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GAVI, officially Gavi, the Vaccine Alliance (previously the GAVI Alliance, and before that the Global Alliance for Vaccines and Immunization) is a public–private global health partnership with the goal of increasing access to immunization in poor countries. In 2016, Gavi channeled more than half of total donor assistance for health, and most donor assistance for immunization, by monetary measure. Gavi supports the immunization of almost half the world's children. Gavi has helped immunize over 760 million children, preventing over 13 million deaths worldwide, helping increase
diphtheria Diphtheria is an infection caused by the bacterium '' Corynebacterium diphtheriae''. Most infections are asymptomatic or have a mild clinical course, but in some outbreaks more than 10% of those diagnosed with the disease may die. Signs and s ...
vaccine coverage in supported countries from 59% in 2000 to 81% in 2019, contributing to reducing child mortality by half. It also seeks to improve the
economics of vaccines Vaccine development and production is economically complex and prone to market failure. Many of the diseases most demanding a vaccine, including HIV, malaria and tuberculosis, exist principally in poor countries. Pharmaceutical firms and biotech ...
, negotiating bulk prices, supporting
price discrimination Price discrimination is a microeconomic pricing strategy where identical or largely similar goods or services are sold at different prices by the same provider in different markets. Price discrimination is distinguished from product differe ...
, and reducing the commercial risks that manufacturers face when selling vaccines to the poor and developing vaccines. It also provides funding to strengthen health systems and train health workers across the developing world, though the effectiveness of its health-system-strengthening programs is disputed. Along with Global Health Initiatives (GHIs) in general, Gavi was described as innovative, effective, and less bureaucratic than multilateral government institutions like the WHO. Gavi programmes may produce quantified results within an election cycle, which is appealing to parties locked in an election cycle. One author described Gavi's approach to public health as business-oriented and technology-focused, using market-oriented measures, and seeking quantifiable results. Gavi follows a model termed the "Gates approach" or US-type approach. It contrasts with the approach typified by the
Alma Ata Declaration Declaration of Alma-Ata was adopted at the International Conference on Primary Health Care (PHC), Almaty (formerly Alma-Ata), Kazakh Soviet Socialist Republic (present day Kazakhstan), Soviet Union 6–12 September 1978.WHODeclaration from the websi ...
, which focuses on the effects of political, social, and cultural systems on health. Gavi facilitates vaccinations in developing countries by working with donor governments, the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level o ...
,
UNICEF UNICEF (), originally called the United Nations International Children's Emergency Fund in full, now officially United Nations Children's Fund, is an agency of the United Nations responsible for providing humanitarian and developmental aid to c ...
, the
World Bank The World Bank is an international financial institution that provides loans and grants to the governments of low- and middle-income countries for the purpose of pursuing capital projects. The World Bank is the collective name for the Inte ...
, the vaccine industry in both industrialised and developing countries, research and technical agencies, civil society, the
Bill & Melinda Gates Foundation The Bill & Melinda Gates Foundation (BMGF), a merging of the William H. Gates Foundation and the Gates Learning Foundation, is an American private foundation founded by Bill Gates and Melinda French Gates. Based in Seattle, Washington, it was ...
and other private philanthropists. Gavi has observer status at the World Health Assembly. GAVI has been criticized for giving private donors more unilateral power to decide on global health goals, prioritizing new, expensive vaccines while putting less money and effort into expanding coverage of old, cheap ones, harming local healthcare systems, spending too much on subsidies to large, profitable pharmaceutical companies without reducing the prices of some vaccines, and its
conflicts of interest A conflict of interest (COI) is a situation in which a person or organization is involved in multiple wikt:interest#Noun, interests, finance, financial or otherwise, and serving one interest could involve working against another. Typically, t ...
in having vaccine manufacturers on its governance board. Gavi has taken steps to address some of these concerns.


