Filling the need for trusted information on national health issues
Filling the need for trusted information on national health issues

Published: Jan 19, 2022
Created in 1999 and formally launched in January 2000, Gavi, the Vaccine Alliance (Gavi) is an independent public-private partnership and multilateral funding mechanism that aims to “save lives and protect people’s health by increasing coverage and equitable and sustainable use of vaccines.”¹ Gavi’s main activities include supporting low- and middle-income countries’ access to new and underused vaccines for vulnerable children through financial support, technical expertise, and market-shaping efforts, such as negotiating with manufacturers, to help lower the cost of procuring vaccines. Gavi operates in 5-year funding cycles, with a revised strategy and goals for each cycle. Gavi’s current five-year strategy, for the 2021-2025 period, includes four core goals:²
This strategy includes a few key shifts, such as emphasis on reducing the number of ‘zero-dose’ children with a goal of reaching no zero-dose children by 2030,³ prioritizing programmatic and financial sustainability of country immunization programs,⁴ additional support for countries that have phased out of Gavi support or have never been eligible for Gavi support,⁵ and providing more tailored approaches for Gavi countries to reach under-vaccinated populations, such as those living in remote or conflict settings, by encouraging countries to adopt strategies that reduce potential barriers to vaccination.⁶ Additionally, each 5-year strategy is accompanied by an updated vaccine investment strategy, which determines the vaccines that will be made available to countries during the strategy period.⁷
In addition to Gavi’s role in routine childhood immunizations, Gavi is one of the organizations leading COVAX, a multilateral effort to support the equitable development, procurement, and delivery of COVID-19 vaccines globally that began in April 2020. Gavi’s role in COVAX is to facilitate the procurement and delivery of COVID-19 vaccines, with particular emphasis on low- and middle-income countries.⁸ See the KFF brief COVAX and the United States for more information.
Gavi’s Secretariat, with its main headquarters in Geneva and an office in Washington, D.C., carries out the day-to-day operations of the partnership.⁹ Gavi does not have program offices or staff based in recipient countries but rather relies on country health ministries and World Health Organization (WHO) regional offices to implement programs.¹⁰ Gavi is led by a Chief Executive Officer (CEO), currently Seth Berkley.
The 28-member Gavi Board sets Gavi’s funding policies and strategic direction and monitors program implementation.¹¹ It includes representation from a broad set of public and private stakeholders: donor governments, implementing countries, multilateral and institutional entities (including WHO, the United Nations Children’s Fund (UNICEF), the World Bank, and the Bill & Melinda Gates Foundation), civil society groups, the vaccine industry in industrialized and developing countries, independent private individuals with expertise in critical areas (such as investment, auditing, and fundraising), and, in a non-voting seat, the CEO of Gavi.¹² Additionally, several Board committees guide and advise the Board and the CEO on Gavi activities under their purview. The U.S. government is represented on Gavi’s Board as an alternate board member for one of the Donor Countries Governments constituency seats and has a seat on the Audit and Finance Committee and the Market-Sensitive Decisions Committee.¹³
From its launch through June 30, 2021, Gavi received more than $21 billion in financing, not including funding for COVAX (see Table 1).¹⁴ Three-quarters (76%) of Gavi’s funding comes from direct donations provided by donor governments and private organizations and individuals. The top three government donors were the United Kingdom, the U.S., and Norway, while the largest private donor (and largest donor overall) was the Gates Foundation. The remainder (24%) of Gavi’s funding came from the proceeds of two unique innovative financing mechanisms – the International Finance Facility-Immunisation (IFFIm) and the Pneumococcal Advance Market Commitment (AMC). The IFFIm was created in 2006 and uses donor funding commitments to back the issuance of special bonds in capital markets, essentially providing “up-front” financing to Gavi. The AMC began in 2010 and supports accelerated access to pneumococcal vaccines through up-front funding commitments from donors. The U.S. does not support either of these mechanisms, due to restrictions on making commitments to multi-year appropriations.¹⁵
In addition to financing Gavi’s regular activities, donors have pledged additional resources to support the Gavi COVAX Advance Market Commitment (COVAX AMC), a financial mechanism within COVAX that supports low- and middle-income countries through procurement and distribution of COVID-19 vaccines; to date, donor governments and private philanthropy have pledged $10.1 billion to the COVAX AMC for vaccine procurement and nearly $800 million for vaccine delivery and logistics.¹⁶
