全球发展中心-超越“符合全球疫苗免疫接种条件”：全球疫苗免疫在不符合条件的中等收入国家提高疫苗获取和吸收的高杠杆机会（英）

Beyondthe“Gavi-Eligible”

High-LeverageOpportunitiesforGavitoEnhanceVaccine

AccessandUptakeinIneligibleMiddle-IncomeCountries

RACHELSILVERMANBONNIFIELD·MORGANPINCOMBE·JANEENMADANKELLER

Abstract

Thegloballocusofundervaccinationisincreasinglyshiftingfromthepoorestcountriesintheworld—whichareeligibleforsupportfromGavi,theVaccineAlliance(Gavi)—to

middle-incomecountries(MICs)thatdonotqualifyfortraditionalGavisupport.Given

thesegrowingchallenges,GavimustrethinkitsengagementwiththoseMICsthatare

ineligiblefortraditionalsupport.Althoughthisengagementisintendedtobe“catalytic”andhasbeenintentionallytargetedtocountryneeds,italsohasbeenrelativelysmall-

scaleandadhoc.Gavi’snextfive-yearstrategicperiodfrom2026to2030,knownas

“Gavi6.0,”offersawindowofopportunityforitsboardandleadershiptoconsidernew

anddifferentwaysforGavitoengagewithMICstoadvanceglobalvaccineaccessand

improvevaccinationoutcomes.Tohavethegreatestimpactinthiscontext,Gavimust

leanintoitscomparativeadvantageinmarketshapinganddemandconsolidation

todriveitscontributionstoglobalvaccinationeffortswithfiniteresources.Weoffer

recommendationsforGavitooperationalizebroaderengagementwithMICs,specifically

byenablinganexpandedcohortofMICstoaccessmoreaffordablepricesforbothnewer,costliervaccinesandfuturevaccinesviaopt-inframeworkagreementsandbysupportingaglobalcoordinatinghubtoshapeaforward-lookingimmunizationinnovationagenda.

POLICYPAPER326•APRIL2024

Beyondthe“Gavi-Eligible”:High-LeverageOpportunitiesforGavitoEnhanceVaccineAccessandUptakeinIneligibleMiddle-IncomeCountries

RachelSilvermanBonnifield,MorganPincombe,andJaneenMadanKeller

CenterforGlobalDevelopment

TheauthorswouldliketothankNimaAbbaszadeh,KellyCarr,KalipsoChalkidou,JavierGuzman,andGavi

colleaguesfortheirfeedbackandinputonearlierdraftsofthispaper.TheCenterforGlobalDevelopmentis

gratefulforcontributionsfromtheBill&MelindaGatesFoundationinsupportofthiswork.

RachelSilvermanBonnifield,MorganPincombe,andJaneenMadanKeller.2024.“Beyondthe“Gavi-Eligible”:

High-LeverageOpportunitiesforGavitoEnhanceVaccineAccessandUptakeinIneligibleMiddle-Income

Countries.”CGDPolicyPaper326.Washington,DC:CenterforGlobalDevelopment.

/

publication/beyond-gavi-eligible-high-leverage-opportunities-gavi-enhance-vaccine-access-and-uptake

.

CENTERFORGLOBALDEVELOPMENT

TheCenterforGlobalDevelopmentworkstoreduceglobal

2055LStreet,NWFifthFloor

povertyandimprovelivesthroughinnovativeeconomic

Washington,DC20036

researchthatdrivesbetterpolicyandpracticebytheworld’s

topdecisionmakers.UseanddisseminationofthisPolicyPaper

1AbbeyGardens

isencouraged;however,reproducedcopiesmaynotbeused

GreatCollegeStreet

forcommercialpurposes.Furtherusageispermittedunderthe

London

termsoftheCreativeCommonsAttribution-NonCommercial4.0

SW1P3SE

InternationalLicense.

TheviewsexpressedinCGDPolicyPapersarethoseofthe

authorsandshouldnotbeattributedtotheboardofdirectors,

CenterforGlobalDevelopment.2024.

fundersoftheCenterforGlobalDevelopment,ortheauthors’respectiveorganizations.

