low or no healthy market dynamics.

    2017 performance

    Three vaccine markets were assessed as having moderate market dynamics in 2017, up from two in 2016. As yet, no market has been ranked in the “high” category.

    The pentavalent vaccine market was one of three to be rated as moderate in 2017. It retained its rating from the previous year, partly on account of the substantial price drop that occurred during the year. The other two markets – those for yellow fever and pneumococcal vaccines – were upgraded to moderate from low health, because of improvements in supply and increased market stability.

    In contrast, the market for HPV vaccine was downgraded from moderate to low because supply failed to keep pace with the increased country demand.

    The remaining eight vaccine markets were classified as having “ low” or “no” market health due to problems related to supply security and inabilities to meet country preferences.

    KPI  

    Looking ahead
    • Throughout this strategic period and beyond, we will continue our work to strengthen the health of vaccine markets and diversify our supplier base through extensive engagement with both industry and recipient countries.

      As an increasing number of countries transition out of our support, the need to monitor and forecast demand is ever more important. Transitioning countries will bring new factors into vaccine markets, both on the procurement side and on the funding side. This requires increased flexibility and broader engagement from all Alliance partners.

    • We are seeing greater diversity among the vaccine markets in which we operate, and acknowledge that we will need to continue to develop bespoke approaches to each one, and set our goals accordingly. For instance, it may not be possible to aim for a high level of healthy dynamics in every market.

      In order to ensure we have the best possible understanding of vaccine market dynamics and market health, we will continue to refine and improve our demand models and data analysis functions. At the same time, we will continue to assess the mix of financial and non-financial interventions required to maximise the health of each market.

    • Since 2000, Gavi has successfully helped to raise immunisation rates across the countries we support. We are now seeing a growing number of countries procuring and funding their own vaccine supplies. However, we do not see this as the end of our role – we will continue to help countries sustain their immunisation programmes well into the future.

     
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