Sponsors

Gavi runs in five-year funding cycles which enables it to negotiate long-term deals with manufacturers, secure in the knowledge that funding will be available. Following the latest Global Vaccine Summit in June 2020 hosted in the UK, $8.8 billion (USD) was raised for the funding cycle 2021 to 2025; exceeding the target of $7.4 billion. This included $2 billion from the UK, $1.6 billion from the Gates Foundation and $1 billion from Norway. The UK government stated that this round of funding would mean that 300 million more children in lower-income countries are immunized for diseases including measles, polio and diphtheria by the end of 2025. Additionally, the funding will support health systems to withstand the impact of coronavirus and maintain the infrastructure necessary to roll out a future COVID-19 vaccine on a global scale. In the period of 2016–2020 over which US$9.3 billion had been received by Gavi, the UK was the largest donor, providing around 25% of total funding, with the
Bill & Melinda Gates Foundation The Bill & Melinda Gates Foundation (BMGF), a merging of the William H. Gates Foundation and the Gates Learning Foundation, is an American private foundation founded by Bill Gates and Melinda French Gates. Based in Seattle, Washington, it was ...
(BMGF), the US and Norway close behind. Industrialised countries are GAVI's principal donors, providing approximately three-quarters of the total funding. All donor governments are represented on the Gavi Board through a constituency system (i.e. one donor country will represent several donors in their constituency). Public-sector workers and academics public health have criticized Gavi, and other global health initiatives (GHIs) with private-sector actors, saying that they have neither the democratic legitimacy nor the capacity to decide on public health agendas. Private donors often find it easier to exert influence through public-private partnerships like Gavi than through the traditional public sector. There is also criticism that staff at GHIs are often recruited directly from elite educational institutions, and have no experience in health care systems, especially those in poorer countries. Some WHO officials have privately criticized Gavi for infringing and weakening the WHO's mandate.


History and programs

Gavi was created in 2000 as a successor to the Children's Vaccine Initiative, which was launched in 1990. In August 2014, Gavi changed its name from "GAVI Alliance" and rebranded itself with a new logo deliberately reminiscent of UN organization logos, but using green as a mark of difference.


Vaccine development and advance market commitments

Advance Market Commitments (AMCs) aim to overcome
market failure In neoclassical economics, market failure is a situation in which the allocation of goods and services by a free market is not Pareto efficient, often leading to a net loss of economic value. Market failures can be viewed as scenarios where indiv ...
by making an advance pledge that if a vaccine for a certain condition is developed, meeting certain specifications, donors will buy a certain number of doses. GAVI seeks to design its AMCs in a way that encourages a
competitive market In economics, competition is a scenario where different economic firmsThis article follows the general economic convention of referring to all actors as firms; examples in include individuals and brands or divisions within the same (legal) firm ...
."Pneumococcal AMC GAVI webpage"
GAVI has been particularly successful at promoting the uptake of newer vaccines.


Vaccination programs

GAVI's main objective is vaccination programs. Gavi has been the main donor funder of vaccination in low and middle income countries. In 2012, the first
Médecins Sans Frontières (MSF; pronounced ), also known as Doctors Without Borders, is a humanitarian medical non-governmental organisation (NGO) or charity of French origin known for its projects in conflict zones and in countries affected by endemic diseases. ...
(MSF) "The right shot" report criticized Gavi for focusing on funding expensive new vaccines and neglecting to give children low-cost older ones. "Twenty percent of the world's children aren't even getting the basic vaccines", MSF's vaccine policy adviser said. MSF criticized the Global Vaccine Action Plan (GVAP), a WHO global collaboration of which Gavi is listed as a leader, as flawed for failing to help those 20%, which is some 19 million children.