Only low- and middle-income countries with a Gross National Income (GNI) per capita below or equal to $1,630 on average over the last three years are eligible for Gavi support, with additional benchmarks for commitment to vaccine delivery and, depending on the vaccine, burden of disease depending on the type of Gavi support.¹⁷ In 2020, 57 countries were eligible for Gavi support;¹⁸ these included 24 of the 25 U.S. priority countries for maternal and child health assistance.¹⁹
Recipient countries’ governments are expected to share responsibility for funding their national immunization efforts through Gavi’s co-financing requirements (introduced in 2008), determined according to country income level. As countries develop economically, they are expected to contribute a greater share of the funding required for immunization programs.²⁰ When a country’s income rises above the GNI per capita threshold ($1,630 average across three years), it moves into a 5-year “accelerated transition” period of increasing domestic financing share, after which the country is expected to fully fund its own immunization programs. As of early 2020, 16 countries have transitioned out of Gavi financial support.²¹
Additionally, as part of its 2021-2025 strategy, the Gavi Board approved limited support for countries that have transitioned out of Gavi eligibility and for middle-income countries that have never been eligible for Gavi support.²² Recognizing that many formerly and never Gavi-eligible countries experience low coverage rates and have yet to make key vaccine introductions,²³ an initial investment of $281 million is expected to provide limited support for 17 former and 22 never Gavi-eligible countries for political advocacy related to immunization, technical assistance, and targeted assistance to reach under-vaccinated communities and, in the long-term, to support an innovative financing facility for procurement.²⁴
Separate from Gavi’s regular activities, countries that meet eligibility requirements can participate in the COVAX AMC, which helps to support countries in the procurement and delivery of COVID-19 vaccines. To be eligible to participate, countries must have been classified as low-income or lower-middle income according to the World Bank,²⁵ or be eligible for support from the International Development Association (IDA).²⁶ Countries that do not meet these requirements can still participate in COVAX, however as fully self-financing participants.²⁷
Gavi provides financing to country programs through different types of support. It offers support in the form of new and underused vaccines as well as technical assistance (i.e., helping countries to introduce and expand the use of new and underused vaccines in their national immunization programs) and support for complementary activities, such as developing vaccine delivery systems, health systems strengthening, cold chain equipment support, and supporting the development of civil society. Additionally, Gavi has provided country support through emergency response funding, including: support for Ebola vaccination in the Democratic Republic of Congo,²⁸ allowing for up to $200 million in reprogrammed Gavi support for COVID-19 response in Gavi-eligible countries,²⁹ and support for the creation of COVAX to help expand access to COVID-19 vaccines in lower-income countries.
Overall, from 2000 to 2018, Gavi has disbursed over $13 billion in support to 77 low- and middle-income countries (see Table 2). Most Gavi support (72%) has been provided for new and underused vaccines funding, followed by health systems strengthening (11%).³⁰
According to Gavi, its support has led to improved child health and immunization indicators in countries that have received it, and coverage rates for certain vaccines are generally high in Gavi countries. For example, in 2019, 81% of infants in Gavi countries had received all three doses of the DPT3 vaccine, a three-dose vaccine that protects against diphtheria, tetanus, and pertussis (whooping cough). Gavi also reports that since its inception in 2000, the organization has contributed to the immunization of over 822 million children in supported countries, saving more than 14 million lives, and that half of children worldwide (49%) have been reached through Gavi-supported vaccine programs. Additionally, Gavi reports that its influence in vaccine market shaping has helped lower the cost of fully immunizing a child from $20.01 in 2015 to $15.57 in 2019 and helped lower the average cost of the pentavalent vaccine³² by nearly 50% since 2015, from $1.68 per dose to $0.86 per dose.³³
The U.S. government has supported Gavi since its creation. President Clinton made the initial U.S. pledge to the newly formed partnership in 2000, and the U.S. provided its first contribution in 2001.³⁴ Currently, the U.S. supports Gavi through financial contributions, participation in Gavi’s governance, and providing technical assistance. It also supports other global immunization activities that, while separate, support the work of Gavi.
