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Currently, only 85% of children worldwide, and 77% of children in Africa, receive the recommended set of childhood vaccines.1
Because of (a) the strong evidence that expanding access to vaccinations for children in the developing world is an effective way to save lives, and (b) the potential for it to do so cost effectively, we sought to answer the question: what giving opportunities would increase immunization coverage globally?
In order to answer this question, we spoke with the organizations working on this program. This page details our impressions from these conversations; most statements are supported by quotes from the conversations and not by detailed analysis.
We have not yet found promising funding opportunities to directly support the expansion of routine immunization activities.
Published: November 2012
Organizations work on three different types of vaccination programs:
In May 2012, UNICEF told us that it was seeking to focus on reaching the approximately 20% of children in the developing world who do not receive routine immunizations. UNICEF told us that specific activities will need to be tailored to the country's needs, and it is working with countries on plans and implementation to strengthen immunization. A representative stated that "Funding is mainly needed in areas such as improving outreach, upgrading and modernizing the cold chain and the supply system, and social mobilization. While in most instances governments pay for the 'traditional' vaccines (BCG, Polio, DTP, Measles), most of the funding for new vaccines (Hepatitis B, Haemophilus Influenzae B, pneumococcal, rotavirus etc) in the poorer countries is provided by the international community through the GAVI Alliance, with recipient governments paying a small part."5
UNICEF is a large diverse organization and we have not investigated how it funds its immunization work or how it prioritizes among its many different activities.
GAVI has also provided some support for traditional vaccines, including supporting immunization campaigns and outbreak response for measles (see below), providing one-time grants to the Global Polio Eradication Initiative and the Maternal and Neonatal Tetanus Elimination Initiative, and purchasing pentavalent vaccines, which include the DTP vaccine, a traditional vaccine.10
Though GAVI primarily funds vaccines that are delivered through routine vaccination systems, it has also supported vaccination campaigns for meningitis A,11 yellow fever,12 and, as noted above, measles, maternal and neonatal tetanus, and polio. In the future, it plans to support combined measles and rubella vaccination campaigns.13
In June 2011, donors pledged $4.3 billion to GAVI for 2011-2015, exceeding GAVI's fundraising target of $3.7 billion.14 As a result of this successful fundraising effort, GAVI told us that additional funding would be used if pledges are not paid and to begin filling the funding gap for 2016 and beyond.15
GAVI receives 76% of its funding from governments (largest donors include U.K., Norway, U.S., France, and Italy), and another 18% from the Gates Foundation.16 GAVI expects to have $7.6 billion available for the period 2011-2015 or an average of $1.5 billion per year.17
(We previously considered GAVI: 2009 review of GAVI.)
According to WHO's website, as of January 2012, it had a funding gap of $224 million for its immunization work in 2012-2013, including $86 million for "measles control and surveillance" and $31 million for "meningitis control and surveillance."19
We have contacted WHO for more information but have not produced publicly available information from this investigation.
In 2012, the Measles and Rubella Initiative expects to receive about 60% of its funding from developed country governments (excluding the CDC, a U.S. government agency) and 40% from the five partners that run the initiative (UNICEF, WHO, American Red Cross, CDC, and the United Nations Foundation) as well as from other contributors, such as Lions Clubs International.27 Its budget for 2012 is $234 million.28
In addition to the funding for measles campaigns and outbreak response discussed above, GAVI has pledged support to the Measles and Rubella Initiative for combined measles and rubella vaccination campaigns in countries that have not yet introduced rubella vaccination.29 The Measles and Rubella Initiative estimates that this support will total $335 million in 2013-2015. In 2013 to 2015, the Measles and Rubella Initiative's anticipates that more than half of the funding for its work will come from GAVI.30 GAVI has not committed to fund measles vaccination campaigns once initial combined measles and rubella campaigns have been completed.31
UNICEF leads the MNT elimination effort at the global level, while national governments are the main implementers of the campaigns. UNICEF provides funding, vaccine procurement, technical support, assistance with planning, and monitoring/supervision of the program.34 In the past ten years UNICEF has raised $200 million for MNT elimination; it is seeking to raise another $100 million by mid-2014. Potential funders include Kiwanis International, Proctor and Gamble, GAVI, U.S. Fund for UNICEF, and the Bill and Melinda Gates Foundation.35
In the first stage, the program will conduct vaccination campaigns targeting 1 to 29 year olds with one dose of vaccine. After the initial campaigns are completed, the program will transition to delivery of the vaccine through routine immunization services and/or follow up campaigns targeting children age 1 to 4.38
The website of the Meningitis Vaccine Project (www.meningvax.org), which developed the vaccine, notes, "Groups or individuals interested in helping meet the funding gap for large-scale introduction of the meningococcal A vaccine in sub-Saharan Africa can contact email@example.com for additional information."39 We have done some investigation into this funding gap but have not produced publicly available information from this investigation.