Contents

Introduction 1

Section1:Whyineligiblemiddle-incomecountriesarebecoming

“groundzero”forglobalunder-immunization 3

KeyPoint1:Non-GaviMICsnowaccountforalarge—and

increasing—shareoftheworld’sundervaccinatedpopulation,

withagrowingconcentrationofzero-dosechildren 3

KeyPoint2:ManyMICsaregettinglessformorewith

theirimmunizationexpenditures 5

KeyPoint3:MICsarestillrecoveringfromCOVID-inducedhealth

andeconomicshocksandfacingaperiodoffiscaltightening 9

Section2:Gavi’sexistingapproachtosupportingmiddle-income

countries 11

OverviewofGavisupportavailabletodifferentcategoriesofMICs 12

ChallengesandgapswithGavi’scurrentapproach 15

Section3:PolicyrecommendationsforrethinkingGavi’sengagement

withmiddle-incomecountries 17

Recommendation1:Fornewerandcostliervaccines,facilitate

opt-inframeworkagreementswithcentrallynegotiatedtiered

pricingforanexpandedcohortofMICs 19

Recommendation2:Forfuturevaccines,facilitateopt-inmarket

entryframeworkagreementswithcentrallynegotiatedtieredpricing

foranexpandedcohortofMICs 21

Recommendation3:Supportaglobalcoordinatinghubforthe

ImmunizationInnovationAgenda(CHIIA) 23

Conclusion 24

AppendixA 25

Figures

1.Introductionsofneworunderutilizedvaccinesbycountryincomegroup

andGavieligibilitystatus........................................................................................................................6

2.Numberofzero-dosechildrenbycountryincomegroupandGavieligibility,

2019–2021......................................................................................................................................................10

Tables

1.Summarybreakdownof108MICs(classificationsforFY2024),data

formostrecentyear 4

2.Pricecomparisonsfromvaccinepurchasesin2020–2022acrosscountrygroups

andbyprocurementmechanism 8

A1.Breakdownof108MICs(classificationsforFY2024),dataformostrecentyear 25

Introduction

Althoughvaccinesaretypicallyadministeredinaprivateinteractionbetweenahealthworkerandapatient,“vaccination”writlargeisaglobalissue.Allcountries,atallincomelevels,haveaninterestinensuringthatexistingvaccinesareaccessibletotheirpopulations,includingvialocallyaffordablepricingandsupplysecurity;promotingvaccineuptakeamongeligiblepopulationstomaximizebothindividualprotectionandpopulation-levelprotectionvia“herdimmunity”;and,tosomeextent,

developingsafeandeffectivenewvaccinestoaddressexistingandpotentialhealththreats.1

Gavi,theVaccineAlliance(Gavi),isamajorglobalinitiativethatseekstopromoteglobalvaccinationandservethisglobalpublicgood.Gaviwasfoundedin2001withthemission“tosavelivesandprotectpeople’shealthbyincreasingequitableandsustainableuseofvaccines.”2Inthenearly25yearssinceitsfounding,Gavihastargeteditssupporttothepoorestcountries,withgrossnationalincome(GNI)percapitaunderapresetthreshold;thisGNIthresholdhasrangedfrom$1,000in2001to$1,810

asof2024.

InGavi’searlyyears,thisfocuswasclearlylogical;the77eligiblecountriesthatmetGavi’s

eligibilitythresholdwerepreviously“groundzero”forglobalundervaccination.Asof2005,forexample,84percentoftheworld’szero-dosechildren—thosewhohavenotreceivedanyroutinevaccination—livedinGavi-eligiblecountries.3However,thesituationischangingatarapidpace.

Increasingly,thegloballocusofundervaccinationismovingfromGavi-eligiblecountries—the

poorestintheworld—tosomewhatwealthiermiddle-incomecountries(MICs)thatnolongerqualifyfortraditionalGavisupport.