U.S. financial support to Gavi has grown over time and includes direct contributions to Gavi but, thus far, has not included support for Gavi’s innovative financing mechanisms. The U.S. has contributed to Gavi every year since 2001, with U.S. contributions increasing from $48 million in 2001 to a high of $290 million in recent years (Figure 1). The current administration has requested level funding for the U.S. contribution to Gavi in FY 2022.³⁵ Congress provides funding for U.S. contributions to Gavi through the Global Health Programs account at the U.S. Agency for International Development (USAID), specifically within the maternal and child health budget line.
Additionally, in response to the COVID-19 pandemic, the U.S. has provided $4 billion in FY 2021 emergency funding to Gavi COVID-19 vaccine procurement and delivery support under COVAX,³⁶ making the U.S. the largest donor to COVAX in terms of total amounts pledged for vaccine procurement (35%, or $3.5 billion, of $10.1 billion total to date) and for delivery and logistics (63%, or $500 million, of $800 million total to date).³⁷ The U.S. is also the largest donor of COVID-19 vaccine doses; see the KFF tracker for the latest information on U.S. international COVID-19 vaccine donations.

A U.S. government representative (from USAID) occupies an alternate seat on the Gavi Board that represents the donor countries governments constituency’s U.S./Australia/Japan/Republic of Korea group. The U.S. government is also represented on the Gavi Board’s Audit and Finance Committee and Market Sensitive Decisions Committee.
The U.S. also provides Gavi with technical support and expertise in the design, implementation, and evaluation of its programs in the field through partnerships with several U.S. agencies. For example, Gavi’s accelerated introduction programs for the pneumococcal and rotavirus vaccines have been conducted with technical support from the Centers for Disease Control and Prevention (CDC) and USAID, along with other partners.³⁸
Support of Gavi is one component of a broader set of global immunization activities of the U.S. government. In addition to multilateral funding for the U.S. contribution to Gavi, the U.S. provides bilateral (country-to-country) support for immunization through USAID, CDC, and other agencies. The two types of assistance – multilateral and bilateral – are intended to be complementary, with funding for Gavi supporting the introduction of new and underused vaccines into routine immunization systems globally, and bilateral aid supporting countries’ immunization system improvements in order to help them deliver Gavi-financed and other vaccines.³⁹ Indeed, many of the countries in which the U.S. carries out its global health programs, including bilateral global immunization activities that are part of U.S. global maternal and child health (MCH) efforts, also receive support from Gavi.⁴⁰  See the KFF fact sheets on U.S. global MCH efforts and U.S. global polio efforts.
The U.S. government has consistently supported Gavi since its inception in 2000 as a means of helping global immunization delivery programs and improving child health in developing countries. As the pandemic continues, its impact on ongoing immunization efforts, including those supported by Gavi, remains a concern. Key policy issues for U.S. engagement with Gavi going forward include:
Gavi, “About our Alliance,” webpage, https://www.gavi.org/our-alliance/about.
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Gavi, “Gavi, the Vaccine Alliance strategy 2021-2025,” undated, https://www.gavi.org/sites/default/files/board/minutes/2019/Gavi%20strategy%202021-2025%20one-pager.pdf; Gavi, “Gavi’s strategy,” webpage, https://www.gavi.org/our-alliance/strategy.
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Gavi, “Gavi’s strategy,” webpage, https://www.gavi.org/our-alliance/strategy; Gavi, “Gavi 5.0: The Alliance’s 2021-25 Strategy,” Report to the Board, June 2019, https://www.gavi.org/sites/default/files/board/minutes/2019/06%20-%20Gavi%205.0_The%20Alliances%202021-2025%20Strategy.pdf.; Gavi, “Reaching Zero-dose Children,” webpage, updated Nov. 4, 2021, https://www.gavi.org/our-alliance/strategy/phase-5-2021-2025/equity-goal/zero-dose-children-missed-communities.
