1. Basic facts about the GAVI Alliance Speaker
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2. Overview About the GAVI Alliance Accelerated vaccine uptake
Rising demand
Innovative financing
Shaping the market
Programmes of support for countries
Moving forward

3. The GAVI Alliance: an innovative partnership
GAVI was established as an alliance in recognition of the fact that expanding and maintaining immunisation coverage in developing countries depend on strong partnerships, involving both the private and public sectors.
The role and commitment of each partner is vital to the success of the partnership:
Multilateral agencies and the Bill & Melinda Gates Foundation: - UNICEF has significant field presence and vaccine procurement capabilities. - WHO develops policies and strategies for vaccine use and provides normative guidance and quality control of vaccines.
- The World Bank plays a key role in innovative financing and helps implementing governments develop sustainable financing for health systems, including immunisation services.
- The Bill & Melinda Gates Foundation is one of the founding members of the Alliance and continues to support GAVI programmes.
Developing country governments
- The most important contribution to the Alliance is the commitment of developing countries themselves, which apply for GAVI funding and implement programmes to ensure the immunisation of hundreds of thousands of children every day.
Donor country governments provide funding for GAVI programmes through official development assistance (ODA).
Civil society organisations play a pivotal role in immunisation and health service delivery in many countries, as well as in advocacy and policy development, while research institutes bring their knowledge and experience to the Board and help build R&D capacity.
The vaccine industry ensures the development of and access to vaccines and provide technical support
Independent individuals bring independent scrutiny to the Board and provide expertise in a range of areas.
The CEO of the GAVI Alliance serves on the Board in a non-voting seat.

4. The GAVI Alliance Board committee structure
The Board is supported by six committees and one advisory committee:
Executive Committee – makes critical, time-sensitive decisions between Board meetings.
Audit/Finance Committee – advises the Board in the areas of corporate accounting, reporting practices, and the quality and integrity of the financial reports.
Fundraising Committee – advises the Board on fundraising and resource mobilisation efforts.
Governance Committee – ensures effective operations of GAVI’s governance bodies, serving as nominating body for new Board members, and overseeing the functioning of other committees.
Investment Committee – advises the Board on investment policies and objectives, asset allocations and portfolio construction.
Programme/Policy Committee – advises the Board on all GAVI programme areas and leads the development of new policies.
Evaluation Advisory Committee – advises the Board on the oversight of GAVI’s evaluation activities.

5. GAVI’s mission
To save children’s lives and protect people’s health by increasing access to immunisation in poor countries
One of the world’s most glaring injustices is the inability of the poorest countries to provide existing and new life-saving vaccines and basic health care for all of their children.
About 8.8 million children die every year before reaching their fifth birthday. Almost ¼ of these deaths could be prevented with currently available or new vaccines.
Ill health impacts on families, communities and countries. A sick child may not be able to attend school and may suffer long-term disabilities, affecting the productivity of the family and the community.
Immunisation is one of the most cost-effective ways to improve health in the long term, and thus reduce the burden on already stretched health services.
WHO/Jim Holmes

6. Four strategic goals
Accelerate the uptake and use of underused and new vaccines
Contribute to strengthening the capacity of integrated health systems to deliver immunisation
Increase the predictability of global financing and improve the sustainability of national financing for immunisation
Shape vaccine markets
GAVI strategy for sets four goals
Accelerate the uptake and use of underused and new vaccines by strengthening country decision making and introduction (“the vaccine goal”).
Contribute to strengthening the capacity of integrated health systems to deliver immunisation by resolving heath systems constraints, increasing the level of equity in access to services and strengthening civil society engagement in the health sector (“the health systems goal”).
Increase the predictability of global financing and improve the sustainability of national financing for immunisation
-At the global level, raising public and private funding and developing innovative finance options to access new and predictable resources (“the funding goal”).
-At the national or country level, the focus is on successful implementation of GAVI’s co-financing policy to ensure that new vaccines are included in domestic budget lines and that there is national financial as well as political commitment for their introduction (“the co-financing goal”).
Shape vaccine markets with regard to pricing and supply security through its ability to pool procurement on behalf of over 50 million children and make catalytic investments to facilitate introduction of appropriate vaccines (“the market-shaping goal”).
Note:
not all vaccines but underused and new vaccines – underused vaccines well under way, now focus on new vaccines
long-term financing (not project-based aid)
concept of public-private partnership is core