We include information about the Global Polio Eradication Initiative (GPEI) for the sake of completeness but do not currently plan to pursue it. While eradicating polio may be a cost-effective use of funds, we feel that the polio eradication effort has reached a stage where the focus is on eradicating the relatively few cases remaining,40 an endeavor that is likely distinct from other immunization campaigns in terms of its high upfront costs and potential long-term benefits. While we have high confidence in the impact of protecting individuals from contracting diseases by providing them with vaccinations, we have not fully investigated the expected benefits and risks of eradicating a small number of remaining cases of one disease. We would guess that, unlike vaccinating individuals for common diseases, an eradication campaign is likely to have high potential impact and high risk of failure. In addition, with eradication, the size of the donation may be important, because conducting the effort at less than full scale could result in failure to accomplish the goal of eradication and thus loss of future gains.
We have not contacted GPEI to discuss what the effect additional funding would have on its activities.
Reported funding needs
In its 2011 annual report, GPEI notes that it has a pressing need for additional funds for 2012-2013.41 GPEI has published details of its 2012-2013 budget and funding commitments and prospects. As of May 2012, it reported a funding gap for this period of $956 million. 42
We believe that GPEI likely has strong prospects for raising the funds it needs because polio eradication is a major focus of the Gates Foundation, which has spent over $1.5 billion on the effort,43 and because polio eradication is one of Bill Gates' "top personal priorities."44
Current sources of funding
In 2011, GPEI raised $1.1 billion for a budget of $0.98 billion; it started the year with a $0.36 billion funding gap.45 About 30% of funding in 2011 came from the Gates Foundation, 30% from developed country governments, 27% from countries at risk of polio, and the remainder from other foundations, non-profits, and other private funders.46
Globally in 2010, UNICEF estimates that 85% of children received 3 doses of DTP vaccine (a common indicator of "vaccination coverage"). In the World Health Organization's African and South East Asian regions, the figure was 77%. UNICEF, "Immunization Summary (Data through 2010)," Pg xiii.
"Routine immunization with traditional vaccines is largely paid for by national governments, including both purchasing vaccines and running the cold chain and logistics. With support from partners, it still largely functions in the way it was set up in the 1980s. The traditional vaccines are procured through UNICEF (which purchases more than half of all vaccines doses globally, allowing it to negotiate lower prices), or directly by governments, and delivered by government health staff." Jos Vandelaer, phone conversation with GiveWell, May 25, 2012.
"These vaccines are inexpensive; they cost about $0.10 to $0.25 per dose." Jos Vandelaer, phone conversation with GiveWell, May 25, 2012.
According to Jos Vandelaer, UNICEF believes that a larger effort is needed to raise immunizations rates further and is beginning to explore with countries how it can help them reach the hard-to-reach. It sees three main areas in which it could contribute going forward:
It could also contribute by:
UNICEF has historically been involved in the areas above, but now thinks that it needs to focus more directly on scaling up its efforts and fundraising to focus on the above.
Jos Vandelaer, phone conversation with GiveWell, May 25, 2012.