Pneumococcal vaccine

In 2011,
Doctors Without Borders Doctor or The Doctor may refer to: Personal titles * Doctor (title), the holder of an accredited academic degree * A medical practitioner, including: ** Physician ** Surgeon ** Dentist ** Veterinary physician ** Optometrist *Other roles ** ...
(MSF) recommended that Gavi change the ways in which it buy vaccines. They criticized the pneumococcal vaccine Advance Market Commitment, which means that
GlaxoSmithKline GSK plc, formerly GlaxoSmithKline plc, is a British multinational pharmaceutical and biotechnology company with global headquarters in London, England. Established in 2000 by a merger of Glaxo Wellcome and SmithKline Beecham. GSK is the tent ...
(GSK) and
Pfizer Pfizer Inc. ( ) is an American multinational pharmaceutical and biotechnology corporation headquartered on 42nd Street in Manhattan, New York City. The company was established in 1849 in New York by two German entrepreneurs, Charles Pfize ...
get a subsidy as well as a per-unit payment for supplying doses of
pneumococcal vaccine Pneumococcal vaccines are vaccines against the bacterium '' Streptococcus pneumoniae''. Their use can prevent some cases of pneumonia, meningitis, and sepsis. There are two types of pneumococcal vaccines: conjugate vaccines and polysaccharide v ...
, as "
corporate welfare Corporate welfare is a phrase used to describe a government's bestowal of money grants, tax breaks, or other special favorable treatment for corporations. The definition of corporate welfare is sometimes restricted to direct government subsidie ...
that is scandalously expensive to donors and taxpayers" (in return, the companies committed to sell at least 30 million doses annually for ten years). The Advance Market Commitment had transferred far more money to GSK and Pfizer than the GAVI grants had transferred to low-cost suppliers for technology transfer and product development. MSF said that large pharmaceutical multinationals had been found to put very high markups on prices, and internationally certified vaccine could be made for about 40% less cost by smaller companies in India and China, despite patent-related obstacles. The duopoly allowed
price discrimination Price discrimination is a microeconomic pricing strategy where identical or largely similar goods or services are sold at different prices by the same provider in different markets. Price discrimination is distinguished from product differe ...
; apart from charging slightly higher prices for GAVI, it charged unaffordable prices (about ten time the GAVI price) for middle-income countries too rich for GAVI aid. MSF also highlighted the success of the adapted vaccines program, which makes vaccines that are easier to deliver in remote areas (no need for a temperature-controlled supply chain, looser age restrictions, fewer shots, lower prices, etc.). They recommended that GAVI spend more money on adapted vaccines and on fostering competition, and less subsidizing large pharmaceutical companies. GAVI responded (on an unspecified date) by agreeing with MSF's goals, but regretting that MSF had discussed the issue in public as well as through its own close ties to GAVI. GAVI said that low prices required large, stable, high-volume deals, and "careful consideration and the support of key constituencies". In January 2015, MSF also called upon GSK and Pfizer to cut the price of the pneumococcal vaccine to US$5 per child in developing countries, a price they estimated as competitive. On January 27, they responded to Pfizer's commitment to reduce prices by 6% to $10 per child. They said that GSK and Pfizer were being paid $21 per child if GAVI subsidies were included, and the change would not greatly increase affordability for mid-wealth countries, those too rich for GAVI help but too poor to afford the vaccine. They said that, as Pfizer had made $16 billion in profits on pneumococcal vaccine in the last four years, a larger price cut would be affordable. In early 2016, they ran the "A fair shot" campaign to pressure GSK and Pfizer to drop prices. Pfizer said that they were already selling the vaccine at "far below" cost, while GSK said that the price enabled them to "just about" cover their costs, and "To discount it further would threaten our ability to supply it to these countries in the long-term".