Thereareseveraltrendsunderlyingthisbroadphenomenon,whichwillbediscussedand

substantiatedatgreaterlengthinSection1.First,sinceitsfoundingin2001,Gavihasseen

substantialsuccessinsupportingpartnercountriestoraisevaccinationrates.VaccinationcoveragegapsbetweenthepoorestcountriesandwealthierMICshavenarrowedand,insomecases,even

closed.Second,manylargeMICshavealreadytransitionedfromGavisupport,orareexpectedtodosoby2030,becausetheirGNIspercapitacurrentlyorwillsoonexceedtheGavieligibilitythreshold.BecauseGavi’seligibilitymodelisbasedonincomeandnotonprogrammaticreadinessorcoveragerates,countriesmaytransitionwithouthavingfirstachievedhighcoverageratesforcertain

vaccines.Third,MICsthathaveneverbeeneligibleforGavisupportsometimesfacehighervaccinepricesthanthosethataremadeavailabletoGavi-eligiblepeers,especiallyfornewervaccinesand

whenself-procuring.ThesecountrieshaveseenslowintroductionofnewWorldHealthOrganization(WHO)-recommendvaccines,inlargepartowingtoaffordabilityandcost-effectivenesschallenges.

1Manylow-andmiddle-incomecountrieswouldstronglyprioritizeaffordableandreliableaccesstoexistingvaccinesoverdevelopmentofnewvaccines;however,thesesamecountriesmightnonethelessbenefitfromdevelopmentofnewvaccinesifandwhentheycometomarketandareofferedatlocallyaffordableprices.

2“AboutOurAlliance,”Gavi,theVaccineAlliance,lastaccessedMarch22,2024,

/our-alliance/about

.

3“GAVIAllianceProgressReport2005,”Gavi,TheVaccineAlliance,2005,

/sites/default/files/

publications/progress-reports/Gavi-Progress-Report-2005.pdf

.

BEYONDTHE“GAVI-ELIGIBLE”:HIGH-LEVERAGEOPPORTUNITIESFORGAVITO1

ENHANCEVACCINEACCESSANDUPTAKEININELIGIBLEMIDDLE-INCOMECOUNTRIES

(Thereare57countriesclassifiedasMICsthathaveneverbeeneligibleforGavisupport,

including13lower-middle-incomecountriesand44upper-middle-incomecountries.)4

Gavi-ineligibleMICsnowaccountforalargeandgrowingshareoftheglobalundervaccination

challenges.YetallMICs—boththosethathavetransitionedfromGavisupportandthosethatwere

neverGavi-eligible—arefacingthischallengewithoutcoordinated,comprehensivesupportfromtheinternationalcommunity.Despitethetremendousinternationalimportanceofvaccination,nosingleinternationalorganizationhastheglobalmandate,broadlyspeaking,tosupportcountriestoprocure

vaccines,ensurehighcoverage,andreachglobalvaccinationgoals.Thereare,ofcourse,several

organizationswithpartialmandatesaroundvaccinedevelopment,access,affordability,quality,coverage,andinnovation,includingtheWHO,theCoalitionforEpidemicPreparednessInnovations(CEPI),the

UnitedNationsChildren’sFund(UNICEF),regionalprocurementplatformsandtechnicalblocs(e.g.,thePanAmericanHealthOrganization[PAHO]),philanthropies,andevenGaviitself.Theseorganizations

engagewithsomenoneligibleMICsthroughnarrowlytargetedformsofsupport(seeSection2).However,formostcountries,theoverallsupportprovidedbythesemechanismsisfragmented,inconsistent,andincomplete.MostMICsreceivelimitedsupportorservicesinaddressingkeyvaccinationobstacles.

IfGaviwishestoremainthepremierorganizationsupportingglobalvaccineaccess,itmustexpanditsbusinessmodelbeyondthegroupofcountrieseligiblefortraditionalsupport,towardfacilitatingandsupportingbettervaccinationoutcomesinMICs.YetGaviisaninitiativewithlimitedfinancialandtechnicalresources,atleastrelativetothescaleofthechallengesconfrontingtheentirecohortofMICs.MICs,asacollective,havelargerpopulations,higherhealthspending,andgreateroverall

resourcescomparedtothecohortoflower-incomecountriesthatareeligiblefortraditionalforms

ofGavisupport.Tohavethegreatestimpactinthiscontext,Gavimustleanintoitscomparative

advantageandbestrategicaboutwhereitcanuseitsfiniteresourcestomakethelargestpossible

contributionstoglobalimmunizationgoals.Gavi’snextfive-yearstrategicperiodfrom2026to2030,knownas“Gavi6.0,”offersawindowofopportunityforitsboardandleadershiptoconsidernewanddifferentwaysforGavitoengagewithMICs,aswellashelpGaviprepareforfurtherevolutioninthepost–SustainableDevelopmentGoalsera.

