Ideas to Action:

Independent research for global prosperity

This note is a draft and may be revised following the Gavi March 2019 board retreat.

Introduction

Gavi’s most important stakeholders are the countries that are eligible for and receive its support. Gavi serves a wide array of functions for eligible countries, providing financing for specific vaccines while shaping vaccine delivery and the global vaccine market. Gavi has additionally expanded its partner engagement and health systems strengthening (HSS) support in recent years, including through targeted country assistance (TCA), which provides technical assistance for country’s national immunization programs. Gavi’s business model aims to provide support that will enhance the ability of countries to develop sustainable and self-financed immunization programs.

Gavi-eligible countries face a variety of upcoming challenges, from impending aid transitions to global health security threats. A projected 26 countries[1] will undergo full Gavi transition by 2025 and only 27 countries will be eligible for Gavi financing in 2040.[2] While this may be viewed as a positive change—an indication of economic development in lower-income countries—it also means that Gavi-supported countries need to build strong fiscal strategies to self-finance their immunization systems and programmatic and institutional capacities. This may be particularly challenging for those countries currently receiving a combination of vaccine, health systems strengthening (HSS), and TCA support. Moreover, prioritization of health spending is more difficult in countries facing conflict, refugee crises, disease outbreaks, and other emergency scenarios. Gavi’s 5.0 strategy process presents an opportunity to assess Gavi’s effectiveness in addressing these competing pressures and to align processes and priorities with the needs of country governments.

In this note, we explore some of the challenges facing Gavi-eligible countries. We then propose procedural improvements or adaptations to Gavi’s operations to better support the needs of country governments and other partners.

Challenges on the Horizon

Countries are struggling to prepare for transition amid competing fiscal pressures, and Gavi Board decisions to extend transition have been ad hoc

Co-financing and self-financing of immunization systems depends on both economic growth and increased budget allocations to health[3],[4], along with budget priority to immunization programs. Gavi’s transition model, which requires gradual increases in co-financing from countries over a five-year period,[5] assumes that economic growth will translate into increased health spending at the national level. However, countries’ abilities to increase domestic vaccine financing varies. For example, in some countries, Gavi’s mandatory increases in co-financing requirements exceed projected growth in health budgets which would require reallocations within an already highly constrained health budget which is politically difficult. In addition, sudden jumps in GNI per capita can push countries over the eligibility criteria well in advance of projections (for example, Ghana exceeded Gavi’s eligibility threshold 15 years prior to the International Monetary Fund’s (IMF) earlier projections).[6] Although Gavi has extended eligibility in these cases by adding two additional years,[7] countries’ preparedness and timeline for co-financing can be limited by these conditions. Countries may also face competing fiscal pressures when transitioning from multiple forms of global health financing simultaneously. Nigeria, Pakistan, Cameroon, Côte d’Ivoire, Lesotho, Myanmar, and Tanzania will all transition from multiple sources of global health financing (e.g., the Global Fund, the International Development Association (IDA)[8], the Global Polio Eradication Initiative, and PEPFAR) by 2031.[9] These simultaneous transitions will create difficulties for these countries as they face increased fiscal burdens yet need to prioritize their health budgets among immunization, HIV, malaria, TB, maternal health, and more.

Decision-making capacities for immunization financing are often weak in Gavi-eligible countries approaching transition and depend on the priorities of ministries of finance and health whose siloed processes can make planning for transition and sustainable immunization programs difficult.[10] For example, Gavi’s focus on equity[11] and hard-to-reach areas suggests that greater levels of immunization spending should go to regions with low immunization coverage, but increased health budget allocations for lower-performing regions, even if it is a priority for health ministers, may not be reflected in national budgets. Ethiopia, a Gavi-eligible country that will begin preparatory transition[12] in 2025, has significant inequities in full immunization coverage, ranging from 15 percent (Afar) to 90 percent (Addis Ababa);[13] however, according to the World Bank’s 2016 Public Expenditure Report for Ethiopia, regions with lower health service coverage and higher costs to reach poorer or more rural populations do not systematically receive larger allocations of health budgets.[14]