7. GAVI making a difference
Catalysing accelerated uptake of vaccines
Prevented more than 5 million future deaths
Projected 288 million additional children immunised
Supporting increasing country demand
Rising demand for new and underused vaccines
US$ 5.9 billion committed to countries
Introducing innovative financing mechanisms
IFFIm raised more than US$ 3 billion on capital markets
AMC pilot accelerates access to pneumococcal vaccines
Shaping markets for vaccines
More manufacturers producing more appropriate vaccines
Increased capacity secures supply, decreases prices
GAVI is having an impact on immunisation and global health – introducing a new model for health and development:
- country-driven demand, long-term support
- innovative financing having impact on immunisation but also on how development funding is done
- shaping markets and having an impact on supply and pricing

8. Overview About the GAVI Alliance Accelerated vaccine uptake
Rising demand
Innovative financing
Shaping the market
Programmes of support for countries
Moving forward

9. Over five million future deaths prevented
Results from routine immunisation and one-off tactical investments, by vaccine
Source: These estimates and projections are produced by the WHO Department of Immunization, Vaccines and Biologicals, based on the most up to date data and models available as of November 2010

10. A strong platform
82% of children now reached through routine immunisation programmes
Immunisation closer to universal coverage than most other health interventions
Enables rapid introduction of life-saving vaccines
Important opportunity to deliver other child and maternal health services
New vaccines can be readily introduced because there is already a sound infrastructure in place to deliver them.
Across the world, 82% of children are now being reached through routine immunisation programmes.
That is a record high.
It means not only that we have a unique platform in place to introduce life-saving vaccines, but also an opportunity to reach children and mothers with other health services.

11. A strong platform
DTP3 coverage in low-income countries was close to 80% in 2009 – just three percentage points below the global average.
This is the highest level ever experienced in the developing world.
Source: WHO; UN DESA, Population Division

12. Immunisation coverage continues to rise
DTP3, hepatitis B and Hib vaccine coverage in GAVI-supported countries,
Source: WHO-UNICEF coverage estimates for , as of July 2010;
WHO ICE- T coverage projections for , as of September 2010; World Population Prospects, the 2008 revision. New York, United Nations, 2009; (surviving infants).

13. Driving equity in vaccine access
Routine use of vaccines in high- and low-income countries
Here we see the result of that unprecedented catch-up by low-income countries.
The red bar shows the percentage of high-income countries using hepatitis B vaccines in the year CLICK This climbed to nearly 80% in CLICK
CLICK: Now we look at the proportion of low-income countries using hepatitis vaccine in And this is how that changed in just 9 years. A huge jump. The same has been achieved for Hib vaccines. CLICK
GAVI was launched to address an inequity – life-saving vaccines available in rich countries are denied to children in the developing world.
These charts show that GAVI has made a difference. Working together we have brought a dramatic change in access to two key vaccines that were hardly in use in the low-income countries in 2000.
Hepatitis B
Hib
Source: WHO, Vaccine introduction database.

14. Impact on the ground
Eliminating Hib meningitis in Kenya (Kilifi district)
Looking behind the headline figures, and translating them to a country level, here’s an example among many of the powerful impact of vaccines.
Hib disease causes meningitis and severe pneumonia. It leads to high mortality rates and often leaves children with permanent disability.
This graph shows the impact of Hib vaccine in Kenya; one of the first countries to introduce the vaccine with GAVI support.
The introduction in 2001 resulted in a 88% drop in cases of this disease in just three years.
Source: Cowgill KD et al. 2006

15. Impact on the ground
Hib meningitis in Uganda drops 85% in 4 years (3 sentinel hospitals)
And this is Uganda. Hib vaccines virtually eliminated the disease in just a few years.
It’s a story replicated throughout the developing world in the few years –
and one that health departments elsewhere will recall from a decade earlier when Hib vaccines were made available to children in high-income countries.
Source: Lewis et al. 2008

