This evaluation of GAVI's Phase 1 performance presents findings on its programmes and activities, and it management and sustainability approaches.
Programs and activities
- On average, coverage rates increased in GAVI countries during the course of Phase 1 DTP3 coverage rate increased from 64% to 71%, HepB3 coverage rate increased from 16% to 46%, and Hib3 coverage rate increased from 1% to 7%.
- Disparities in immunization coverage based on urban/rural residence and gender were reduced during Phase 1, and changes can be correlated to GAVI funding.
- GAVI has not developed effective approaches for facilitating support to underperforming countries.
- The cost per additional child immunized with DTP3 was $8.31, while the cost per pertussis death averted was $933. The cost per child reached with HepB/Hib/YF vaccine was $5.31 data limitations made it impossible to calculate cost per death averted by new vaccine. The lack of cost data disaggregated by vaccine is a very important finding, as it prevents GAVI from accurately evaluating the cost effectiveness of the programs and vaccines that it supports.
- Prices of vaccines did not go down and GAVIs assumption that market forces would bring down vaccine prices was unrealistic.
- GAVI has done very little to tackle important in-country introduction issues such as cold chain, storage or logistics.
- GAVI did not always have strong scientific evidence, or universal support for all of its strategic policies such as Hib introduction. As a result, there was a perception that GAVI pushed new vaccines inappropriately.
- Installing an investment case approach to guide decision-making in 2005 made analysis of new activities more rigorous, but it lacks a strategic framework for resource allocation.
- 18% of GAVI funding was allocated to increasing access to immunization services, 73% to expanding use of new vaccines, 4% to accelerated disease control, and 4% to accelerating development and introduction of new vaccines. These allocations were not based on consideration of strategic priorities, activity costs, potential impact, and cost effectiveness.
- Despite its success in fund raising, many respondents believe that GAVI has not fully carried out its responsibility as the global advocate for immunization.
- Total funding for immunization increased during Phase 1, mostly as a result of GAVI funding, and mostly for new vaccines. For countries that introduced pentavalent vaccine, immunization program costs totaled 9.2% of government health expenditures.
- GAVI funding flexibility, and the minimal reporting burden at country level, were important advantages of GAVI support that should be maintained.
- Despite concerted efforts, limited progress made towards country level sustainability.
- Funding flows for immunisation have changed and bilateral donor assistance now goes through GAVI, making it more difficult for countries to generate increased funding from in-country donors.
- GAVI encourages countries to apply for more expensive pentavalent vaccine, which may meet its short-term objectives, but there are no long-range agreements on the appropriate level of financial responsibility to be assigned to countries, or projections of GAVIs own ability to continue financing these and other newer vaccines.
- GAVI has primarily used its advocacy voice for global level fundraising, and has underutilized its position to build country level ownership and commitment.
- GAVI should focus more attention on improving performance in under-performing countries, working with in-country partners to provide additional support.
- To respond to the perception that GAVI promoted certain vaccines inappropriately, the GAVI Board should strengthen the scientific evidence underpinning its policies, and commission an independent review to determine whether its priorities correspond to country level priorities.
- GAVI should ensure it has sufficient information to allow accurate cost effectiveness evaluation of its programs.
- Because it was difficult for developing country Board members to represent their constituents during Phase 1, GAVI should take advantage of opportunities presented by regional meetings to engage in substantive dialogue with countries, and propose a plan for how those discussions would feed into global level decision-making.
- To respond to the criticism that GAVI has not increased total funding for immunization but merely redirected it, GAVI should commission an assessment to determine whether total funding for immunization has increased since the inception of GAVI, as well as develops a methodology for reporting on future funding changes.