Study Details

Introducing New Vaccines in the Poorest Countries: What did we Learn from the GAVI Experience with Financial Sustainability?


Lydon P.  Levine R.  Makinen M  et al 


December 2008


Vaccine  Volume 26, Issue 51, pp6706-6716

Web Link

View PDF


Expanded Programme on Immunization (EPI)


Funding; GAVI.

Study Type

Independent desk-based review.


To review the experience of GAVI introducing Hep B and Haemophilus influenzae type b vaccines in the poorest countries; explore how financing has changed since GAVI Fund resources were made available during its first wave of support 2000-20006; to test the original assumptions of GAVI financing approach against realities of wide set of countries. NB: This paper is the second in a series of three papers describing the work of the Financing Task Force in the first five years of the GAVI Alliance. The first document focuses on the Financing Task Force as a model for interagency coordination, and the third one looks at national strategies for achieving financial sustainability in the poorest countries funded by GAVI.


Quantitative and qualitative analysis of immunization expenditure and financing data from GAVIs Financing Taskforce database, using a subset of 50 of the 75 GAVI countries for which the information reported in countries Financial Sustainability Plan was deemed of sufficiently high quality and comparability.. Data presented compare baseline before GAVI, a year with GAVI support, and a future projected period between 2005-10 (to capture phase out and transition to national and partner financing).


Expenditures for routine immunization have increased from $6 before GAVI, to $9.2 one year in, to projected $17.5 per infant for 2005-10. Scale up of immunization during this latter period must therefore increase by a factor of three compared to baseline. In addition, the review found that...

  • Vaccines are the single largest cost driver of routine delivery systems in the past, Human Resources was the largest immunization expenditure.
  • GAVI fund commitments during first wave of support average $4.9 per infant per year over the 2005-10 period the second largest source of financing (37%) after the government (42%). No evidence that GAVI funding has replaced existing finances, it is additional but this is an average figure and there are variations in countries. Of the 50 countries, 5 saw an overall drop in financing for immunisation even with GAVI support, and if GAVI support is excluded 17 countries dropped routine immunisation financing.
  • Despite the positive trends, expected future funds will not be enough to match the needs to sustain the gains nor scale up immunisation to complete the HepB and Hib agenda as envisioned by GAVI, because growth rate in financing is far outpaced by growth rates in future resource requirements.
  • $17.5 per infant is needed annually during 2005-10. This means an average funding gap of $4.3 per infant per year if both committed and non-committed funds are considered. Even this optimistic scenario means there is 25% gap.
  • GAVIs approach to generate a market impact on vaccines to make them more affordable has not worked and prices have risen. Declining value of dollar and also not sufficient time to see a difference.
  • Routine immunisation = 2.4% of government health expenditure in baseline year up to 3.7% during 2005-10. NB. in 8 countries it was 10% and in 2 it was 20%. The pressure on health budgets drops with income levels, as immunisation accounts for a decreasing share. In countries with income less that $1 dollar a day, immunisation = 9% of total government expenditure, whereas countries with $3 per day immunisation = just 1%. Variations largely down to GAVI vaccines introduction of HepB and Hib account for majority of increase in expenditure. Pressure on government health budgets greatest where country chooses to introduce combination vaccines with Hib

Conclusions /

  • GAVI is the only global partnership making financial sustainability at county level a priority.
  • GAVIs Financial Sustainability Plans process was welcomed by countries, but vaccine introduction decisions made on poor evidence of disease burden and cost effectiveness.
  • GAVI needs to strengthen its monitoring of immunisation financing at country level as well as close monitoring of the funding gap

Sponsored by DFID, Danida, Irish Aid