16. Overview About the GAVI Alliance Accelerated vaccine uptake
Rising demand
Innovative financing
Shaping the market
Programmes of support for countries
Moving forward

17. Rising country demand Countries approved and eligible for GAVI support
Country demand is rising. Alliance partners have been successful in stimulating demand.
Source: GAVI Alliance data as at 31 July 2010

18. US$ 5.9 billion committed to countries
As at 4 November 2010
GAVI has committed US $5.9 billion in funding to countries until 2015.
By far the majority of GAVI funds are committed to the provision of vaccines: over 80%
Source: GAVI Alliance data as at 4 November 2010

19. Overview About the GAVI Alliance Accelerated vaccine uptake
Rising demand
Innovative financing
Shaping the market
Programmes of support for countries
Moving forward

20. International Finance Facility for Immunisation (IFFIm)
Uses long-term donor commitments to sell AAA rated vaccine bonds
Raised US$ 3 billion since 2006
Frontloads aid through GAVI for immunisation and health systems
Has disbursed US$ 1.6 billion (June 2010) to support GAVI programmes and targeted immunisation initiatives

21. IFFIm frontloading IFFIm donor contributions and bond issuances
20/04/ :29
IFFIm frontloading
IFFIm donor contributions and bond issuances
IFFIm provides funding upfront that would otherwise only be available over 20 years.
Bonds are issued against donors’ future-dated grants, thus filling the funding gap identified in the early years. As bonds are issued, cash is used to purchase vaccines, support vaccination programmes and increase health systems strengthening in GAVI countries.
This is frontloading.
The concept behind frontloading is that IFFIm can take long term pledges and “convert them” into cash funding now. This can have a huge impact on the effectiveness of vaccines, and on the reliability of funding.
Source: World Bank, December 2010
HARWYN\Presentations\GROUP Presentation Oct 05 FINAL.ppt

22. Capital market funding
20/04/ :29
How IFFIm works
Donors
Up to 20-year grants
Financial management
Country-driven
Immunisation
programmes
Investors
Capital market funding
IFFIm receives long-term commitments from donor governments.
Under the financial management of the World Bank, the funds secure bonds on the capital markets, which are sold to individual and institutional investors in bond issuances.
The proceeds from the bond issuances are used to fund GAVI programmes as well as one-off tactical investments in immunisation initiatives.
Source: World Bank

23. IFFIm donor contributions
Donors
Length of commitment
Grant amount
United Kingdom
20 years
£1,380 million £250 million
France
€1,240 million
Italy
€473.5 million
Spain
€189.5 million
Sweden
15 years
SEK million
Norway
5 years
US$ 27 million NOK 1,500 million
South Africa
US$ 20 million
Netherlands
7 years
€80 million
Approx.
US$ 5.9 billion
Note: In addition, Australia has pledged to commit Australian $ 250 million to IFFIm.

24. US$ 1 billion for expanded IFFIm to support health system strengthening
GAVI/09/Olivier Asselin
Zoellick : “A good example is our partnership with the GAVI Alliance, the Global Fund, and the WHO to develop a platform to coordinate and channel aid to health systems – including funds from some of the innovative financing mechanisms identified today .”
US$ 1 billion commitment from UK, Norway and Australia announced September 23rd 2009 to expand IFFIm for health system strengthening. Conditional on platform with the Global Fund, World Bank and GAVI.
Affirms success of IFFIm.
Will impact MDGs 4, 5 and 6.
“Innovation can be the key to making significant progress on reaching the MDGs, strengthening health systems and improving millions of lives – especially the lives of women and children.”
Robert Zoellick, President, World Bank

25. Advance Market Commitment (AMC)
Accelerates the manufacture and delivery of vaccines:
Donors commit funds for new vaccines at pre- agreed price
Manufacturers get incentive to invest in R&D for new vaccines
Vaccines must meet stringent criteria and be requested by developing countries
Manufacturers legally commit to supplying vaccines at lower price long term
Long-term price paid by beneficiary countries and GAVI