Bill Gates William Henry Gates III (born October 28, 1955) is an American business magnate and philanthropist. He is a co-founder of Microsoft, along with his late childhood friend Paul Allen. During his career at Microsoft, Gates held the positions ...
responded to MSF, saying "I think there is an organisation that's wonderful in every other respect, but every time we raise money to save poor children's lives, they put out a press release that says the price of these things should be zero". He said that criticizing pharmaceutical company pricing deterred them from investing in medicines for the developing world, and said that instead, pharmaceutical companies should be praised for
price discrimination Price discrimination is a microeconomic pricing strategy where identical or largely similar goods or services are sold at different prices by the same provider in different markets. Price discrimination is distinguished from product differe ...
: "We get a great price for these things, which is tiered pricing... And that's how we manage to cut childhood death in half". He also advocated improving low-temperature supply chains (a.k.a.
cold chain A cold chain is a low temperature-controlled supply chain network. An unbroken cold chain is an uninterrupted series of refrigerated production, storage and distribution activities, along with associated equipment and logistics, which maintain qu ...
s) in developing countries. In August 2019, MSF asked GAVI to stop giving Advance Market Commitment subsidies to GSK and Pfizer, whom they called a
duopoly A duopoly (from Greek δύο, ''duo'' "two" and πωλεῖν, ''polein'' "to sell") is a type of oligopoly where two firms have dominant or exclusive control over a market. It is the most commonly studied form of oligopoly due to its simplicit ...
, and instead buy vaccine from a new third manufacturer, the
Serum Institute of India Serum Institute of India (SII) is an Indian biotechnology and biopharmaceuticals company, based in Pune. It is the world's largest manufacturer of vaccines. It was founded by Cyrus Poonawalla in 1966 and is a part of Cyrus Poonawalla Group. ...
, which offered the vaccine at 2/3 of the price then offered by the two. As the pneumococcal vaccine made up 40% of GAVI's vaccine purchasing costs, a 33% price drop would save GAVI billions (13% of its total vaccine purchasing costs). Pneumonia kills more than a quarter of children dying before the age of five, almost a million children each year. MSF said that GSK and Pfizer's pricing was exploitative and had left millions of children who could have been protected vulnerable. In December 2019, they reiterated this request, pointing out that the GSK/Pfizer pneumococcal vaccine often costs US$80 in middle-income countries too rich for GAVI support. In January 2020, MSF repeated the appeal for Gavi to bulk-buy the cheaper pneumococcal vaccine and vaccinate more of the 55 million children who are not vaccinated with it. They also appealed to the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level o ...
,
UNICEF UNICEF (), originally called the United Nations International Children's Emergency Fund in full, now officially United Nations Children's Fund, is an agency of the United Nations responsible for providing humanitarian and developmental aid to c ...
, and the
Gates Foundation The Bill & Melinda Gates Foundation (BMGF), a merging of the William H. Gates Foundation and the Gates Learning Foundation, is an American private foundation founded by Bill Gates and Melinda French Gates. Based in Seattle, Washington, it was ...
, and said that Gavi could have done more to lower vaccine prices.


