GAVI

GAVI, officially Gavi, the Vaccine Alliance is a public–private global health partnership with the goal of increasing access to immunization in poor countries. It is the largest organisation distributing donations of money towards vaccines; from 1990 to 2016, more than a third of donor money for immunisation was channelled through Gavi.
Gavi supports the immunization of almost half the world's children. Gavi has helped immunize over 760 million children, preventing over 13 million deaths worldwide, helping increase diphtheria vaccine coverage in supported countries from 59% in 2000 to 81% in 2019, contributing to reducing child mortality by half. It also seeks to improve the economics of vaccines, negotiating bulk prices, supporting price discrimination, and reducing the commercial risks that manufacturers face when selling vaccines to the poor and developing vaccines. It also provides funding to strengthen health systems and train health workers across the developing world, though the effectiveness of its health-system-strengthening programs is disputed.
Along with Global Health Initiatives in general, Gavi was described as innovative, effective, and less bureaucratic than multilateral government institutions like the WHO. Gavi programmes may produce quantified results within an election cycle, which is appealing to parties locked in an election cycle. One author described Gavi's approach to public health as business-oriented and technology-focused, using market-oriented measures, and seeking quantifiable results. Gavi follows a model termed the "Gates approach" or US-type approach. It contrasts with the approach typified by the Alma Ata Declaration, which focuses on the effects of political, social, and cultural systems on health.
Gavi facilitates vaccinations in developing countries by working with donor governments, the World Health Organization, UNICEF, the World Bank, the vaccine industry in both industrialised and developing countries, research and technical agencies, civil society, the Bill & Melinda Gates Foundation and other private philanthropists. Gavi has observer status at the World Health Assembly. Gavi has been criticized for giving private donors more unilateral power to decide on global health goals, prioritizing new, expensive vaccines while putting less money and effort into expanding coverage of old, cheap ones, harming local healthcare systems, spending too much on subsidies to large, profitable pharmaceutical companies without reducing the prices of some vaccines, and its conflicts of interest in having vaccine manufacturers on its governance board. Gavi has taken steps to address some of these concerns.

Funding

Gavi runs in five-year funding cycles which enables it to negotiate long-term deals with vaccine manufacturers. Industrialised countries are Gavi's principal donors, providing approximately three-quarters of the total funding. All donor governments are represented on the Gavi Board through a constituency system.
In the period of 2016–2020, Gavi received US$9.3 billion, with over half of the total funding provided by the three largest donors: the UK, the Bill & Melinda Gates Foundation, and the USA.
Following the Global Vaccine Summit in June 2020 hosted in the UK, $8.8 billion was raised for the funding cycle 2021 to 2025; exceeding the target of $7.4 billion. This included $2 billion from the UK, $1.6 billion from the Gates Foundation and $1 billion from Norway.
For the 2026-2030 funding cycle, the UK announced it was committing to donate £1.25 billion, The Gates Foundation announced a $1.6 billion contribution, and the US announced it was donating $0. As a result, Gavi announced it would fall almost $3 billion short of its budget aim of $11.9 billion with a total budget of $9 billion.

Donor

Proceeds

United Kingdom

History and programs

GAVI was created in 2000 as a successor to the Children's Vaccine Initiative, which was launched in 1990. In August 2014, Gavi changed its name from "GAVI Alliance" and rebranded itself with a new logo deliberately reminiscent of UN organization logos, but using green as a mark of difference.

Vaccine development and advance market commitments

Advance Market Commitments aim to overcome market failure by making an advance pledge that if a vaccine for a certain condition is developed, meeting certain specifications, donors will buy a certain number of doses. Gavi seeks to design its AMCs in a way that encourages a competitive market.
Gavi has been particularly successful at promoting the uptake of newer vaccines.

Vaccination programs

Gavi's main objective is vaccination programs. Gavi has been the main funder of vaccination in low and middle income countries.
In 2012, the first Médecins Sans Frontières "The right shot" report criticized Gavi for focusing on funding expensive new vaccines and neglecting to give children low-cost older ones. "Twenty percent of the world's children aren't even getting the basic vaccines", MSF's vaccine policy adviser said. MSF criticized the Global Vaccine Action Plan, a WHO global collaboration of which Gavi is listed as a leader, as flawed for failing to help those 20%, which is some 19 million infants.

