Theresa Ryckman

Immunization Support Expiring for Some: GAVI, partners aim to help countries achieve successful ‘graduation’

Since its founding in 2000, the GAVI Alliance has committed more than $8 billion in assistance to more than 75 of the world’s poorest countries, leading to an additional 440 million immunized children and preventing an estimated 6 million future deaths.

In 2011, GAVI — with input from the institute I work for, Results for Development (R4D) — updated the threshold at which the transition process begins and countries are no longer eligible for GAVI support, setting 16 countries on the path to graduation. Four more countries – Nicaragua, Papua New Guinea, Timor-Leste and Uzbekistan – recently entered the graduation process.

GAVI’s policy dictates that graduating countries ramp up funding over five years, until vaccines and supplies are fully funded domestically. GAVI’s funding simultaneously decreases and then phases out completely.

Fresh analysis from a team of authors from the GAVI Alliance, the World Health Organization and myself and others at R4D shows that these “graduating” countries will face a variety of challenges to achieving self-sufficiency. Much is already being done by GAVI and other stakeholders to examine sustainable financing, procurement, informed decision-making and other key issues to improve countries’ chances for successful graduation in order to ensure that they are able to continue vaccinating more than 10 million children against life-threatening diseases.

Helen Saxenian, R4D senior expert and lead author of our study, noted:

“The graduating countries, most classified as lower-middle income, are not wealthy, yet they are moving rapidly to reduce their dependence on donors and take over financial and managerial responsibility for their immunization programs, including the new life-saving vaccines that GAVI helped them to introduce.”

Our study also has important implications for other global health donors, many of whom do not have such structured graduation processes and begin transitioning countries at much higher income levels. Study co-author and R4D Managing Director Robert Hecht added, “This is an exciting and challenging effort to put countries swiftly on the road to self-sufficiency. Our study demonstrates that a proactive partnership between the recipient governments and GAVI, including active engagement and joint planning and assessment, can effectively identify and address the obstacles to a successful transition to sustainable financing. Further, these lessons can be applied beyond immunization to other areas such as AIDS, malaria and family planning.”

Our findings are contained in a paper entitled “Overcoming challenges to sustainable immunization financing: Early experiences from GAVI graduating countries,” published Feb. 9 in “Health Policy and Planning.” Our paper summarizes the findings from “graduation assessments” carried out in 2012 in five of the graduating countries — Bhutan, Republic of Congo, Georgia, Moldova and Mongolia. The assessments, conducted by the governments of the five countries plus their international partners, have been translated into national plans containing specific actions aimed at strengthen the countries’ finances, procurement processes, regulatory institutions and technical and policy skills in immunization — areas which have been identified as key challenges in many of the graduating countries.

The various countries, GAVI, WHO and other stakeholders are addressing these challenges in a variety of ways. For example, on sustainable financing, the countries are meeting their co-financing requirements for vaccines and are creating additional budgetary space to account for growing financial needs for vaccines, some using analysis from a tool created by R4D and GAVI that predicts vaccine resource needs under a range of vaccine introduction, pricing and economic growth scenarios.

In Mongolia, this tool showed that a vaccine for hepatitis A, which is generally not widely provided in countries but was piloted due to an outbreak in the western part of the country, absorbed around a third of the government’s expenditures on vaccines, leading them to consider less costly options to address the disease. On procurement, GAVI and other donors are working with countries to make sure they are getting the best prices for their vaccines, usually achieved by using the UNICEF Supply Division for GAVI-supported and many non-GAVI-supported vaccines, and that their procurement and supply chain systems are functional and efficient.

Uzbekistan, visited in 2013 after finalization of our study, recently switched from self-procurement to procurement through UNICEF in order to access better prices and avoid stock-outs.

In other countries with legal requirements for national self-procurement, GAVI, the countries’ governments and other stakeholders are working together to identify barriers and target inefficiencies to make these systems more effective.

GAVI is continuing to study innovative ways to support graduating countries and may issue new policies and guidelines for its next five-year strategy during 2014-15, based in part on our findings.

Theresa (Tess) Ryckman is a senior program associate at the Results for Development Institute and works with the Global Health Team.

Environment, Health Care
governance, infrastructure, vaccines