Health systems strengthening debate

In the 20-naughts, Gavi had intense internal debate about its role in vaccinations and in health systems strengthening (HSS). This was part of a broader discussion in healthcare about "vertical" approaches (often targeting specific diseases or behaviours) and "horizontal" ones, targeting broad programs such as
primary care Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care ...
. At GAVI, some argued that vaccination could not be effectively carried out and sustained without strengthening healthcare, citing experiences in Gavi's vaccination programmes, where availability of staff, training, transport, and funds had hindered vaccination and reporting of vaccination coverage and stocks. There were also worries that Gavi was undermining and paralyzing health care systems. Others argued that HSS was a distraction from Gavi's single-minded focus on vaccines, and HSS was a nebulous concept that could not be defined and quantified. Major donors
Norway Norway, officially the Kingdom of Norway, is a Nordic countries, Nordic country in Northern Europe, the mainland territory of which comprises the western and northernmost portion of the Scandinavian Peninsula. The remote Arctic island of ...
and
Britain Britain most often refers to: * The United Kingdom, a sovereign state in Europe comprising the island of Great Britain, the north-eastern part of the island of Ireland and many smaller islands * Great Britain, the largest island in the United King ...
supported HSS;
USAID The United States Agency for International Development (USAID) is an independent agency of the U.S. federal government that is primarily responsible for administering civilian foreign aid and development assistance. With a budget of over $27 bi ...
and the
Bill & Melinda Gates Foundation The Bill & Melinda Gates Foundation (BMGF), a merging of the William H. Gates Foundation and the Gates Learning Foundation, is an American private foundation founded by Bill Gates and Melinda French Gates. Based in Seattle, Washington, it was ...
(and
Bill Gates William Henry Gates III (born October 28, 1955) is an American business magnate and philanthropist. He is a co-founder of Microsoft, along with his late childhood friend Paul Allen. During his career at Microsoft, Gates held the positions ...
personally) opposed it. The majority of vaccine experts tended to favour technological rather than HSS-based approaches. Pharmaceutical industry representatives were supportive of HSS, possibly because they saw it as key to sustainable markets for their products. In 2005, a narrow vote brought Gavi to endorse an HSS goal. Up to a quarter of Gavi's funding was dedicated to "strengthening the capacity of integrated health systems to deliver immunisation", in practice it's been around 10%. After 2010, this funding went through a joint-venture Health Systems Funding Platform. Gavi's funding for this platform was conditional on the platform meeting vaccine coverage goals. As of the mid-2010s, few in Gavi were working on HSS, most of the former pro-HSS people had left, and some at Gavi dismissed HSS as PR to gain support from pro-HSS donors and counter criticisms that Gavi was harming healthcare systems. Such criticisms were generally not a topic that GAVI engaged with internally; the lack of internal engagement with the issue has been criticized. The disagreements were fairly intense; when Bill Gates came to visit GAVI headquarters, employees would hide the HSS-related posters so that he would not be reminded of this aspect of GAVI's work. Julian Lob-Levitt, who was Gavi's CEO between 2004 and 2010, was rumoured to have left over conflicts around his support for
health system strengthening Health systems strengthening (also health system strengthening, abbreviated HSS) is a term used in global health that roughly means to improve the health care system of a country. Within this general definition, it can mean increasing funding for h ...
.
Seth Berkley Seth Franklin Berkley (born October 18, 1956) is an American medical epidemiologist, the CEO of Gavi, the Vaccine Alliance and a global advocate of the power of vaccines. He is the founder and former president and CEO of the International AIDS Va ...
has been the CEO of Gavi since 2011, . It has been argued that GAVI's HSS spending in the early 2010s went to selective, disease-specific interventions repackaged as HSS. GAVI's HSS support at this time tended to focus on immunisation strengthening support, especially the building of
cold chain A cold chain is a low temperature-controlled supply chain network. An unbroken cold chain is an uninterrupted series of refrigerated production, storage and distribution activities, along with associated equipment and logistics, which maintain qu ...
s. GAVI measured HSS using vaccination coverage as the sole indicator. It set the reporting indicators which were required of recipients of its funding; countries were not allowed to use similar indicators they already collected; this has been criticized for conferring a heavy accounting burden and diverting attention from indigenous goals. National government representatives did sit on the board, but had little influence; one European representative described the environment in the mid-2010s as "highly intimidating". A 2016 funding-allocation analysis of a sample of GAVI grants found that just over half the money went to purchasing drugs, equipment, supplies, and facilities (and 3% on bonuses and incentive pay,). These are short-term funding activities which the WHO does not consider HSS. The proportions were higher in less-developed healthcare systems. There was no spending on operational research, improving use of existing resources, or developing national drug and vaccine policies. In some grants, HSS funds were mostly spent on day-to-day operational costs, with no exit plan for the funding. GAVI subsequently (before 2018) shifted HSS aid to focus more on sustainability and the principles of the Paris Declaration for Aid Effectiveness.


Market shaping

In 2011 Gavi added "shape the market for vaccines and other immunisation supplies" to its strategic goals.


Pentavalent vaccine

GAVI spent 15 years (2005–2020) with a program for shaping the
pentavalent vaccine A pentavalent vaccine, also known as a 5-in-1 vaccine, is a combination vaccine with five individual vaccines conjugated into one. Pentavalent vaccine frequently refers to the 5-in-1 vaccine protecting against diphtheria, tetanus, whooping coug ...
market to be more stable and competitive. The vaccine price fell with increased competition, and
price discrimination Price discrimination is a microeconomic pricing strategy where identical or largely similar goods or services are sold at different prices by the same provider in different markets. Price discrimination is distinguished from product differe ...
declined. Whether Gavi met quantitative goals will be assessed in 2020. File:Prequalified pentavalent and years of sales to UNICEF. Figure 5.jpg, The number of manufacturers making certified pentavalent vaccine increased, making the market more competitive. Graph by Gavi; manufacturers are not named. File:Pentavalent per-dose price ranges, to UNICEF, 2005–2019. Figure 7.jpg, All pentavalent vaccine prices fell and
price discrimination Price discrimination is a microeconomic pricing strategy where identical or largely similar goods or services are sold at different prices by the same provider in different markets. Price discrimination is distinguished from product differe ...
almost vanished. Graph by Gavi; non-UNICEF prices not shown