ThispaperwillfirstdemonstratewhyMICsarenowcentraltoglobalchallengesofundervaccination.ItwilldescribethespecificchallengesMICsfacewithvaccinationandconsiderhowthesechallengesdifferacrosssubcategoriesofMICs—forinstance,formerlyeligibleGavicountriescomparedwith

neverGavi-eligiblecountries.Second,itwillreviewGavi’sexistingeffortsandmodesofsupportinMICs,highlightwhatweknowabouthowtheseeffortshaveworkedtodate,andassesswheretheycontinuetofallshort.Finally,itwillofferthreeideasforhowGavicanexpanditsengagementwithMICs,buildingonitscomparativeadvantageinmarketshaping,formaximumglobalbenefits.

4Authors’calculationsbasedonfiscalyear(FY)2024WorldBankincomegroupsand2024Gavieligibility:“WorldBankCountryandLendingGroups,”WorldBank,lastaccessedMarch22,2024,

/

knowledgebase/articles/906519-world-bank-country-and-lending-groups

;“Eligibility,”Gavi,theVaccineAlliance,lastaccessedMarch22,2024,

/types-support/sustainability/eligibility

.

BEYONDTHE“GAVI-ELIGIBLE”:HIGH-LEVERAGEOPPORTUNITIESFORGAVITO2

ENHANCEVACCINEACCESSANDUPTAKEININELIGIBLEMIDDLE-INCOMECOUNTRIES

Section1:Whyineligiblemiddle-incomecountriesare

becoming“groundzero”forglobalunder-immunization

KeyPoint1:Non-GaviMICsnowaccountforalarge—and

increasing—shareoftheworld’sundervaccinatedpopulation,withagrowingconcentrationofzero-dosechildren

AtGavi’sfounding,thepoorestcountriesintheworld—thosethatwereeligibleforGavisupport—

hadverylowuptakeofbasicchildhoodvaccinations.In2000,Gavi-eligiblecountrieshadabout

65percentcoverageofthethirddoseofthecombineddiphtheria,tetanus,andpertussiscontainingvaccine(DTP3);around20percentcoverageoftheHepatitisBvaccine;and0percentcoverage

oftheHaemophilusinfluenzaetypeb(Hib)vaccine.5Sincethen,Gavi’sinvestmentshavehelped

eligiblegovernmentsachieveremarkablegainsinvaccinecoverage.Asof2022,countriesthat

remainedGavi-eligiblehadpentavalentcoverageof81percent(includingDTP3,HepatitisB,andHibprotection)—justslightlylowerthanglobalcoveragerates(84percent).6Perhapsmostremarkably,Gavireportedin2022thatthe“breadthofprotection”acrossallvaccinetypeswasnowhigherin

Gavi-eligiblecountriesthanintherestoftheworld.7

Yettheglobalpictureisnotquitesorosy.Astaggeringlyhighnumberofchildrenaroundtheworldcontinuetomissoutentirelyorpartiallyonroutinevaccination,leavingthemunprotectedagainstpreventableillnesses.Inpart,butnotentirely,duetoGavi’sownsuccessinraisingcoveragerateswithineligiblecountries,agrowingproportionofthesechildrennowlivewithinthecohortofnon-GaviMICs—includingbothformerlyeligiblecountriesandnever-eligiblecountries(seeTableA1inAppendixA).Countryexperiencesvaryamongthediversecohortofnon-GaviMICs,butthereareseveralalarmingdatapoints.8

First,severallargerMICsthathavetransitionedfromGavistillcontainsignificantpocketsof

underimmunizedgroups,oftenconcentratedinspecificgeographicregionsorsocioeconomic

subgroups(seesummarybreakdowninTable1).IntheexamplesofAngolaandBolivia—both

lower-middle-incomecountriesthattransitionedfromGavisupportin2017—DTP3coverageis

42percentand69percent,respectively,andcoverageoftheseconddoseofthemeaslescontainingvaccine(MCV2)is25percentand49percent,respectively,asof2022(seeTableA1inAppendixA

5GAVIAllianceProgressReport2008,Gavi,TheVaccineAlliance,2008,

/sites/default/files/

publications/progress-reports/Gavi-Progress-Report-2008.pdf

.