Given these and other fiscal pressures, Gavi assesses countries’ abilities to fully self-finance and has begun to grant transition extensions to middle-income countries. In 2017, a readiness assessment for all transitioning countries, both current and entering during the 2016–2020 strategic period, was used to identify high-risk countries requiring tailored approaches.[15] During Gavi’s April 2017 Board retreat, Nigeria, Papua New Guinea, the Republic of Congo, Timor-Leste, and Angola were identified as countries with the highest transition risks.[16] In June 2018, though several members voiced concerns about risks,[17] Gavi’s Board approved an extension to Nigeria’s accelerated transition timeline through 2028.[18] Gavi is now developing an extension plan for Papua New Guinea, pending Board approval in 2019.[19]

While these extensions are merited given the challenges facing these countries, the criteria that allow for exceptions are not clear in Gavi’s strategies or policies, and the Board decisions were made well into the accelerated transition phase. Similarly, in November 2018, Gavi’s Board approved an additional $10 million in post-transition support (within the PEF) for Angola and Timor-Leste;[20] however, Gavi’s criteria for allowing this additional funding, though outlined verbally to Gavi’s Board, have not been developed as a formal Board-approved policy. The added processes that accompany exceptions to Gavi’s policies are also unclear and are not formalized. For example, in regard to Nigeria’s transition extension, the Board requested that an accountability framework be developed by November 2018, and in the cases of Angola and Timor-Leste, the Board requested that “robust country plans” be presented to the Program and Policy Committee (PPC).[21] This lack of clarity may create uncertainty for other Gavi-eligible countries about the circumstances allowing for continued support and, if granted, what is expected from countries in exchange for extended support.

Further, most of the 16 countries that have already transitioned did so readily because -unlike the new batch of transitioning countries- they did not face significant financial pressures. Vaccine support is < 1% of GHE equivalent which could be absorbed by most countries. Challenges for this first wave of countries were around capacities, such as decision-making or procurement. As others have signaled, the next cohort of transitioning countries are very different from earlier cohorts.[22]

Countries are facing increased threats pertaining to global health security, displacement, and conflict that influence their ability to meet immunization coverage goals and to self-finance programs

The 2018 Ebola outbreak in the DRC is the second largest in its history and the first in an active conflict zone.[23] The DRC has a 45 percent full immunization coverage nationally,[24] indicating an already-struggling health system. Gavi’s primary response included mobilizing 300,000 investigational doses of the rVSV-ZEBOV Ebola vaccine, providing $3.9 million in support of the country’s response plan, and providing support to neighboring countries through WHO for preventative vaccination.[25] About 87,000 people have received the vaccine, which has been highly effective in helping to control the epidemic, but the supply is expected to run out between May and mid-September 2019.[26] Given limited vaccine availability, strategies for continuing to ramp up Ebola preparedness in neighboring countries should be a significant priority for Gavi.[27] The vaccine has proven effective in the DRC, but ramping up preparedness and vaccine availability in neighboring countries should continue to be a priority for these countries and Gavi.[28]

The DRC is just one example of a country combatting disease outbreaks, refugee crises, and conflict scenarios that require emergency response and a departure from business-as-usual for Gavi. Pandemic preparedness and global health security moved into the spotlight after the 2014 West Africa Ebola epidemic,[29] but financing for this use adds additional burdens to lower-income countries. A 2018 study, using WHO’s National Comprehensive Multi-Year Plans (cMYPs), found that spending for vaccine-preventable disease surveillance is minute but varies widely between countries, with a median expenditure of $.04 per capita.[30] In some countries, such as Nigeria ($.15 per capita), spending is explained by the urgent need for surveillance of specific diseases (e.g., polio). In other cases, however, there is little analysis or explanation of expenditures (e.g., $.34 per capita in Zambia and $.01 per capita in Pakistan), [31] indicating the need for further investigation of countries’ expenditure decision-making regarding preparedness. Additionally, in countries that rely on the Global Polio Eradication Initiative (GPEI) for surveillance,[32] the potential phase down of GPEI support may create increased urgency for domestic funding of preparedness.

In the coming years, Gavi may also be responsible for filling a key role within the global health security landscape: introducing and supporting countries in deploying new preventative vaccines. For example, the National Institute of Allergy and Infectious Diseases is currently developing a universal influenza vaccine,[33] which, if cost-effective, might be delivered across the world by Gavi. Controlling for negative regional externalities, [34] including disease outbreaks, can also be considered a global public good (GPG). Although only one-fifth of global health funding goes towards GPGs,[35] there are high returns for investing in them, including for HIV vaccine development ($67 return for every dollar invested in vaccine development).[36]