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Gavi, “Gavi’s strategy,” webpage, https://www.gavi.org/our-alliance/strategy; Gavi, “Gavi 5.0: The Alliance’s 2021-25 Strategy,” Report to the Board, June 2019, https://www.gavi.org/sites/default/files/board/minutes/2019/06%20-%20Gavi%205.0_The%20Alliances%202021-2025%20Strategy.pdf
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Gavi, “Gavi 5.0: The Alliance’s 2021-25 Strategy,” Report to the Board, June 2019, https://www.gavi.org/sites/default/files/board/minutes/2019/06%20-%20Gavi%205.0_The%20Alliances%202021-2025%20Strategy.pdf.
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Gavi, “Prevent, Protect, Prosper: The Gavi Investment Opportunity 2021-2025,” Replenishment Launch presentation, Aug. 30, 2019, https://www.slideshare.net/Gavi-Vaccine-Alliance/the-gavi-investment-opportunity-20212025.
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Gavi, “History of Vaccine Investment Strategy,” webpage, https://www.gavi.org/our-alliance/strategy/history-of-vaccine-investment-strategy.
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WHO, “What is the ACT-Accelerator?,” webpage, https://www.who.int/initiatives/act-accelerator/about.
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Gavi, “Gavi Secretariat,” webpage, https://www.gavi.org/operating-model/gavi-secretariat.
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Gavi, “Operating model,” webpage, https://www.gavi.org/our-alliance/operating-model.
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Gavi, “Gavi, the Vaccine Alliance Board,” webpage, https://www.gavi.org/our-alliance/governance/gavi-board.
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Gavi, “Board composition,” webpage, https://www.gavi.org/governance/gavi-board/composition.
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Gavi, “Audit and Finance Committee,” webpage, https://www.gavi.org/governance/gavi-board/committees/audit-finance-committee; Gavi, “Market Sensitive Decisions Committee,” webpage, https://www.gavi.org/governance/gavi-board/committees/market-sensitive-decisions-committee.
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Gavi, “Cash Receipts 30 June 2021,” https://www.gavi.org/news-resources/document-library/cash-receipts.
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For further information about restrictions on U.S. support for these innovative financing mechanisms, see KFF, Innovative Financing Mechanisms for Global Health: Overview and Considerations for U.S. Government Participation, Sept. 2011.
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In addition to direct contributions provided to the COVAX AMC by donor governments and private donors, funds have been made available to the COVAX AMC through the IFFIm and unallocated Pneumococcal AMC funds. Gavi, “COVAX AMC Donors Table,” Nov. 9, 2021, https://www.gavi.org/sites/default/files/covid/covax/COVAX-AMC-Donors-Table.pdf.
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Gavi support types include health system strengthening, vaccine, cold chain, and targeted country assistance. Gavi, “Eligibility,” webpage, https://www.gavi.org/types-support/sustainability/eligibility.
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Gavi, “Eligibility,” webpage, https://www.gavi.org/types-support/sustainability/eligibility.
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USAID, “Priority Countries,” webpage, https://www.usaid.gov/global-health/health-areas/maternal-and-child-health/priority-countries.
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Gavi, “Gavi, the Vaccine Alliance, Co-Financing Policy Version 2.0,” https://www.gavi.org/sites/default/files/document/gavi-co-financing-policypdf.pdf.
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These include Angola, Armenia, Azerbaijan, Bhutan, Bolivia, Cuba, Georgia, Guyana, Honduras, Indonesia, Kiribati, Moldova, Mongolia, Sri Lanka, Timor-Leste, and Vietnam. Gavi, “Transitioning out of Gavi support,” webpage, https://www.gavi.org/types-support/sustainability/transition.
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This would include countries with GNI per capita below $4,000, as well as upper-middle income countries, as defined by the World Bank. Gavi, “Gavi’s approach to engagement with former and never-eligible Middle Income Countries (MICs),” Board presentation, Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20MICs%20-%20Presentation.pdf.
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Center for Global Development (CGD), “New Gavi Modalities for a Changing World,” June 24, 2019, https://www.cgdev.org/publication/new-gavi-modalities-changing-world.