6“ImmunizationCoverage,”WorldHealthOrganization(WHO),lastaccessedMarch22,2024,

/

news-room/fact-sheets/detail/immunization-coverage

.

7BreadthofprotectionisdefinedastheaveragevaccinationcoverageacrosskeyGavi-supportedvaccines.See:“EightThingsYouNeedtoKnowabouttheStateofGlobalImmunization,”Gavi,theVaccineAlliance,July18,2023,

https://www.gavi.

org/vaccineswork/eight-things-you-need-know-about-state-global-immunisation

;AnnualProgressReport2022,Gavi,theVaccineAlliance,lastupdatedJanuary2024,

/progress-report

.

8RobertJohnKolesar,RokSpruk,andTshetenTsheten,“EvaluatingCountryPerformanceAfterTransitioning

FromGaviAssistance:AnAppliedSyntheticControlAnalysis,”GlobalHealth:ScienceandPractice11,no.4(2023),

/10.9745/GHSP-D-22-00536

.

BEYONDTHE“GAVI-ELIGIBLE”:HIGH-LEVERAGEOPPORTUNITIESFORGAVITO3

ENHANCEVACCINEACCESSANDUPTAKEININELIGIBLEMIDDLE-INCOMECOUNTRIES

forbreakdownbycountry).Othercountries,likeHondurasandBolivia,haveseencoverageratesofcertainvaccinesdropofffollowingtransitionfromGavisupport.9

TABLE1.Summarybreakdownof108MICs(classificationsforFY2024),adataformostrecentyear

StatusofGavi

GDPPer

Average

CurrentHealth

DTP3

MCV2

TotalBirths

Share

Eligibility

Capita

GDP

Expenditure

Coverage

Coverage

(Thousands)c

ofTotal

(USD)b

Growth

OverPast

5years(%)a

(USDMillions)b

(%)b

(%)b

MICBirth

Cohort

(%)c

Transitioningby2030

2,454

3.25

3,959

79

58

14,718

15

Nottransitioningby2030

1,543

2.75

1,632

80

67

15,236

16

FormerGavi

5,159

2.46

50,800

87

82

20,907

22

(noIndia)

Indiad

2,411

4.16

104,211

93

90

23,114

24

NeverGavi

7,423

1.33

14,063

86

78

23,563

24

Notes:(a)SeeTableA1inAppendixAforbreakdownbycountry.Numberandshareofzero-dosechildrenareexcludedfromthissummarytable

becausethedataincludeimpreciseestimatesforsomecountries.(b)Figuresreflectaveragesacrossthegroup.(c)Figuresreflectthesumofvaluesforthegroup.(d)Indiaisseparatedouttoavoidskewingsummarystatistics,givenIndia’slargeeconomyandbirthcohort.GDP=grossdomestic

product;USD=U.S.dollars.

Sources:SeeTableA1inAppendixAforallsources.

Second,coverageforroutinevaccinesalsoremainslowinsomeneverGavi-eligibleMICs,includingthePhilippines(DTP3=72percent;MCV2=64percent)andEquatorialGuinea(DTP3=53percentandMCV2=13percent).10Inaddition,immunizationcoverageremainshighlyinequitableinsomenon-

GaviMICs,mostnotablythosewithlargebirthcohorts.Forexample,coverageofage-appropriate

vaccinationsamongchildrenaged12to23monthsinthePhilippinesvariesacrossregionsfrom

15percentto82percent.11(ThePhilippineshasneverbeeneligiblefortraditionalGavisupportbutis

currentlyeligibleforlimitedsupportundertheMICsApproach,discussedatgreaterlengthinSection2.)

Third,anincreasingconcentrationofzero-dosechildren(thosewhohavenotreceivedtheirfirst

doseoftheDTPvaccine)liveinnon-GaviMICs(seeTableA1inAppendixAforadditionaldata).12

Nearlyaquarterofzero-dosechildrenliveinjustfiveMICsthatareineligiblebasedon

9BrianWebster,LydiaRegan,andVictoriaFan,“AfterGraduation,HowDoGavi-EligibleCountriesFare?,”Centerfor

GlobalDevelopment(blog),March20,2024,

/blog/after-graduation-how-do-gavi-eligible

-

countries-fare

.

10“InputtotheWHO/UNICEFEstimatesofNationalImmunizationCoverage(WEUNIC),”WHO,July17,2023,

https://

/publications/m/item/wuenic_input

.

