Countries on the Edge: Evaluating the Sustainability of Gavi’s Immunization Support in Former Gavi-supported Countries: Evidence from the COVID-19 Pandemic

Abstract

Gavi, the Vaccine Alliance, has been critical in improving immunization coverage and equity in low- and middle-income countries (LMICs) since its inception in 2000. Based on Gavi’s unique transition model, 19 countries have transitioned from Gavi’s support and become “Gavi graduates,” expecting to sustain their immunization performance as a self-financing country. However, the COVID-19 pandemic tested the resilience of these countries' immunization systems and raised concerns about their sustainability after graduation. This study evaluated whether Gavi’s past investments contributed to building resilient immunization systems in former Gavi-supported countries (FGCs) and what systemic challenges they faced. This study applied a mixed-methods approach by integrating Difference-in-Differences (DiD) analysis and key informant interviews (KIIs). The quantitative analysis compared immunization performance trends in 19 FGCs and 26 never-Gavi-supported LMICs (NGCs) during the pandemic, focusing on DTP3, DTP1, and MCV1 coverage using WHO-UNICEF Estimates of National Immunization Coverage (WUENIC) data. The qualitative component consists of 20 semi-structured interviews with policymakers, global health experts, and immunization program managers to explore systemic factors affecting immunization sustainability in FGCs. The DiD analysis revealed that FGCs experienced 3.74 (95% CI -4.92, -2.56) percentage points greater decline in DTP3, 3.85 (95% CI -4.78, -2.93) percentage point in DTP1, and 5.7 (95% CI -6.72, -4.69) percentage points in MCV1, compared to NGCs by 2023. The decline of DTP1 coverage in FGCs is equivalent to 371,000 to 430,000 additional zero-dose children. Qualitative findings revealed systemic gaps in vaccine procurement capacity, budget constraints, and governance systems. Stakeholders noted that graduation criteria may not fully capture a country’s readiness to sustain immunization performance, and the lack of tailored transition support limits the sustainability of immunization programs in FGCs. The study proposed prioritized recommendations: refining graduation criteria to assess country readiness in the short-term, establishing a post-transition technical assistance mechanism in the mid-term, and institutionalizing the MICs Approach for tailored support in the long term. As Gavi enters its 6.0 strategy cycle (2026–2030), there is a window opportunity to implement these recommendations and strengthen the sustainability of immunization systems in FGCs and transitioning countries.