26. How the pneumococcal AMC pilot works:
Italy, UK, Canada, Russia, Norway, the Bill & Melinda Gates Foundation have committed to supporting pneumococcal vaccine market with US$ 1.5 billion
Manufacturers agree to supply set quantities of the vaccine for 10 years
As GAVI countries demand the vaccine, companies receive US$ 7 per dose
Companies ensure supply of remaining doses at $ per dose or less
First vaccines were delivered to countries in 2010
Italy, UK, Canada, Norway, Russia, Bill & Melinda Gates Foundation made a legally binding financial commitment to support the pneumococcal vaccine market with $ 1.5 billion.
Interested companies who develop an appropriate vaccine commit to supplying certain quantities of the vaccine for 10 years.
As GAVI eligible countries demand the vaccine, companies receive $ 7 per dose for about 20% of the initial doses of vaccine. This price is funded by the AMC and should allow companies to quickly recoup investment costs.
In exchange, companies are required to ensure the supply of the vaccine for the remaining doses at $3.50 per dose or less.
This price is close to manufacturing cost of the vaccine to ensure sustainable access, and is funded by beneficiary countries and GAVI.

27. AMC commitments: US$ 1.5 billion
US$ millions
Italy
635
United Kingdom
485
Canada
200
Russian Federation 80
Norway 50
Bill & Melinda Gates Foundation
Total
1,500
Source: GAVI Alliance, 2009

28. Overview About the GAVI Alliance Accelerated vaccine uptake
Rising demand
Innovative financing
Shaping the market
Programmes of support for countries
Moving forward

29. Increased competition reduces vaccine price
Number of manufacturers and price decline of pentavalent vaccine
In 2010 the weighted average price projection for pentavalent vaccine for 2011 fell to US$ 2.58, a drop of almost US$ 0.40 per dose compared to the year before.
This is important as pentavalent is a major cost driver for GAVI.
The price drop will allow the GAVI Alliance to immunise many more children against five deadly diseases through the pentavalent vaccine: diphtheria, tetanus, pertussis, Hib and hepatitis B.
Source: UNICEF Supply Division, 2010

30. Tiered pricing
GAVI-eligible countries are now firmly established as the accepted low-income pricing tier.
This means manufacturers use GAVI countries as a benchmark in their pricing strategies. Vaccines are available to the world’s poorest countries at significantly lower prices than to industrialised countries.
Blue is GAVI market. Purple is US public market.
For example, the price of pneumococcal vaccines for GAVI countries is less than 5% of what is paid for the same product in the US.
Source: UNICEF Supply Division; CDC

31. Sustainable immunisation safety
Similar price trend for syringes as for vaccines:
Increased volumes has meant that the price of autodisable syringes has been reduced by nearly half (to US$0.05 each, weighted average price).
Source: UNICEF Supply Division, 2009

32. Country co-financing: exceeding commitments
Over 40 countries co-financed vaccines in 2009
17 countries paid more than required
GAVI’s co-financing policy aims to ensure long-term sustainability. The level of co-financing is based on the country’s expected ability to pay.
In 2009, 44 countries fully met their co-financing requirements for GAVI-supported vaccines – almost 90% of those required to co-finance. 17 countries paid more than required.
Three countries chose to co-finance ahead of the required start date.
Co-payments in 2009 totalled more than US$ 25 million.