"The approximately 20% of children who are not vaccinated tend to also lack access to other services and are therefore more likely to get diseases (e.g., due to poor nutrition or lack of water and sanitation) and more likely to die if they get sick (due to lack of access to healthcare).
Funding is mainly needed in areas such as improving outreach, upgrading and modernizing the cold chain and the supply system, and social mobilization. While in most instances governments pay for the 'traditional' vaccines (BCG, Polio, DTP, Measles), most of the funding for new vaccines (Hepatitis B, Haemophilus Influenzae B, pneumococcal, rotavirus etc) in the poorer countries is provided by the international community through the GAVI Alliance, with recipient governments paying a small part...
UNICEF has historically been involved in the areas above [see previous footnote], but now thinks that it needs to focus more directly on scaling up its efforts and fundraising to focus on the above.
Initially, UNICEF will focus this 'scale up' in 13 priority countries, where many of the unimmunized children live, including Uganda, Chad, and DRC. Once plans are finalized, there will be a process to determine if the government or existing funders can fund the additional activities. If there is still a gap, which is likely, additional funders will be sought." Jos Vandelaer, phone conversation with GiveWell, May 25, 2012.
For example, the DTP vaccine cost between $0.14 and $0.42 per dose in 2011, while the "pentavalent" vaccine, which contains DTP plus Hepatitis B and Hib vaccines, cost between $1.75 and $3.20 per dose in 2011. The pneumococcal vaccine cost $3.50 per dose in 2011.
UNICEF, "DTP Prices (2001-2011)."
UNICEF, "DTP-HepB-Hib Prices (2001-2011)."
UNICEF, "PCV Prices (2010-2011)."
Total program expenses (2010): $910 million
New and underused vaccines programme disbursements (2010): $506 million
Health system strengthening program disbursements (2010): $78 million
Funding for "activities related to Alliance programmes undertaken by Alliance partners UNICEF, WHO, the World Bank, the Program for Appropriate Technology in Health (“PATH”) and Johns Hopkins University" (2010): $66 million
GAVI Alliance, "Annual Financial Report (2010)," Pgs 11-12.
"GAVI currently offers the following portfolio of programme support:
GAVI Alliance, "What We Do."
"GAVI Alliance which distributes the funds raised by IFFIm…
Of the US$ 912 million being given to countries in 2007: …
"First Year Results - IFFIm Provides US$ 1 Billion to Prevent Disease."
"GAVI’s funding includes three components:
GAVI Alliance, "Meningitis A Vaccine Support: GAVI's Response."
"Countries at risk can apply for GAVI support for preventive campaigns, which can significantly reduce the risk of yellow fever disease and the occurrence of epidemics." GAVI Alliance, "Yellow Fever Vaccine Support: GAVI's Response."
"GAVI anticipates introducing MR [measles-rubella] vaccine into 30 countries by the end of 2015 and by 2018 we expect to support at least a further 20 developing countries." GAVI Alliance, "Rubella Vaccine Support: GAVI's Response."
"Donors committed US$ 4.3 billion at the first pledging conference held by the GAVI Alliance. This exceeded an initial target of US$ 3.7 billion." GAVI Alliance, "Pledging Conference (June 2011)."
"GiveWell: It sounds like funding is not a constraint to expanding immunization coverage in the next couple of years.
GAVI: Given what we have said about ensuring delivery of pledges, our forward planning and forecasting, in terms of being able to make commitments to countries, we do not expect funding to be a critical issue through 2013. Our need for new resources – above those already pledged – arises in 2014 when we must secure new money for the 2016-2020 period."
David Ferreira and Alex Palacios, phone conversation with GiveWell, February 2, 2012.
GAVI Alliance, "Donor Profiles."
"The pledges bring GAVI’s total available resources for the period 2011 to 2015 to US$ 7.6 billion." GAVI Alliance, "Pledging Conference (June 2011)."
World Health Organization, "Immunization, Vaccines and Biologicals: About Us."
World Health Organization, "WHO Global Immunization Work 2012-13 (January 2012)."
Kate Elder, phone conversation with GiveWell, July 13, 2012.