To support countries in developing robust preparedness systems, Gavi should be considered an integral part of the Global Health Security Agenda (GHSA)[37] architecture by the global health community. In October 2017, a Gavi Board member noted that Gavi’s role in relation to epidemics will likely increase and that there should be more attention to this topic.[38] Gavi has exhibited growing recognition of preparedness as a critical issue. It currently has three active vaccine stockpiles (yellow fever, meningitis, and cholera) ready for emergency response and invests in measles outbreak response efforts and the Ebola vaccine stockpile. Moreover, Gavi developed a Fragility and Immunization Policy in 2012, which allows the organization to increase funding for countries with emergency and protracted circumstances (e.g., Yemen in 2015, Chad in 2013).[39] Gavi’s Board continued these efforts by approving a Fragility, Emergencies, and Refugees (FER) policy in June 2017, which allows Gavi to provide flexible financial, administrative, and programmatic support to Gavi-eligible fragile states[40] and countries facing emergencies and/or hosting refugees.[41] However, this policy does not extend to global health security and preparedness, which is particularly relevant for the neighbors of countries managing emergencies, fragility, and displacement.

Gavi’s grant processes create barriers for countries in programmatic implementation and national planning

The perspectives of developing country governments on Gavi’s policies and operations are represented by five government officials, most often ministers of health, on Gavi’s Board.[42] Beyond Board and committees representation, countries mainly engage with Gavi through grant processes: grants for vaccine support, grants for HSS support, and partner engagement frameworks.[43] Countries are required to submit applications if they are applying for vaccine support, health systems strengthening support, cold chain equipment support and post-transition engagement (PTE).[44] While the application requirements differ, each stream requires reporting against milestones and targets that are not standardized across support type and country. In addition, a Joint Appraisal (JA) process, a review of the implementation of Gavi’s support, is required annually. On top of Gavi-mandated materials, countries must submit cMYPs or similar multi-year plans for immunization.

Partner engagement frameworks (PEF), introduced in 2016 for Gavi’s 2016–2020 strategy, support engagement with country governments through three pillars: (1) targeted country assistance, (2) foundational support, and (3) special investment in strategic focus areas (e.g., data, supply chain, sustainability). PEF support is provided to all Gavi-eligible countries (and country partners), but varies in amount according to Gavi’s view on the size of the challenge. [45] Currently, targeted country assistance is concentrated in 10 countries with the “most under-immunized children”[46] and 10 countries with “high level of inequity or conflict.”[47] Funding is given directly to partners like WHO, UNICEF, World Bank and others (not country governments) and also allows for the placement of staff in country to manage Gavi support ($85 million of a total $150 million of the PEF budget went to country assistance in 2018).[48],[49] PEF support may be valuable, but as most is not channeled through governments, there may be implementation and sustainability challenges when the support ends.

The Gavi Full Country Evaluation, conducted in 2015 and 2016 in Bangladesh, Mozambique, Uganda and Zambia, found that some of Gavi’s processes negatively influenced the ability of the limited set of countries studied to effectively manage grants and implement programs.[50], [51] These barriers included high administrative and management responsibilities associated with Gavi’s grants, which constricted program capacity and management. In regard to programmatic and financial capacity, it was found that the timelines for applications and implementation are “overly optimistic” and restrict countries’ ability to effectively manage their grants.[52] Furthermore, the Joint Appraisal process often did not align with national planning timelines, limiting integration with national systems, and Gavi’s technical assistance did not align with countries’ cMYPs, sometimes creating confusion.[53][54] It is important to note that the findings of this evaluation may not be generalizable particularly to fragile and Francophone countries where conditions may be worse.

Since 2016, Gavi has aimed to address these challenges and improve collaboration with countries through the introduction of three-to-five-year portfolio planning (previously CEF), the Program Support Rationale (PSR) template, and PEF support. Portfolio planning, along with the PSR, combines separate streams of support (HSS, CCEOP, vaccine support) into one application and aims to align better with country processes.[55] Results have not yet been assessed.

Recommendations for Gavi’s Future Approach

1. Through additional analysis of fiscal pressures, support eligible countries in developing strong decision-making, prioritization, and transition strategies; develop clear guidelines for exceptions to transition timelines; and increase communication between ministers of health, ministers of finance, and Gavi to improve shared understanding of challenges and lessons learned

Countries are often unprepared for the sequencing, timing, and magnitude of the financial implications of transition from aid.[56] While it is vital to increase domestic vaccine financing over time, it is also important for Gavi to understand the consequences of different universal health coverage (UHC) financing arrangements on resource allocation and budgetary trends. New UHC schemes that put the emphasis on financing curative services may affect the availability of funding for immunization and preventative services, for example.[57] Although Gavi aims to support planning and preparedness, including by working with the World Bank to conduct Health Systems Financing Assessments (HSFAs),[58] readiness assessments and analyses of countries’ macro-fiscal challenges should be conducted for Gavi-eligible countries more frequently and well before entering transition in order to address issues.