33. Overview About the GAVI Alliance Accelerated vaccine uptake
Rising demand
Innovative financing
Shaping the market
Programmes of support for countries
Moving forward

34. How GAVI works

35. Programmes of support for countries
New and underused vaccines
Health system strengthening
Immunisation services
Civil society organisations
Injection safety
GAVI/10/Jim Holmes

36. New and underused vaccine support
New vaccines: pneumococcal and rotavirus vaccines
Underused vaccines: Hib, hepatitis B, yellow fever, measles second dose. Also:
support for the 5-in-1 pentavalent formulation
meningitis and yellow fever vaccine stockpiles
Vaccines prioritised for future support: human papillomavirus (HPV), Japanese encephalitis, rubella and typhoid vaccines
72 GAVI countries have been approved for support for at least one vaccine

37. Hepatitis B vaccine
Approved for hepatitis B vaccine support 2000 – 2010
Source: GAVI Alliance, 2010

38. Haemophilus influenzae type b vaccine
Approved for Hib vaccine support 2000 – 2010
Source: GAVI Alliance, 2010

39. Pentavalent vaccine
Approved for pentavalent vaccine support 2000 – 2010
Source: GAVI Alliance, 2010

40. Yellow fever vaccine
Approved for yellow fever vaccine support 2000 – 2010
Source: GAVI Alliance, 2010

41. Pneumococcal vaccine
Approved for pneumococcal vaccine support 2000 – 2010
Source: GAVI Alliance, 2010

42. Rotavirus vaccine Approved for rotavirus vaccine support 2000 – 2010
Source: GAVI Alliance, 2010

43. Four new vaccines in future portfolio
Human papillomavirus (HPV): leading cause of cervical cancer, 80% of cervical cancer cases are among women in developing world
Japanese encephalitis: serious brain infection transmitted by mosquitoes, particularly in Asia
Rubella: risk of pregnant women transmitting to unborn foetus causing death or deformity
Typhoid: serious public health problem, affecting million people per year
Four vaccines were identified by the GAVI Vaccine Investment Strategy and approved for consideration for future support.
A strategic decision at this point, not a funding commitment.
These diseases were selected as they represent the greatest burden of disease on poor countries.

44. Health system strengthening (HSS) support
Strong health systems essential to expand and sustain immunisation coverage
Examples:
Health workforce
Supply, distribution, maintenance
Organisation, management
New platform for funding HSS
Partnership with the Global Fund, the World Bank and WHO
Courtesy of Aga Khan Health Services, Pakistan
The objective of GAVI HSS is to achieve and sustain increased immunisation coverage, through strengthening the capacity of the health system to deliver immunisation and other health services.
To date, over 50 countries have been approved for support.
GAVI is developing a new platform for funding health systems together with the Global Fund to Fight Aids, Tuberculosis and Malaria; the World Bank and WHO.
The platform will make support to HSS more harmonised and aligned with country systems, and thus help accelerate progress towards the MDGs.

45. Support to civil society organisations (CSOs)
CSOs deliver up to 60% of immunisation services in some countries
GAVI provides support:
to involve local CSOs in planning and delivery of immunisation and other child health services
to encourage cooperation and coordination between the public sector and civil society
© UNICEF/NYHQ Anita Khemka
In many countries, CSOs are the backbone of the health system and deliver much of the immunisation services, especially to remote and vulnerable populations.

46. Immunisation services support (ISS)
Flexible cash support (two- three years) to scale up immunisation services, increase coverage
Performance-based reward: US$ 20 for each additional child vaccinated with 3 doses of DTP
Helped countries reach additional 2.4 million children with DTP3
GAVI/08/Olivier Asselin
62 countries have been approved for ISS to date. All GAVI-eligible countries can apply.
Independent evaluations of ISS have determined that an additional 2.4 million children were reached with 3 doses of DTP as a result of ISS funding.

47. Injection safety support (INS)
Catalytic: three-year funding
Sustainable: countries continue to procure Autodisable (AD) syringes after GAVI support ends
Affordable: decrease in price of AD syringes
Transformative: new standards for injection safety in GAVI-supported countries
GAVI/08/Olivier Asselin
Safe injection use and immunisation practices are critical to preventing disease transmission.
GAVI provides three-year funding to national immunisation programmes for autodisable syringes, safety boxes for syringe disposal and activities to support wide-spread AD use.
Countries expected to find sustainable financing to continue injection safety programmes at completion of GAVI support.
Results are highly promising. Independent evaluation shows that out of 58 countries receiving INS support, 30 are fully government-funded, 11 rely on mixture of donor funding and government support, 15 rely on donor funding, and only 2 have not been able to sustain support after GAVI’s support ended.

