With the Global Fund and Global Polio Eradication Initiative replenishments successfully concluded, donors are turning their attention to the Gavi Alliance whose third replenishment process is scheduled to culminate in summer 2020. In June, together with CGD colleagues, we published a briefing book on key issues to address in Gavi’s next phase, known as “Gavi 5.0.” Since then, Gavi released its 2021-2025 strategy and investment opportunity. As the final Gavi Board meeting of 2019 kicks off next week, it’s time to sharpen goals and double down on strategies to enhance the partnership’s public health impact.
We have three recommendations:
Focus on vaccine coverage levels, starting with lower-coverage vaccines, not numbers of children immunized.
At the goal level, Gavi has long tracked and reported on the numbers of children immunized with selected vaccines. This involves looking at the period increment in coverage as reported in WUENIC data, applying that increment to the cohort of children estimated by census or other data, and then backing out the number of children.
However, looking at absolute numbers of children may not reflect real progress since the public health impact of vaccines is only realized if herd immunity (~85 percent coverage or greater) is attained and sustained. Of course, there are individual and community benefits to each child who receives a vaccine dose, but that is not the same as the population-level health impact of herd immunity on which Gavi’s investment case is based. As we’ve seen from recent measles outbreaks around the world, it is the share of children covered in every community that matters most for disease incidence.
This point is doubly important as the data suggest many countries are still far from herd immunity on individual vaccines and even further from full vaccination for age—an indicator which represents the true measure of protection among young children (particularly important when herd immunity is not achieved).
The Gavi 5.0 strategy focus on equity is therefore welcome, particularly as recent data illustrates that while there has been much progress, there are still far too many cases of low coverage levels in some eligible countries with large and still expanding birth cohorts. And an equity focus also means getting closer to achieving herd immunity in all communities, including the poorest and most marginalized ones.
But Gavi has proposed “no-DTP1” (i.e., no first dose of DTP) to measure equity – and this seems to miss the point. Most of the shortfall in coverage is no longer related to DTP which has reached 86 percent of children, on average. While those without DTP1 are undoubtedly “left behind” in different ways, the high-level of DTP3 coverage on average means these children are likely protected via herd immunity.
Instead, Gavi should take a more comprehensive approach and focus on average national coverage of a broader set of vaccines, including Penta3, PCV3, or MCV1 or MCV2, as well as an adapted Gini coefficient of vaccination coverage to more effectively measure the inequality of vaccination at the subnational level within countries. As a start, WUENIC brings together all available survey sources as well as administrative reports and is generating regular coverage estimates; WUENIC has also initiated a database with subnational estimates (though it is likely incomplete, and more work is needed).
With equity at the heart of its strategy, these measures should headline Gavi’s performance dashboard and be the primary focus of their work going forward.
Work as a partnership to increase coverage—and make the Alliance greater than the sum of its parts.
A great strength of Gavi is its partnership model that aims to “capitalize on the sum of our partners’ comparative advantages.” Each partner–UNICEF, WHO, the World Bank, Gates Foundation, civil society organizations, and others–has a role to play in supporting eligible countries in the achievement of coverage goals.
Yet there is more that the organization can do to mobilize real partnership in-country, particularly where there is evidence of stagnation or backsliding. A recent example comes from Nepal, where full vaccination for age of children under 2 years old dropped from 87 percent in 2011 to 78 percent in 2016–and this drop is not related to effects of the 2015 earthquake. In fact, vaccination rates were higher among earthquake-affected districts and people. While hard to pinpoint or privilege specific causes of the drop in coverage, one hypothesis is that the earthquake response had skewed effort away from the overall goal of high coverage for all. In other countries, such as Nigeria, drops in coverage or slow progress has been linked to stock-outs of vaccines.
How is Gavi using its partnership to address slow progress and backsliding, whatever its cause? Are respective roles and lines of accountability sufficiently clear? While governments themselves are clearly accountable for their own vaccination rates, how does the Gavi partnership as a whole respond or deploy when problems surface?
A first step is to set vaccination coverage as the main goal as described above. This will assure that the Partnership focuses on this core outcome and takes ownership not just for introducing new vaccines and immunizing more kids, but also for reaching adequate coverage levels for existing vaccines. When the coverage level stagnates or drops, that will also be a sign that course correction is needed and a reexamination of each partner’s role in increasing coverage is a priority.
A second step is to develop accountability tools and processes to help the government and Gavi partners work towards progress in an effective manner. Each organization has its own mission and comparative advantage, as well as its own budgets–so the question is what could galvanize all to work more effectively together towards higher coverage at policy and practical levels? There is no clear—or easy—answer as yet, but regular country-level partnership plans and–perhaps–some civil society oversight of progress against plans would seem a good option.
In parallel, it would be useful for Gavi to deploy its health system strengthening (HSS) grants more effectively in support of these kinds of efforts; this may mean working more collaboratively with partners on the initial design as well as implementation of the grants. Cordelia Kenney and I (Amanda) addressed the challenges and options for reform of the Gavi HSS window in this CGD note.
Develop an incentives structure to sustain coverage during and post-transition.
Gavi’s Board committees have proposed a time-limited extension of the accelerated transition phase—which a country enters once it crosses the GNI per capita eligibility threshold (averaged over three years). During this period (currently five years), Gavi support ramps down and co-financing requirements increase in tandem; countries can also apply for vaccine support and/or health system and immunization strengthening grants. Considering ten more countries are poised to transition out of Gavi support during the 2021-2025 period, the Board’s attention on this issue is well-placed.
However, a laser-sharp focus on stronger and clearer incentives will be critical to improve delivery, sustain coverage, and avoid backsliding during and post transition. This will be particularly relevant when considering that by 2030, 70 percent of under-immunized children are projected to live in MICs, including Nigeria, India, and Pakistan.
In some instances, a key driver of inequities is a mismatch between needs and public spending. The case of Ethiopia illustrates this resource allocation issue: large variations in public spending on health mirror staggering inequities in full immunization coverage which ranges from as low as 15.2 percent in the Afar region to almost 90 percent in Addis Ababa. We hope to see a real shift towards improved incentive structures at the policy and budget allocation levels—one that renews focus on the basics of incentivizing domestic resources for routine immunization. Gavi’s HSS window also offers a tangible lever to create strong incentives to tackle key constraints to vaccine delivery and coverage in underserved populations through performance-based management and financing approaches tailored to specific contexts.
“Immunization challenges,” building on existing models such as Salud Mesoamerica and the Nigeria Governor’s Immunization Leadership Challenge, offer one potential way to advance this agenda. This approach would help align high-level political will and provide flexible grants to national and/or subnational governments that can demonstrate increased immunization coverage for underserved populations (see more here). Interventions that provide community report cards and monitoring, for example, can also improve service delivery and uptake through local accountability mechanisms. Finally, a greater focus on advocacy and information efforts, including social signaling, can counter low demand for immunization and potentially address vaccine hesitancy.
Considering a portfolio of approaches would help ensure a tailored model can be deployed in different contexts and it should ideally build in rigorous, independent evaluation to expand our collective understanding of the most effective and efficient approaches. We’ll be watching to see if the resources set aside for targeting this kind of tailored support through the accelerated transition phase are adequate and realistic.
How Gavi operationalizes these core issues to adapt to the ever-evolving global health landscape in its next strategic phase will be critical to its ability to realize the goal to “reach every child everywhere with vaccines against preventable diseases.”