In close consultation with ministries of finance and health, Gavi should support the development of multi-year plans on spending for immunization that align with cost-effectiveness criteria for public spending as well as immunization goals, are consistent with fiscal constraints over time, and provide recommendations to address identified financial pressures. Further, Gavi should provide more systematic priority-setting support to countries . For example, Gavi Board members have pointed to the possibility of creating a dashboard for measuring transition, including tracking post-transition middle-income countries.[59] If a dashboard were created, it could provide information on lessons learned from successful transitions, particularly regarding budget decision-making. Gavi should also share lessons learned from Nigeria’s eligibility extension and from Angola and Timor-Leste’s increased post-transition support allowance.[60]

Given the likelihood that Gavi will adjust its transition policies in the future (e.g., extending transition timelines for high-risk MICs), Gavi should support currently-eligible countries by making guidelines and processes for transition as user-friendly and clear as possible. Steps towards this goal should include:

  • introducing in-country transition planning meetings with ministries of health and finance to ensure preparedness and alignment

  • developing and integrating the criteria for receiving an extended transition period into Gavi’s policies, and providing clarity to all Gavi-eligible countries on the process for receiving an extension

  • approving extended transition periods well in advance of accelerated transition (optimally prior to or during preparatory transition)

  • formalizing and systematizing processes that are required after receiving an exception to Gavi’s eligibility and PTE policies, including accountability frameworks and country plans

For Gavi to support eligible countries in becoming self-sustaining, the organization should explore innovations to its funding model that would increase equity and immunization coverage and better prepare countries for successful transitions. For example, to lessen the financial burden facing Gavi-eligible countries approaching transition, Gavi could provide budget support for immunization programs (following multilateral development bank guidelines/restrictions on use of funds) contingent on independently verified progress on immunization coverage. Providing flexible, results-based grant funds as budget support to national and subnational governments may produce better coverage results for underserved populations, especially in areas with large clusters of under-immunized children. Other global health programs, including Salud Mesoamerica[61] and the Nigeria Governors’ Immunization Leadership Challenge,[62] have successfully reduced health equity gaps through innovative immunization incentives and can help inform Gavi’s next phase of operations.

Finally, in order to provide country governments with a greater voice and more visibility in Gavi’s processes, Gavi should facilitate annual meetings of ministers of finance and ministers of health from Gavi-eligible countries alongside the spring World Bank/IMF meetings (for example, or at another mutually agreed upon venue). During a discussion of post-transition engagement in the November 2017 Board meeting, a member noted that countries should assume a larger role in helping the Board understand countries’ challenges during and post transition.[63] By increasing in-person dialogues, Gavi could improve communication between country-level stakeholders about financial and health systems priorities. To add to the diversity of perspectives, the participation of countries that do not hold representation on Gavi’s Board (including MICs) should be ensured.

2. Adapt Gavi’s business model to include global health security and response to emergencies as a strategic focus area

Gavi should devote more time to analysis and discussions of health security preparedness within its fragility and emergencies policies. Gavi’s FER policy could be revised to include a percentage investment (from Gavi) in preparedness as a requirement for granting additional support to fragile states and emergency settings. For example, in countries with large refugee populations, a percentage of HSS grant funding should be designated for disease surveillance. Investment from Gavi in global health security should also include a focus on helping countries to increase prioritization of preparedness in the long-term, including providing resources on an ideal per capita spending amount for surveillance. Significant updates on Gavi’s role in global health security should be reported to Gavi’s Board on a semi-annual basis and/or when major crises occur.