11SeeMap10.1inPhilippinesDHS,2022—FinalReport,DHSProgram,June2023,

/publications/

publication-FR381-DHS-Final-Reports.cfm

.

12“Zero-Dose:TheChildrenMissingOutonLife-SavingVaccines,”UNICEF,April2023,

/resources/

zero-dose-the-children-missing-out-on-life-saving-vaccines/

.

BEYONDTHE“GAVI-ELIGIBLE”:HIGH-LEVERAGEOPPORTUNITIESFORGAVITO4

ENHANCEVACCINEACCESSANDUPTAKEININELIGIBLEMIDDLE-INCOMECOUNTRIES

Gavi’sstandardeligibilitycriteria:India(7.92percentofglobalzero-dosechildren),Angola

(4.32percent),Indonesia(4.02percent),thePhilippines(4.48percent),andBrazil(3.03percent).13

Thisgeneraltrend—anincreasingconcentrationofundervaccinationinGavi-ineligibleMICs—islikelytoaccelerateinthecomingyearsasadditionalcountriestransitionfromGavisupport.

Mostnotably,NigeriaiscurrentlyprojectedtotransitionfromGavisupportin2028,eventhoughitsDTP3coverageratesaveragejust62percentnationwideand51percentinthe20least-vaccinated

districts.14And,asof2022,Nigeriaishometo2.2millionzerodosechildren,nearly16percentoftheworld’sunvaccinatedpopulation(seeTableA1inAppendixA).Atthenationallevel,thismeansthat

NigeriaislikelytotransitionfromGavisupportlongbeforereachingherdimmunity,evenforroutinevaccines.Cambodia,Comoros,theKyrgyzRepublic,Nepal,Senegal,andTajikistancouldalsocross

Gavi’seligibilitythresholdby2040,losingaccesstofullsupportfromGavi.15

KeyPoint2:ManyMICsaregettinglessformorewiththeir

immunizationexpenditures

Althoughtheunderlyingfactorsdrivingdifferencesmayvary,non-GaviMICgovernments

have,onaverage,significantlyhigherexpendituresonroutineimmunization.Forexample,in2022,theaverageGavi-ineligibleMICspent$170.13onroutineimmunizationpersurvivinginfant—aboutsixtimesasmuchasGavi-eligibleMICs($26.93)andlow-incomecountries

(LICs)($29.04).16Moreover,despitesignificantlyhigherimmunizationexpendituresby

MICgovernments,childreninGavi-ineligibleMICsreceivefewervaccinesonaveragethandotheirpeersinGavi-eligiblecountries.ManyMICshavenotyetintroducednewerWHO-recommended

vaccines,suchasthepneumococcalconjugatevaccine(PCV),thehumanpapillomavirus(HPV)

13Shareofzero-dosechildrenfrom“WUENICAnalytics,”UNICEF,lastaccessedMarch22,2024,

https://unicef-dapm.

shinyapps.io/wuenic-analytics-2023/

.IndiatransitionedfromGavisupportin2021andnowhasaspecialpartnershipwithGaviuntil2026witha$250millionenvelopeandparticularfocusonreachingzero-dosechildren.See“GaviandGovernmentofIndiaEstablishNewPartnershiptoProtectMillionsofChildrenby2026,”Gavi,theVaccineAlliance,

February3,2023,

https://ww/news/media-room/gavi-and-government-india-establish-new-partnership

-

protect-millions-children-2026

.Angola,thePhilippines,andIndonesiaareeligibleundertheMICsApproach,but

thisisforsmall-scaleandone-offtargetedformsofsupport(seeSection2).Seealso:“ListofCountriesandEconomiesEligibleforSupportundertheMICsApproachasof1July2023,”Gavi,theVaccineAlliance,lastaccessedMarch22,

2024,

https://ww/sites/default/files/programmes-impact/support/Countries-and-economies-eligible-for

-

support-under-Gavi-MICs-Approach.pdf

.

14“Nigeria,”Gavi,theVaccineAlliance,lastaccessedMarch22,2024,

https://ww/programmes-impact/

country-hub/africa/nigeria

.

