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Financial Sustainability of GAVI funding for immunisation programmes. Marianela Castillo-Riquelme Health Economics Unit- University of Cape Town HEPNet workshop on Donor Funding Livingstone, Zambia 26-28th May 2008. Outline of the presentation .

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Financial Sustainability of GAVI funding for immunisation programmes

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Financial sustainability of gavi funding for immunisation programmes l.jpg

Financial Sustainability of GAVI funding for immunisation programmes

Marianela Castillo-Riquelme

Health Economics Unit- University of Cape Town

HEPNet workshop on Donor Funding

Livingstone, Zambia 26-28th May 2008.

Outline of the presentation l.jpg

Outline of the presentation

  • Background on immunisation programmes

  • Global Immunisation Vision and Strategy (GIVS)

  • GAVI funding model

    • Phase 1 (ended)

    • Trends in expenditure on immunisation programmes after GAVI

    • Phase 2

  • Challenges on sustainability (new vaccines)

  • Conclusion and reflections

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Background information on immunisations

  • One of the basic healthcare prevention programmes => Considered very cost-effective

  • Phenomenon of various new vaccines (Hep B & Hib, then rotavirus, Japanese Encephalitis, meningococcal A/pneumococcal conjugate, HPV, and rubella)

  • New vaccines including combination vaccines are much more expensive

  • WHO-UNICEF Global Immunization Vision and Strategy, 2006-2015

  • Many developing countries rely on donor funding to conduct immunisations programmes – mainly GAVI

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Immunisation schedule (generic)

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Global Immunization Vision and Strategy (GIVS) for the period 2006-2015

  • UNICEF/WHO initiative

  • Reduce mortality due to vaccine-preventable diseases by 2/3 by 2015

  • Reach 90% coverage by 1015

  • Introduce new vaccines (which?)

  • Can we afford GIVS? Wolfson et al. (2008) try to answer this!

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Global Alliance for Vaccines and Immunisations (GAVI)

  • Created in 2000 (initially for 5 years)

  • Financial sustainability plans [FSP], 10 years

  • Definition of eligible countries

    • Grouping by income (4 groups using UN definition of less developed and income threshold of GNI $1000 per capita)

  • Three components of funding:

    • Immunisations services support (ISS) [DPT3<80%]

    • Injection safety support (INS) disposable syringe & safety boxes

    • New vaccines support (NVS)

  • 2 phases

    • First phase 2001-2006 $1.2 billion

    • Second phase 2006-2015 (around 5.5 billion committed)

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GAVI experience 1st phase

  • 71 out of 75 eligible countries have benefited

  • Vaccine introduction grant ($100.000 one time)

  • Immunisation coverage has increased

  • Injection safety component very well evaluated

  • ISS with a performance based component $20 for additional FVC


  • Financial sustainability not achieved in 5 years

  • New vaccines’ prices have not decreased as expected

  • Donors unable to make multi-year commitment

  • Therefore second phase was needed

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Evaluation of GAVI funding (1)Lydon et al. 2008

  • Some findings

    • Total cost of $153 million (baseline) to increase to $500 million in 2010 (to sustain and gain scale-up)

    • Cost per child $6 (baseline), $9.2 (GAVI) and $17,5 (2010)

    • Cost profile of immunisation services changing=> vaccines 20% (baseline) and expected to reach 50% (new vaccines)

    • Other cost of introducing new vaccines: training and social mobilisation

    • Increase in recurrent expenditures of 22% (cold chain equipment and maintenance, training, additional human resources, vehicles, transportation, and surveillance activities)

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Evaluation of GAVI funding (2)Patrick Lydon (WHO)

  • Unknown trends in the absence of the new vaccines (Hep B and hib)

  • Immunisations services strengthening (ISS) would account for 11% increase on non-vaccine expenditure

  • Variability in costs across countries respond to vaccine schedule, HR costs, economic development, demographic, performance and delivery strategies

  • Supplemental activities (mass campaigns, NID, mop-up activities & outbreak responses) can be a considerable part of total costs (25%). Normally these costs exceed those of routine delivery services

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GAVI phase 2

  • Period: 2006-2015

  • Countries consultative process

  • Introduction of co-financing also called bridge-funding

  • ISS continues

  • International Finance Facility for Immunisation (IFFIm) [4 billion] borrowing from international capital markets

  • [Pneumo] Advance Market Commitment (AMC) [1.5 billion] from Feb 2007

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Challenges for phase 2- Cost of new vaccines

Very high!

e.g. Pentavalent account for 92% of the overall cost on vaccines in Malawi (GAVI, 2005) – no secure funding after 2007

  • Rotavirus projected price $5.75 per dose in 2010 and $1.88 in 2015 (Wolfson et al, 2008)

  • Meningococcal Conjugate $0.44 (2010) & $0.58 (2015) (Wolfson et al, 2008)

  • Japanese Encephalitis $3.02 (2010) & $2.96 (2015) (Wolfson et al, 2008)

  • Pneumococcal Conjugate $5 (2010) & $4 (2015) (Wolfson et al, 2008)

  • Plus costs of introduction

  • Plus other recurrent costs associated to delivery

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Cost of reaching GIVS, Wolfson et al.2008


  • 117 low and middle income countries included

  • Using country planning documents

  • Botton-up ingredients approach to scale-up

  • Introducing: Rotavirus, Conjugate Meningococcal A, Japanese Encephalitis and Pneumococcal Conjugate


  • The 72 poorest countries spent $1.1 billion in 2000, which increased to $2.5 b in 2005 and it is projected $4 b for 2015.

  • Total costs between 2006-2015 = $35 b:

    • $19.3 b to maintain current level,

    • $8.7 b for vaccines &

    • $5.6 b for system scale-up

  • These costs almost double for the 117 countries

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From Report to GAVI secretariat, July 2005 (page 17)

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GAVI’s new co-financing policy for new vaccines (2007-2010)

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Conclusions and reflections (1)

  • GAVI’s aim of increasing coverage has been achieved

  • Increased awareness of financial sustainability at country level

  • Sustainability of the current level of immunisations is challenging

  • Introducing new vaccines is even more challenging

  • Some new vaccines have been introduced on cost-effectiveness results basis, however CE does not guaranty affordability

  • Sustainability was not achieved at the end of phase 1 (due to wrong assumptions). Can this happen again with phase 2?

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Conclusions and reflections (2)

  • More research is needed at country level prior introduction of a new vaccine

  • Introduction of combination & new vaccines need to be evaluated in relation to other non-vaccine preventable disease interventions

  • Question on allocative-efficiency => Do we really know the opportunity cost of introducing pentavalent vaccine? Or rotavirus? Or other vaccine?

  • Are GIVS unrealistic?

  • Changing donor behaviour SWAp versus specific disease programmes (in-kind v/s budget donation)

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Lydon P at al (2008) New Vaccines in the Poorest Countries - What did we learn from the GAVI experience with financial sustainability? Submitted to Vaccine

Wolfson et al (2008). Estimating the costs of achieving the WHO-UNICEF Global Immunisation Vision and Strategy, 2006-2015. Bulleting of the World Health Organisation, 86(1):27-39

GAVI, Lessons learned from GAVI Phase 1 and design of Phase 2; Findings of the Country Consultation Process. Available at

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