Kate Elder, phone conversation with GiveWell, July 13, 2012.
"MSF creates its operational budgets based on operational needs and priorities. The operations/finance team then checks with the fundraising departments internationally that funding can be raised to meet the goals outlined. So far the goals have been achievable. 90% of the funds raised are unrestricted, so what that means is that funds are directed to priority medical projects first and foremost, not to specific project envelopes (such as vaccinations)…
We can and will accept restricted funds for vaccinations, but a restricted gift for this project may not mean that we do 'more.' Our vaccination budget is huge, tens of millions of dollars every year. So, unless we were awarded an extraordinarily large grant (we are talking something like $50 million+ here) for a specific purpose like vaccines, we would not necessarily do 'more.' Even then we would have to determine if we have the human resources or medical tools available to do more than we already are doing."
Jennifer Tierney, email to GiveWell, September 6, 2012.
"The Measles & Rubella Initiative supports mass vaccination campaigns as an effective strategy to ensuring nationwide coverage and reaching the un-immunized.
A measles vaccination campaign (also referred to as 'Supplementary Immunization Activity' or SIA in countries) refers to the process of vaccinating all children in a defined age range in a short period of time, often in just a few days or weeks. Campaigns are usually countrywide but may take place in multiple phases." Measles and Rubella Initiative, "The Strategy."
GAVI Alliance, "Review of Board Decisions (June 2012)."
Expected GAVI contributions in GAVI Alliance, "Options for Enhancing GAVI’s Investment in Measles Prevention (Presentation)," Pg 7. Contributions for 2012-2015 for measles campaigns: $105 million; contributions for outbreak response for 2012-2015: $35 million.
Measles and Rubella Initiative funding gap from Measles and Rubella Initiative, "Financial Resource Requirements (2012-2015)." Funding gap for 2012-2015 excluding outbreak response: $72.4 million; budget for outbreak response for 2012-2015: $40 million ($35 million per year if the first half of 2012 is excluded).
Note that the GAVI funding for outbreak response will go to the Measles and Rubella Initiative, while the additional funding for measles campaigns will flow directly to implementing governments, rather than through the Measles and Rubella Initiative. However, these funds will cover costs that the Measles and Rubella Initiative planned to fund, and therefore, they reduce the Measles and Rubella Initiative's funding gap. From GAVI Alliance, "Options for Enhancing GAVI’s Investment in Measles Prevention (Report)," Pgs 2-3 and 9:
Andrea Gay, email to GiveWell, August 2, 2012.
"We also will have received almost $15M from Lions." Andrea Gay, email to GiveWell, August 9, 2012.
Measles and Rubella Initiative, "Contributions and Costs (2012-2015 as of April 11, 2012)."
"The board opened a new window for support for the Measles-Rubella (MR) vaccine, and we are working with the (recently renamed) Measles Rubella Initiative to produce strategies to reach children with the combined vaccine through campaigns in countries that introduce MR into their routine immunization programmes." GAVI Alliance, "CEO Report to Board (June 2012)."
As of early 2012, the Measles and Rubella Initiative projected a budget of $677 million for 2013-2015. In this budget, the Measles and Rubella Initiative projected $335 million in revenues from GAVI for combined measles and rubella vaccination campaigns. Measles and Rubella Initiative, "Contributions and Costs (2012-2015 as of April 11, 2012)."
In June 2012, GAVI estimated that it would contribute an additional $134 million in 2013-2015 to measles campaigns and outbreak response. GAVI Alliance, "Options for Enhancing GAVI’s Investment in Measles Prevention," Pg 7.
Andrea Gay, email to GiveWell, August 9, 2012.
"The Maternal and Neonatal Tetanus Elimination Initiative was launched by UNICEF, WHO and UNFPA in 1999, revitalizing the goal of MNT elimination as a public health problem." World Health Organization, "Maternal and Neonatal Tetanus (MNT) Elimination."
