Gavi Mid-Term Review: Countries Speak Up on Immunization

Last updated June 28, 2023

Written by: Lori Sloate, Senior Director of Global Health, United Nations Foundation


From June 13-15, representatives from all constituencies of Gavi, the Vaccine Alliance, met in Madrid to discuss the Alliance’s progress toward its 2021-2025 immunization targets halfway through the programmatic implementation. While official numbers were discussed, some of the most impactful insights into the program’s progress came from implementing countries. As one participant said, the partnership of the Alliance is “not successful unless governments feel it’s a success and it’s felt by the communities they serve.” 

Here are some of the main takeaways, based on what countries had to say: 

The Big Catch-up is underway.  

With immunization coverage rates for basic vaccines falling 5% globally from 2019 to 2021, largely due to the impact of the pandemic, a global effort was launched earlier this year by the World Health Organization (WHO), countries, and partners to intensify actions to catch-up, restore, and strengthen immunization systems. Health ministers from several countries, including the Republic of Congo and Malawi, as well as partners from UNICEF and WHO, and Gavi CEO Seth Berkley all referenced the importance of “The Big Catch-up” and getting back on track. 

While official data from 2022 will be released in mid-July (as part of the WHO/UNICEF estimates of national immunization coverage), initial data and country experiences shared at the meeting underlined the progress that has been made, as well as the long way left to go. For instance, Diphtheria tetanus toxoid and pertussis (DTP3) coverage data in the 57 Gavi-supported countries showed nine countries increased coverage, 13 countries were stable, and 35 countries had reduced coverage since 2019.  

There was also much discussion about serving those children who have never been reached by vaccines. In Republic of Congo, it is estimated there are 68,000 children who have never had basic vaccines, and the government has set that target as its goal. In Yemen, of the estimated 70,000 “zero-dose kids,” 15,000 have been reached so far. 

Countries are investing more in their immunization programs – but with challenges. 

Of the 11 key indicators against which the Alliance measures its success, the increase in country financing for vaccines is especially impressive. While falling short of the goal to reach $3.6 billion in country financing ($3.4 billion is now envisioned), the proportion of vaccines funded by countries, vis-à-vis Gavi support, has increased dramatically with each new strategic period. From 2011 to 2015, 8% of vaccine financing in Gavi-supported countries came from the countries. For the period of 2016 to 2020, that number jumped to 23%, and for the 2021 to 2025 period, countries are on track to contribute 39% of the $8.8 billion total in vaccine financing.  

However, this funding does not come without challenges in light of financial constraints mentioned by several countries. The Minister of Health from Uganda questioned what could be done if governments simply don’t have the funds to cover the co-financing required by Gavi to reach zero-dose children. 

The question of how to avoid wasting unused COVID-19 vaccines from COVAX, the vaccines pillar of the Access to COVID-19 Tools (ACT) Accelerator, was also discussed. In response, it was noted that the Gavi Board has given some flexibility for countries who are under fiscal stress or conflict. Exceptional waivers can be given for the co-financing required from countries to receive Gavi support when a country shows evidence of economic hardship or stress, as in the case of Somalia and South Soudan. Discussions with manufacturers to reduce the number of vaccines produced may also be taken.  

Not mentioned in the Mid-term Review (MTR), but discussed at the Gavi board meeting on June 26 was what will be done with the “large amounts” of unused money referenced by Uganda and the $2.6 billion underspend of funds earmarked for COVID-19 and COVAX activities. While six options were proposed by donors (from financing core Gavi activities to supporting regional vaccine manufacturing to giving the money back to donors), it was decided that more discussion is needed with costing proposals for those alternatives, and a decision on reallocation will be made at the December board meeting. 

Expansion of human papillomavirus (HPV) and malaria vaccination is a top priority for countries. 