New tools, such the Global Health Security Agenda’s Joint External Evaluation’s (JEE)[64] and the Global Health Security (GHS) Index (which uses technical assessments, health system strength, global goal commitments, socioeconomic circumstances, and more),[65] can be used by countries to develop costed plans and by Gavi to guide financing for preparedness in vulnerable countries. However, Gavi’s assistance in preparedness and emergency response should be carefully constructed to avoid further inequities in vaccine delivery. For example, at Gavi’s June 2017 Board meeting, DRC Minister of Health Félix Kabange expressed appreciation for Gavi’s assistance during the Ebola outbreak, but also noted the equity challenges that accompany decision-making around vaccine delivery in crises.[66] In an illustrative case, pregnant and lactating women were excluded from receiving rVSV-ZEBOV until February, 2019.[67] This lapse in providing vaccination for an extremely vulnerable population highlights the need for designing approaches to preparedness and disease surveillance that consider equity and ethics.[68] Gavi should assess lessons learned from the 2018 Ebola outbreak in the DRC and should share findings with high-risk countries.

Using the JEE and GHS Index to understand different country challenges, Gavi should require eligible countries to include preparedness targets in vaccine support and HSS grant proposals. Global health security should be prioritized in Joint Appraisal discussions and integration of preparedness targets in cMYPs and national plans should be encouraged. Senior country managers should work closely with recipient countries to ensure understanding and identification of appropriate preparedness targets that are achievable. Guidance on setting preparedness targets should be developed and disseminated at the country level.

As countries move along the transition process and increase their co-financing commitments, thereby freeing up resources Gavi would have spent on those countries, Gavi can redirect funding towards additional resources for global health security, and activities that increase preparedness in Gavi-eligible countries. These activities may include supporting the Ebola stockpile, funding for disease surveillance in lower-income countries, inactivated polio vaccine support, and more. Along this vein, in November 2018, Gavi’s Board approved support for inactivated poliovirus vaccine (IPV) with country financing arrangements. This decision will add to Gavi’s 5.0 replenishment request, as IPV support alone will cost an estimated $848 million that was not included in Gavi’s 2015 replenishment.[69] As Gavi ramps up its IPV support for eligible countries, it should be mindful of the potential added strains that transitioning from an additional form of Gavi support may put on country governments.

3. Better align grant requirements with country budgets, timelines and processes in order to lessen administrative and operational burden

Moving forward, it is vital for Gavi to continue to adjust and streamline its processes to consolidate efforts and lighten the burden for countries that receive multiple modes of support. Gavi should continually consider ways to increase alignment with national planning and budgeting processes. To reduce the operational burden on countries, Gavi should continue to build on the Program Support Rationale by ensuring alignment with PEF/TCA operational plans and priorities. The Alliance should also ensure that joint appraisal timelines and audits are aligned with national planning processes and technical assistance priorities, including multi-year immunization plans. Any additional modes of support or administrative processes formalized during the 5.0 period, such as accountability frameworks for countries receiving transition extensions, should be aligned with country processes and joint appraisals.

Gavi should explore integrating technical assistance funding into HSS and EPI grants in order to ensure cohesion of capacity-building priorities and the long-term sustainability of systems and programs within countries.

Finally, the annual meetings of country stakeholders proposed in recommendation 1 should be treated as an opportunity to solicit and receive feedback on concerns about Gavi processes and grants. Gavi should address country challenges quickly while keeping in mind simplicity.



[1] Gavi estimates 26 countries based on those that already transitioned (16), are in transition (8), and that will enter in 2020 (2). Silverman (2018) projects that 31 countries will undergo full transition by 2025. Differences may be attributable to differences in projected trends in economic growth, among others.

[2] Silverman, Rachel. “Projected Health Financing Transitions: Timeline and Magnitude.” Washington, DC: Center for Global Development, 2019, 11.

[3] “Immunization Financing: A Resource Guide for Advocates Policymakers, and Program Managers.” Washington, DC: Results for Development, 2017.

[4] There are three primary sources of domestic public funding for health: general revenue, social insurance, and domestic trust funds.

[5] “Transition Process,” Gavi, The Vaccine Alliance, accessed 15 March 2019, https://www.gavi.org/support/sustainability/transition-process/.  Countries pay $0.20 per dose for any new vaccine introduced. If a country GNIpc is above $1050, the country co-procures the equivalent of $0.20 per dose + 15%. Once a country has crossed the threshold of $1580 GNIpc (3 year average), they enter the Accelerated Transition (AT) phase, during which they will have five years to ramp up their co-financing to become self-sufficient. For countries in the middle, Preparatory Phase: if they are in that phase for 7 years of more, they will already be financing pentavalent vaccine due to the 15% ramp-up year on year.

[6] Kallenberg, Judith et al. “Gavi’s Transition Policy: Moving from Development Assistance to Domestic Financing of Immunization Programs.” Health Affairs 35, NO. 2 (2016): 250–258.