"The program targets women of childbearing age to protect both them and their future newborns. If women are adequately vaccinated during pregnancy, their newborns are protected for 2 months after birth, after which children should receive additional tetanus immunizations through the routine immunization system... The MNT Elimination Initiative supports vaccination campaigns in which government takes lead and government health workers vaccinate all women of childbearing age (usually 15- 45 years old) in targeted high-risk areas. Campaigns consist of three rounds. A single dose of tetanus vaccine is ineffective." GiveWell, "Summary of Phone Conversation with UNICEF Regarding the Maternal and Neonatal Tetanus Elimination Initiative (June 22, 2012)."
"UNICEF leads the MNT elimination effort at the global level. Governments are the main implementers of the program. UNICEF provides funding for vaccine procurement, technical support, assistance with planning, and monitoring/supervision of the program." GiveWell, "Summary of Phone Conversation with UNICEF Regarding the Maternal and Neonatal Tetanus Elimination Initiative (June 22, 2012)."
"The program has raised more than $200 million over the past 10 years. The main funders to date have been GAVI, Bill and Melinda Gates Foundation, UNICEF Natcoms, Proctor and Gamble, Becton, Dickenson and Company, and, more recently, Kiwanis International. UNICEF seeks to raise an additional $100 million by mid-2014 in order to reach elimination by the target date of 2015...
Current and potential funders include:
GiveWell, "Summary of Phone Conversation with UNICEF Regarding the Maternal and Neonatal Tetanus Elimination Initiative (June 22, 2012)."
"GAVI has budgeted US$370.4 million to help rid the 'meningitis belt' of meningitis A. For its 2011-2015 programme, GAVI plans to support immunisation all 25 countries in the region." GAVI Alliance, "Meningitis A Vaccine Support."
"The remainder of the US$571 million budget to eliminate group A meningitis in Africa will come mostly from the countries themselves." GAVI Alliance, "Meningitis A Vaccine Support."
"Mass immunization campaigns: Comprehensive mass immunization campaigns of 1- to 29-year olds with a single dose of MenAfriVac™ are a cornerstone of the meningococcal A conjugate vaccine introduction plan...
Protection of birth cohorts: After mass vaccination campaigns have been conducted among 1- to 29-year olds, the main challenge will be protecting birth cohorts throughout infancy. The strategy used will depend on the results obtained in the infant study currently taking place in Ghana and on Expanded Programme on Immunization (EPI) coverage rates in the involved countries.
Meningitis Vaccine Project, "Vaccine Introduction Strategy."
Meningitis Vaccine Project, "Funding."
"In 2011, there were 650 cases of polio worldwide." Global Polio Eradication Initiative, "Polio This Week (May 30, 2012)."
"Compounding this emergency is a 50% gap in financing needed to fully carry out the necessary activities in 2012−2013 (as of April 2012). In the first quarter of 2012, this has already dictated the scale-back of activities in 24 countries in Asia and Africa, increasing the risk of unchecked spread if poliovirus from endemic areas enters these countries." Global Polio Eradication Initiative, "Annual Report (2011)," Pg 4.
Note that the budget does not specify which activities will be cut if the funding gap is not filled. Global Polio Eradication Initiative, "Financial Resource Requirements (2012-2013, as of May 1, 2012)."
Gates Foundation, "Grant Search." Data recorded in GiveWell, "Gates Foundation Polio Grants."
Three of the Gates Foundation's ten largest grants over its history have gone to fight polio (same source, sorted by amount).
"Ending polio is one of my top personal priorities and a big focus of our foundation’s work in global health." Gates Notes, "Creating a Polio-Free World Requires Action Now."
"2011 was a year of unprecedented political and financial support, despite a bleak beginning marked by a US$ 335 million funding gap in January against a US$ 982 million budget. The gap had been reduced to US$ 125 million at the start of the fourth quarter when, by a combination of new and forward funding targeted particularly at west, central and east Africa, the total of contributions for 2011 suddenly rose to over US$ 1.1 billion, the largest amount ever received by the GPEI." GPEI, "Annual Report (2011)," Pg 35.
Global Polio Eradication Initiative, "Annual Report (2011)," Pg 36.