There was a lot of optimism around the expansion of HPV and malaria vaccination. It is estimated that for every 70 girls vaccinated, one life is saved, making HPV one of the most impactful of all vaccines. Previous supply constraints on HPV vaccines have now been alleviated, and a new target has been set to reach 86 million girls by 2025. A grass roots movement calling for the elimination of cervical cancer has garnered over 1,100 signatures from 100+ countries, including global citizens, ministers, heads of agencies, academic and scientific institutions, and others. The Minister of Health of Rwanda shared the country’s experience of HPV rollout and noted the need to get back to the 2019 97% coverage rate, which fell to 87% by 2021. But as several participants noted: we have supply, we have lessons learned, and we now have a single-dose recommendation from WHO, making the goal of reaching 86 million girls and averting 1.4 million deaths possible. 

The malaria vaccine is one of the most in-demand vaccines on the African continent since the successful pilot program in high-burden areas in Kenya, Malawi, and Ghana. A panel including the Minister of Health of Malawi, USAID, two manufacturers, and other partners highlighted the challenges and optimism for the future of this vaccine. For Malawi, the Minister of Health noted that, in a population of 19 million, 40% of all out-patient health care visits are due to malaria, so the vaccine is most welcomed. Malawi introduced the vaccine in 12 districts, and while they experienced challenges delivering the fourth dose, overall, the vaccine was highly demanded and effective. It took nearly 30 years and $900 million to develop the vaccine – the first ever against a parasite. GSK is now transferring that technology to Bharat Biotech, which can produce it at lower cost. A second supplier, Serum Institute, may be able to help supply constraints if it passes the pre-qualification of WHO later this year. Noting a lead time of four months once pre-qualification is given, 100 million doses could be produced as early as 2024.  

Help countries prepare for the future with equitable, sustainable solutions. 

Throughout the MTR, countries pressed for new ways of working to meet modern challenges. Several health ministers made passionate pleas for partners and investors to support regional vaccine manufacturing. “Sixty thousand Malawians were affected by cholera, and WHO was willing to give us the vaccine, but none were to be found (due to shortage of supply). Help us build regional manufacturing for vaccines,” said the Minister of Health from Malawi. The Minister of Health for Ghana made a similar call, stating, “We are ready as implementing partners. There is no manufacturing in Africa, and we are consumers. Ghana is ready to produce tomorrow. No one is talking about it. Pleading with development and financers. We are ready!”  

Other urgent pleas came from the ministers from Chad and, again, Malawi for more support for cross-border collaboration in fighting disease outbreaks, citing the success of multi-antigen campaigns of polio, cholera, and Vitamin A, as examples to build upon. In support of building a partnership of countries in crisis, the minister from the Central African Republic called immunization “a peace factor,” citing that in the fight against polio, the government ended up negotiating with armed groups to provide a mechanism for vaccination. This recovery plan put the country in a good place to manage COVID. 

While not new, there has been an evolution in data showing health care’s climate “footprint” is 5% of the global total. The Alliance for Transformative Action on Climate and Health (ATACH) proposed seven high impact health actions that could save up to 5 million lives if implemented. These included such steps as powering health care with 100% clean, renewable electricity and investing in zero emissions. Somalia was featured for their work to reduce climate change impact. The need to shift our mindset from powering individual ad-hoc solutions to developing a system powered by innovative renewable resources was also highlighted. A good example is Gavi’s plan to expand support of solar-powered refrigerators to solar-powered health facilities, which it will initially carry out in four countries.  

To learn more about the outcomes of the meeting including some innovative partnerships investing in country support for immunization, click here.  

About the Author

Lori Sloate is the Senior Director for Global Health at the UN Foundation. Prior to her work at the Foundation, Lori was the Deputy Director of Advocacy and Public Policy at Gavi, the Vaccine Alliance for four years. She also worked with the World Health Organization for nearly 10 years, working with ministries and partners and advocating for global campaigns around various health issues. She has worked with other UN agencies, such as UNESCAP in Bangkok and UNOPS in Vietnam. Lori has a Master’s Degree in intercultural and international management from the School for International Training in the United States and has studied economics and development at the University of Nice, France.

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