[7] According to consultations with Gavi staff.

[8] Note that the IDA threshold crossing does not automatically imply ineligibility from IDA itself, there is usually a phasing out period.

[9] Silverman, “Projected Health Financing Transitions,” 26-27.

[10] Saxenian, Helen, Logan Brenzel, Leah Ewald, and Meghan O’Connell. Blog: 4 Things Ministers of Finance Need to Know About Immunization in Gavi Transitioning Countries.” Washington, DC: Results for Development, 2019.

[11] “Gavi’s Strategy,” Gavi, The Vaccine Alliance, accessed 15 March 2019, https://www.gavi.org/about/strategy/.

[12] Defined as above the World Bank’s low-income country threshold.

[13] Glassman, Amanda and Liesl Schnabel. “Gavi Going Forward: Immunization for Every Child Everywhere?” Washington, DC: Center for Global Development, 2019.

[14] “Ethiopia Public Expenditure Review.” Washington, DC: World Bank, 2016, http://documents.worldbank.org/curated/en/176471468178145744/pdf/ACS14541-WP-OUO-9-Ethiopia-PER-final-May-12.pdf.

[15] According to consultations with Gavi staff.

[16] Gavi November 2017 Board meeting minutes.

[17] “Board members raised many concerns relating to the long period of sustained work that would be required from Nigeria and associated risks of failure. Several members supported the idea to ensure that an exit strategy is created for transition from Gavi support. The importance of monitoring domestic health expenditure and improving data monitoring was also underlined by Board members.” (Board Meeting Minutes, June 2018).

[19] According to consultations with Gavi staff.

[20] Gavi Alliance Board Review of Decisions, 28-29 November 2018, Gavi, The Vaccine Alliance, https://www.gavi.org/about/governance/gavi-board/minutes/2018/28-nov/.

[21] June 2018, November 2018.

[23] Maxmen, Amy. “Violence Propels Ebola Outbreak Toward 1,000 Cases.” Nature 567, 153-154 (2019), https://www.nature.com/articles/d41586-019-00805-7.

[24] 2013-14 Ethiopia DHS.

[25] “Gavi’s Response to the DRC Ebola Outbreak,” Gavi, The Vaccine Alliance, accessed 15 March 2019, https://www.gavi.org/library/news/statements/2018/gavi-s-response-to-the-drc-ebola-outbreak/. Note: Gavi has informed CGD that $3.9 million was made available for the DRC’s response plan, as well as support for neighboring countries via WHO.

[26] Grady, Denise. “Ebola Epidemic in Congo Could Last Another Year, C.D.C Director Warns.” New York Times, March 16 2019, https://www.nytimes.com/2019/03/16/health/ebola-congo-cdc.html

[27] “Highlights on Ebola Preparedness in Democratic Republic of Congo and Surrounding Countries.” Geneva, Switzerland: World Health Organization (WHO), accessed 15 March 2019, https://extranet.who.int/sph/news/highlights-ebola-preparedness-democratic-republic-congo-and-surrounding-countries.

[28] “Highlights on Ebola Preparedness in Democratic Republic of Congo and Surrounding Countries.” Geneva, Switzerland: World Health Organization (WHO), accessed 15 March 2019, https://extranet.who.int/sph/news/highlights-ebola-preparedness-democratic-republic-congo-and-surrounding-countries.

[29] “Global Health Security Agenda,” USAID, accessed 15 March 2019, https://www.usaid.gov/ebola/global-health-security-agenda.

[30] Hossain, Azfar, Claudio Politi, Nikhil Mandalia, and Adam L. Cohen. 2018. "Expenditures On Vaccine-Preventable Disease Surveillance: Analysis And Evaluation Of Comprehensive Multi-Year Plans (Cmyps) For Immunization.” Vaccine 36 (45): 6850-6857, 6452. Elsevier BV. doi:10.1016/j.vaccine.2018.07.068.

[31] Hossain et al. 2018. 6455.

[32] “Surveillance,” Global Polio Eradication Initiative (GPEI), accessed 15 March 2019, http://polioeradication.org/who-we-are/strategy/surveillance/.

[33] “Universal Influenza Vaccine Research,” National Institute of Allergy and Infectious Diseases, accessed 15 March 2019, https://www.niaid.nih.gov/diseases-conditions/universal-influenza-vaccine-research.