COVID-19 pandemic

In April 2020, Gavi's CEO
Seth Berkley Seth Franklin Berkley (born October 18, 1956) is an American medical epidemiologist, the CEO of Gavi, the Vaccine Alliance and a global advocate of the power of vaccines. He is the founder and former president and CEO of the International AIDS Va ...
commented that the
COVID-19 pandemic The COVID-19 pandemic, also known as the coronavirus pandemic, is an ongoing global pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The novel virus was first identi ...
needed a global response whereby the best global facilities for separate parts of the processes should then be integrated into a global process. He said he hoped that the G20 countries should work together with a budget of tens of billions of dollars, and that individual countries should be prepared for finished vaccines to be allocated according to greatest need. In September 2020, Gavi was announced as one of the organisations leading the COVAX vaccine allocation plan, created to ensure that any new
COVID-19 vaccine A COVID19 vaccine is a vaccine intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2), the virus that causes coronavirus disease 2019 (COVID19). Prior to the COVID19 pandemic, an e ...
would be shared equally between the world's richest and poorest countries. The following month, Gavi announced the approval of up to $150 million to help 92 low- and middle-income countries prepare for the delivery of future COVID-19 vaccines, including technical assistance and
cold chain A cold chain is a low temperature-controlled supply chain network. An unbroken cold chain is an uninterrupted series of refrigerated production, storage and distribution activities, along with associated equipment and logistics, which maintain qu ...
equipment. In January 2021, Seth Berkley announced that Gavi hoped to deliver 145 to 150 million doses of COVID-19 vaccines in the first quarter of 2021 and 500 million doses in the second quarter, and then 1.5 billion in the second half of the year. In January 2022,
the Washington Post ''The Washington Post'' (also known as the ''Post'' and, informally, ''WaPo'') is an American daily newspaper published in Washington, D.C. It is the most widely circulated newspaper within the Washington metropolitan area and has a large n ...
reported that following 309 million coronavirus vaccine doses being delivered in December 2021, COVAX had delivered approximately 910 million doses in 2021.


Awards

Gavi was awarded the 2019 Lasker-Bloomberg Public Service Award for "providing sustained access to childhood vaccines around the globe, thus saving millions of lives, and for highlighting the power of immunization to prevent disease". Gavi was nominated for the 2021
Nobel Peace Prize The Nobel Peace Prize is one of the five Nobel Prizes established by the will of Swedish industrialist, inventor and armaments (military weapons and equipment) manufacturer Alfred Nobel, along with the prizes in Chemistry, Physics, Physiolo ...
by Norwegian MP Carl-Erik Grimstad. Gavi was awarded the
Sunhak Peace Prize The Sunhak Peace Prize (선학평화상, 鮮鶴平和賞) was established to continue the legacy of Sun Myung Moon and is given biennially in Seoul, Korea, in recognition of individuals and organizations that have made enduring contributions to hel ...
in 2022 for Promoting vaccine equity at the forefront of COVID-19 by leading COVAX and Improving overall health of humanity by increasing access to vaccine for children in vulnerable countries.


See also

* CEPI * COVAX *
Economics of vaccines Vaccine development and production is economically complex and prone to market failure. Many of the diseases most demanding a vaccine, including HIV, malaria and tuberculosis, exist principally in poor countries. Pharmaceutical firms and biotech ...
*
Vaccine resistance Vaccine resistance is the evolutionary adaptation of pathogens to infect and spread through vaccinated individuals, analogous to antimicrobial resistance. It concerns both human and animal vaccines. Although the emergence of a number of vaccine ...
*
Vaccine equity Vaccine equity means ensuring that everyone in the world has equal access to vaccines. The importance of vaccine equity has been emphasized by researchers and public health experts during the COVID-19 pandemic but is relevant to other illnesses an ...


References


External links

*
GAVI Vaccine Fund
{{authority control International medical and health organizations Vaccination-related organizations International responses to the COVID-19 pandemic Organizations established in 2000