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  Gavi, “Gavi’s approach to engagement with former and never-eligible Middle Income Countries (MICs),” Board presentation, Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20MICs%20-%20Presentation.pdf; Gavi, “GAVI’S APPROACH TO ENGAGEMENT WITH FORMER AND NEVER-ELIGIBLE MIDDLE-INCOME COUNTRIES (MICS),” Report to the Board, Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20Gavi%27s%20approach%20to%20engagement%20with%20former%20and%20never-eligible%20MICs.pdf.; Gavi, “Annex C: Summary of support proposed under the MICs Approach,” Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20Annex%20C%20-%20Summary%20of%20support%20proposed%20under%20the%20MICs%20Approach.pdf; Gavi, “Annex B: Paragraphs referenced in decision points for the MICs Approach,” Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20Annex%20B%20-%20Paragraphs%20referenced%20in%20decision%20points%20for%20the%20MICs.pdf.
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The World Bank, “World Bank Country and Lending Groups,” webpage, https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.
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IDA is “the part of the World Bank that helps the world’s poorest countries. Established in 1960, IDA aims to reduce poverty by providing zero to low-interest loans (called ‘credits’) and grants for programs that boost economic growth, reduce inequalities, and improve people’s living conditions.” IDA, “What Is IDA?,” webpage, https://ida.worldbank.org/en/about. According to IDA, “eligibility for IDA support depends first and foremost on a country’s relative poverty, defined as GNI per capita below an established threshold and updated annually. IDA also supports some countries, including several small island economies, that are above the operational cutoff but lack the creditworthiness needed to borrow from” the World Bank’s the International Bank for Reconstruction and Development (IBRD). IDA, “Borrowing Countries,” webpage, https://ida.worldbank.org/en/about/borrowing-countries.
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KFF, COVAX and the United States, Feb. 18, 2021.
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Gavi, “Gavi boosts funding for Ebola outbreak response,” press release, May 20, 2019, https://www.gavi.org/news/media-room/gavi-boosts-funding-ebola-outbreak-response.
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Gavi, “Responding to COVID-19,” webpage, https://www.gavi.org/covid19.
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KFF analysis of Gavi, “Disbursement by Year Paid (Inception to Nov. 30, 2018),” Nov. 26, 2019, https://www.gavi.org/programmes-impact/our-impact/disbursements-and-commitments.
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Gavi, “Facts and Figures,” Feb. 22, 2021, https://www.gavi.org/sites/default/files/document/2021/Gavi-Facts-and-figures-February-21.pdf; Gavi, “Our impact,” webpage, https://www.gavi.org/programmes-impact/our-impact; Gavi, “About our alliance,” webpage, https://www.gavi.org/our-alliance/about.
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Pentavalent vaccine protects against diphtheria, tetanus, pertussis (whooping cough), hepatitis B, and Haemophiles influenza disease.
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Gavi, “About our alliance,” webpage, https://www.gavi.org/our-alliance/about.
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Congressional Research Service (CRS), Health in Developing Countries: The U.S. Response, RL30793, Feb. 27, 2001, https://www.everycrsreport.com/files/20010227_RL30793_d6a2932fbec1fd24ee44c9af96185d1dbbf2e79e.pdf.
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KFF, White House Releases Full FY 2022 Budget Request, June 2, 2021.
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KFF, Global Funding Across U.S. COVID-19 Supplemental Funding Bills.
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The U.S. announced it would donate 500 million Pfizer doses to COVAX at the G7 Summit in June 2021. However, a portion of these doses were purchased using funds appropriated to Gavi ($2 billion for 300 million Pfizer doses), while the remaining 200 million doses were purchased using $1.5 billion in other emergency funds from the American Rescue Plan Act. To avoid double-counting, Gavi counts the U.S. funding that was contributed to Gavi under its COVAX funding contributions, with only 200 million of the doses – those purchased directly by the U.S. – counted as COVAX vaccine dose donations. KFF personal communication with Gavi, Nov. 12, 2021; White House, “FACT SHEET: President Biden Announces Historic Vaccine Donation: Half a Billion Pfizer Vaccines to the World’s Lowest-Income Nations,” June 10, 2021; Gavi, “COVAX AMC Donors Table,” Nov. 9, 2021, https://www.gavi.org/sites/default/files/covid/covax/COVAX-AMC-Donors-Table.pdf; USAID, “USAID’s COVID-19 Response: Ending The Global Pandemic and Building Back Better,” Oct. 2021,  https://www.usaid.gov/sites/default/files/documents/USAID_COVID_Response_Fact_Sheet_Oct_2021_FINAL.pdf. See also KFF, U.S. International COVID-19 Vaccine Donations Tracker.