[34] “Intensified Multilateral Cooperation on Global Public Goods for Health: Three Opportunities for Collective Action.” Durham, NC: Duke Global Health, 2018, 1.

[35] “Global Public Goods for Health,” Duke, 2018, 1.

[36] Hecht, Robert, Dean T. Jamison, Jared Augenstein, Gabrielle Partridge, and Kira Thorien. "Vaccine research and development." Rethink HIV: smarter ways to invest in ending HIV in sub-Saharan Africa (2012): 299-320.

[37] “Global Health Security Agenda,” accessed March 15, 2019, https://www.ghsagenda.org/.

[39] “On the Frontline: Gavi’s Support to Fragile States,” Gavi, The Vaccine Alliance, accessed 15 March 2019, https://www.gavi.org/library/news/gavi-features/2016/on-the-frontline--gavi-s-support-to-fragile-states/.

[41] “Fragility, Emergencies, and Refugees Policy,” Gavi, The Vaccine Alliance, accessed 15 March 2019, https://www.gavi.org/about/programme-policies/fragility-emergencies-and-refugees-policy/.

[42] “Board Composition,” Gavi, The Vaccine Alliance, accessed 15 March 2019, https://www.gavi.org/about/governance/gavi-board/composition/.

[43] “How We Work Together: Quick Start Guide for New Members of the Vaccine Alliance.” Geneva, Switzerland: Gavi, The Vaccine Alliance, 2018.

[44] “Support Guidelines,” Gavi, The Vaccine Alliance, accessed 15 March 2019, https://www.gavi.org/support/process/apply/.

[45] PEF partners are required to align with governments technical assistance plans.

[46] Afghanistan, Chad, The Democratic Republic of the Congo, Ethiopia, India, Indonesia, Kenya, Nigeria, Pakistan, Uganda.

[47] Central African Republic, Haiti, Madagascar, Mozambique, Myanmar, Niger, Papua New Guinea, Somalia, South Sudan, Yemen.

[48] “How We Work Together,” Gavi, 2018.

[49] “The support is mainly provided in the form of full-time staff based in partners’ country offices” (see “How We Work Together,” 2018).

[50] Gavi Full Country Evaluations Team. “Cross-country: Findings from the 2015 Gavi Full Country Evaluations.” Seattle, WA: IHME, 2016.

[51] “2016 Full Country Evaluations – Alliance Management Response.” Geneva, Switzerland: Gavi, The Vaccine Alliance, 2017.  

[52] “2015 Gavi Full Country Evaluations,” IHME.  

[53] “2015 Gavi Full Country Evaluations,” IHME. 

[54] This may not always be a bad thing, as the cMYP becomes out of date rather quickly. However, there does need to be good alignment with country annual operating plans.

[55] “How We Work Together,” Gavi, 2018.

[56] Silverman, “Projected Health Financing Transitions,” 1.

[57] “Immunization Financing,” Results for Development, 24.

[58] According to consultations with Gavi staff.

[59] Gavi Alliance Board Meeting Minutes, 29-30 November 2017, https://www.gavi.org/about/governance/gavi-board/minutes/2017/29-nov/.

[60] Gavi Board indicated importance of sharing lessons learned from countries granted exceptions in June 2018 Board m

[61] “Salud Mesoamérica Initiative (SMI),” IHME, accessed 15 March 2019, http://www.healthdata.org/salud-mesoamérica-initiative.

[62] “Immunization Leadership Challenge for Nigeria’s Governors,” Global Polio Eradication Initiative (GPEI), accessed 15 March 2019, http://polioeradication.org/news-post/immunization-leadership-challenge-for-nigerias-governors/.

[63] Gavi Board Minutes, November 2017.  

[64] “JEE Dashboard,” World Health Organization, accessed 15 March 2019, https://extranet.who.int/sph/jee-dashboard.

[65] Berkley, Seth. "Health Security's Blind Spot." Science, Vol. 359, Issue 6380 (2018): 1075-1075. DOI: 10.1126/science.aat4714.

[67] Branswell, Helen. “Ebola Vaccine Will be Provided to Women Who are Pregnant, Marking Reversal in Policy.” STAT, 2019.

[68] Carleigh Krubiner. “Time to Deliver: New Ebola Findings Highlight the Need to Improve Evidence and Interventions for Pregnant Women.” Washington, DC: Center for Global Development, 2018.

[69] Board Review of Decisions, November 2019.

 

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