15MorganPincombeetal.,“ProjectionsofEligibilityandTransitionTrajectoriesupto2040:ImplicationsforGavi’sNextStrategicPeriodandBeyond,”CenterforGlobalDevelopment,December14,2023,

https://ww/publication/

projections-eligibility-and-transition-trajectories-2040-implications-gavis-next

.

16Authors’calculationsbasedontotalexpenditureofvaccinesfrom2022andnumberofbirthssurvivingtoage1from

2021.See:“FinancingforImmunizationCountryDashboard,”WHO,lastaccessedMarch22,2024,

https://ww/

teams/immunization-vaccines-and-biologicals/vaccine-access/planning-and-financing/immunization-financing

-

indicators

;“WorldPopulationProspects2022,”UnitedNationsDepartmentofEconomicandSocialAffairs,PopulationDivision,2022,

/wpp/Download/Standard/MostUsed/

.

BEYONDTHE“GAVI-ELIGIBLE”:HIGH-LEVERAGEOPPORTUNITIESFORGAVITO5

ENHANCEVACCINEACCESSANDUPTAKEININELIGIBLEMIDDLE-INCOMECOUNTRIES

vaccine,andtherotavirusvaccine(RV).17Gavi-eligiblecountrieshaveaccesstosupportfornew

vaccineintroductions,butoncetheytransitiontofullyself-financing,thissupportissignificantlydownsizedandmoretime-limited(seeSection2).

TheslowintroductionofnewervaccinesisespeciallyapparentinMICsthathaverecently

transitionedfromGavisupport,aswellasinneverGavi-eligiblecountriesthatarejustabove

Gavi’seligibilitythreshold(seeFigure1).Forexample,93percent(26/28total)ofGavi-eligible

MICshaveintroducedPCV,butonly78percent(18/23total)offormer-GaviMICsand74percent

(42/57total)ofneverGavi-eligibleMICshaveincorporatedPCVintonationalimmunization

programs.18Importantly,vaccineadoptiondecisionsrequiredelicatetrade-offsbetweencostandhealthbenefit,andcountriesmayberationallyhealth-maximizingiftheopportunitycostofanewvaccineinvestmentoutweighsitsexpectedhealthimpact.Nevertheless,limiteduptakeoflife-

savingvaccinesbythesecountries—howeverrational—isamissedopportunityfornewvaccine

technologiestotranslateintopublichealthimpact.19

FIGURE1.IntroductionsofneworunderutilizedvaccinesbycountryincomegroupandGavieligibilitystatus

100%90%80%70%60%50%40%30%20%10%0%

93%

81%

79%

77%

78%

74%

70%

54%

52%

52%

54%

42%

PCVIntroductionsHPVVaccineIntroductionsRVIntroductions

Lowincome(n=26)Gavi-eligibleMIC(n=28)Former-GaviMIC(n=23)Never-GaviMIC(n=57)

Note:DatareflectintroductionsintonationalimmunizationprogramsasofFebruary20,2024,usingFY2024WorldBankincomegroupsand2024Gavieligibility.

Sources:InternationalVaccineAccessCenter,“VIEW-hub,”JohnsHopkinsBloombergSchoolofPublicHealth,last

accessedFebruary20,2024,

/

;“WorldBankCountryandLendingGroups,”WorldBank,lastaccessedMarch22,2024,

/knowledgebase/articles/906519-world-bank-country-and-lending

-

groups

;“Eligibility,”Gavi,theVaccineAlliance,lastaccessedMarch22,2024,

/types-support/

sustainability/eligibility

.

17ThispatternisparticularlyvisiblewithPCVandRVintroductions.However,ahighershareofGavi-ineligiblecountrieshasintroducedtheHPVvaccinecomparedtoGavi-eligiblecountries,asshowninFigure1.

18InternationalVaccineAccessCenter,“VIEW-hub,”JohnsHopkinsBloombergSchoolofPublicHealth,lastaccessedFebruary20,2024,

/

.

19JasonZhuetal.,“OpportunitiestoAccelerateImmunizationProgressinMiddle-IncomeCountries,”Vaccine(2023),

/10.1016/j.vaccine.2023.06.079

.

BEYONDTHE“GAVI-ELIGIBLE”:HIGH-LEVERAGEOPPORTUNITIESFORGAVITO6

ENHANCEVACCINEACCESSANDUPTAKEININELIGIBLEMID