Pneumococcal vaccine

In 2010, as part of a 10-year pneumococcal vaccine Advance Market Commitment, the companies GlaxoSmithKline and Pfizer were both allocated $225 million in AMC subsidies to provide 30 million doses annually at a maximum tail price of $3.50 per dose.
In 2011, Médecins Sans Frontières recommended that Gavi change the ways in which it procures vaccines. MSF argued that the Advance Market Commitment had transferred more money to GSK and Pfizer than the Gavi grants had transferred to low-cost suppliers for technology transfer and product development. MSF said that large pharmaceutical multinationals had been found to put very high markups on prices, and internationally certified vaccine could be made for about 40% less cost by smaller companies in India and China, despite patent-related obstacles.
In January 2015, MSF also called upon GSK and Pfizer to cut the price of the pneumococcal vaccine to US$5 per child in developing countries, a price they estimated as competitive. They said that, as Pfizer had made $16 billion in revenue on pneumococcal vaccine in the last four years, a larger price cut would be affordable. In early 2016, they ran the "A fair shot" campaign to pressure GSK and Pfizer to drop prices. Pfizer said that they were already selling the vaccine at "far below" cost, while GSK said that the price enabled them to "just about" cover their costs, and "To discount it further would threaten our ability to supply it to these countries in the long-term".
Bill Gates said that criticizing pharmaceutical company pricing deterred them from investing in medicines for the developing world, and said that instead, pharmaceutical companies should be praised for price discrimination which reduces the price in poor countries. He also advocated improving low-temperature supply chains in developing countries.
In August 2019, MSF asked Gavi to stop giving Advance Market Commitment subsidies to GSK and Pfizer, whom they called a duopoly, and instead buy vaccine from a new third manufacturer, the Serum Institute of India, which offered the vaccine at 2/3 of the price then offered by the two. As the pneumococcal vaccine made up 40% of Gavi's vaccine purchasing costs, a 33% price drop would save Gavi billions. Pneumonia kills more than a quarter of children dying before the age of five, almost a million children each year. MSF said that GSK and Pfizer's pricing was exploitative and had left millions of children who could have been protected vulnerable. Gavi responded that low prices required large, stable, high-volume deals, and "careful consideration and the support of key constituencies". In June 2020, under Gavi's Advance Market Commitment, UNICEF and the Serum Institute of India entered an agreement which reduced the price of pneumococcal conjugate vaccines to $2 per dose.

Health systems strengthening debate

In the 20-naughts, Gavi had intense internal debate about its role in vaccinations and in health systems strengthening. This was part of a broader discussion in healthcare about "vertical" approaches and "horizontal" ones, targeting broad programs such as primary care. At Gavi, some argued that vaccination could not be effectively carried out and sustained without strengthening healthcare, citing experiences in Gavi's vaccination programmes, where availability of staff, training, transport, and funds had hindered vaccination and reporting of vaccination coverage and stocks. There were also worries that Gavi was undermining and paralyzing health care systems. Others argued that HSS was a distraction from Gavi's single-minded focus on vaccines, and HSS was a nebulous concept that could not be defined and quantified.
Major donors Norway and Britain supported HSS; USAID and the Bill & Melinda Gates Foundation opposed it. The majority of vaccine experts tended to favour technological rather than HSS-based approaches. Pharmaceutical industry representatives were supportive of HSS, possibly because they saw it as key to sustainable markets for their products. In 2005, a narrow vote brought Gavi to endorse an HSS goal. Up to a quarter of Gavi's funding was dedicated to "strengthening the capacity of integrated health systems to deliver immunisation", in practice it has been around 10%. After 2010, this funding went through a joint-venture Health Systems Funding Platform. Gavi's funding for this platform was conditional on the platform meeting vaccine coverage goals.
As of the mid-2010s, few in Gavi were working on HSS, most of the former pro-HSS people had left, and some at Gavi dismissed HSS as PR to gain support from pro-HSS donors and counter criticisms that Gavi was harming healthcare systems. Such criticisms were generally not a topic that Gavi engaged with internally; the lack of internal engagement with the issue has been criticized. The disagreements were fairly intense; when Bill Gates came to visit Gavi headquarters, employees would hide the HSS-related posters so that he would not be reminded of this aspect of Gavi's work. Julian Lob-Levitt, who was Gavi's CEO between 2004 and 2010, was rumoured to have left over conflicts around his support for health system strengthening. Seth Berkley has been the CEO of Gavi since 2011, as of 2020.
It has been argued that Gavi's HSS spending in the early 2010s went to selective, disease-specific interventions repackaged as HSS. Gavi's HSS support at this time tended to focus on immunisation strengthening support, especially the building of cold chains. Gavi measured HSS using vaccination coverage as the sole indicator. It set the reporting indicators which were required of recipients of its funding; countries were not allowed to use similar indicators they already collected; this has been criticized for conferring a heavy accounting burden and diverting attention from indigenous goals. National government representatives did sit on the board, but had little influence; one European representative described the environment in the mid-2010s as "highly intimidating".
A 2016 funding-allocation analysis of a sample of Gavi grants found that just over half the money went to purchasing drugs, equipment, supplies, and facilities. These are short-term funding activities which the WHO does not consider HSS. The proportions were higher in less-developed healthcare systems. There was no spending on operational research, improving use of existing resources, or developing national drug and vaccine policies. In some grants, HSS funds were mostly spent on day-to-day operational costs, with no exit plan for the funding. Gavi subsequently shifted HSS aid to focus more on sustainability and the principles of the Paris Declaration for Aid Effectiveness.