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CRS, Global Vaccination: Trends and the U.S. Role, R45975, Oct. 18, 2019, https://sgp.fas.org/crs/row/R45975.pdf; Center for Strategic & International Studies (CSIS), Sustaining U.S. Support for Gavi: A Critical Global Health Security and Development Partner, Feb. 24, 2020, https://www.csis.org/analysis/sustaining-us-support-gavi-critical-global-health-security-and-development-partner.
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Richard Murray Trostle & Angela K Shen, “Three decades of USAID investments in immunization through the child survival revolution,” In Emerging Microbes & Infections, 3:1, 1-9, DOI: 10.1038/emi.2014.13, published online Feb. 26, 2014.
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These included 24 of the 25 U.S. priority countries for maternal and child health assistance. KFF analysis of Gavi recipient countries and USAID maternal and child health priority countries. Gavi, “Eligibility,” webpage, https://www.gavi.org/types-support/sustainability/eligibility; USAID, “Priority Countries,” webpage, https://www.usaid.gov/global-health/health-areas/maternal-and-child-health/priority-countries.
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KFF: Putting U.S. Global COVID-19 Vaccine Donations in Context, May 25, 2021; Tracking U.S. COVID-19 Vaccine Donations, Sept. 22, 2021; U.S. International COVID-19 Vaccine Donations Tracker.
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While donors have already provided over $12 billion to the Access to COVID-19 Tools Accelerator (ACT-A, the overarching umbrella initiative for global COVID-19 response tools, including vaccines, that COVAX falls under) for vaccine efforts specifically, ACT-A estimates an additional $15 billion will be needed for the upcoming year for vaccine efforts led by ACT-A as well as complementary investments (such as support for in-country vaccine delivery). Of the $15 billion, $7 billion is estimated to be needed for vaccine efforts led by ACT-A to support $4.8 billion directed to COVAX for the procurement of COVID-19 vaccine doses and $2.2 billion for COVID-19 vaccine delivery support ($1.6 billion) and R&D ($590 million), to be led by Gavi, UNICEF, and WHO. WHO, ACT-A Strategic Plan & Budget: October 2021 to September 2022, Oct. 28, 2021, https://www.who.int/publications/m/item/act-accelerator-strategic-plan-budget-october-2021-to-september-2022.
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These goals include a global vaccination target of 70% by mid-2022 and securing at least 1.4 billion doses before 2022, down from COVAX’s original goal of delivering 2 billion doses before 2022. WHO, “COVAX Joint Statement: Call to action to equip COVAX to deliver 2 billion doses in 2021,” news release, May 27, 2021, https://www.who.int/news/item/27-05-2021-covax-joint-statement-call-to-action-to-equip-covax-to-deliver-2-billion-doses-in-2021; UNICEF, “Joint COVAX statement on supply forecast for 2021 and early 2022.” press release, Sept. 8, 2021, https://www.unicef.org/press-releases/joint-covax-statement-supply-forecast-2021-and-early-2022; WHO, ACT-A Strategic Plan & Budget: October 2021 to September 2022, Oct. 28, 2021, https://www.who.int/publications/m/item/act-accelerator-strategic-plan-budget-october-2021-to-september-2022.
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For example, Gavi helped pilot the RTS,S malaria vaccine in several countries (see: https://www.gavi.org/news/media-room/partnership-welcomes-launch-first-malaria-vaccine-pilot) and could be involved in introduction and scaling up of other updated vaccine formulations and/or new combination vaccines. See also WHO, “WHO recommends groundbreaking malaria vaccine for children at risk - Historic RTS,S/AS01 recommendation can reinvigorate the fhight against malaria,” news release, Oct. 6, 2021, https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk; Gavi, “Gavi Board approves funding to support malaria vaccine roll-out in sub-Saharan Africa,” news release, Dec. 2, 2021, https://www.gavi.org/news/media-room/gavi-board-approves-funding-support-malaria-vaccine-roll-out-sub-saharan-africa.
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