48. Women’s health and immunisation
Child and maternal mortality inextricably linked
Immunisation a platform for other child and maternal health services
GAVI supported immunisation of 40 million women against maternal and neonatal tetanus
Prioritised HPV and rubella vaccines for future portfolio
Supports strengthening of health systems to better meet needs of women and children
GAVI/09/Olivier Asselin
Countries with the highest child mortality rates also have a high burden of maternal deaths, as well as high rates of birth and population growth.
Integrated programmes which combine maternal, newborn, child and reproductive health services can accelerate progress towards achieving the health MDGs.
Currently almost 80% of children in low-income countries are reached with immunisation. This provides an important opportunity for women to access an integrated package of maternal, newborn and child health services.
Together with UNICEF, GAVI has supported the immunisation of 40 million women with vaccines protecting against maternal and neonatal tetanus.
GAVI has prioritised two vaccines that specifically benefit women’s health: HPV vaccine, which protects against cervical cancer, and rubella vaccines, preventing congenital rubella syndrome and reducing the risk of miscarriage and stillbirth.
GAVI support to HSS helps countries to provide better health services to women and children.

49. Equal immunisation coverage of girls and boys
2010 study by WHO’s Strategic Advisory Group of Experts (SAGE) on gender and immunisation found
no significant difference in immunisation coverage in girls and boys at the global level
in some countries, low status of women prevents them from accessing immunisation services for their children.
GAVI instigated the SAGE study (in collaboration with WHO and PATH) to ensure that all girls and boys have equal access to vaccines.
A WHO study on gender and immunisation, conducted in 2010, showed no significant differences in immunisation rates between boys and girls at the global level, although exceptions exist in settings with high gender inequity.
In some countries, the low status of women prevents them from accessing immunisation services for their children, both boys and girls. GAVI works with its partners to increase immunisation coverage and to overcome barriers to immunisation and related health services.
GAVI implements a gender policy that aims to ensure that all girls, boys, women and men, have equal access to immunisation and health services. Activities implemented include this review of the evidence base on gender and immunisation in collaboration with WHO and PATH, as well as desk reviews of the impact of antigens on the health of women and mothers, and the influence of immunisation services on maternal and child health services. In 2011, a gender help desk will be established at GAVI.

50. Overview About the GAVI Alliance Accelerated vaccine uptake
Rising demand
Innovative financing
Shaping the market
Programmes of support for countries
Moving forward

51. Over 23 million children still unimmunised
Global number of under-five children unimmunised with 3 doses of DTP
There are a total of 23.2 million children who remain unimmunised in the world.
DTP = diphtheria-tetanus-pertussis vaccine
Source/credits: WHO/UNICEF coverage estimates , July 2010

52. Causes of child deaths in low-income countries
Pneumonia and diarrhoeal diseases are the leading causes of infectious disease causing death in children under the age of five.
Every year over two million children die from vaccine-preventable diseases.
Deaths in low-income countries account for 95% of all child deaths.
Pneumonia and diarrhoea together account for 36% of child deaths worldwide.
GAVI has the vaccines to prevent many of the major child killer diseases, including the main causes of pneumonia and severe diarrhoea.
Source: WHO, World Health Statistics 2010

53. Vaccines against major child killer diseases
Projected GAVI vaccine expenditure
Pneumococcal vaccine is the single biggest projected expenditure for GAVI from 2011 until 2020 – representing almost 50% of vaccine expenditure.
Pentavalent and rotavirus vaccines are the second biggest projected expenditures.
Source: GAVI Alliance, 2010

54. Potential impact 2011 – 2015
GAVI could prevent 3.9 million future deaths in the next 4 years
By 2015, GAVI programmes have the potential to prevent a further 3.9 million future deaths.
Over 5 million deaths have been averted in first decade, to which GAVI could add a further 3.9 million in just four years.
The demand is there, the platform for delivery is stronger than ever and the vaccines are available.
All that is needed is sufficient funding.

55. Thank you
GAVI/10/Ricci Shryock