GAVI: notes and remaining questions
- The GAVI Alliance is one of the most promising charities we've come across based on a) its singular focus on immunization, a proven cost-effective intervention and b) its commitment to transparency, as evidenced by the information available on its website. For more, see Holden's email to this list: http://groups.yahoo.com/group/givewell/message/101. What does GAVI primarly spend its money on? The program that GAVI is most well-known for is their Immunisation Services Support (ISS) program in which they provide funds to countries that demonstrate increased immunization coverage relative to the set benchmark. However, in 2007, this program accounted for an extremely small part of their total expenses.
I spent a couple of hours yesterday beginning to review GAVI because we think there's a good chance that we'd ultimately recommend them. After reviewing the documents on their website, however, I'm now less sure. These are the most significant questions we have:
The bottom line is that approximately 40% of GAVI's funds are granted to external programs/organizations, such as the Global Polio Eradication Initiative, which may indicate that GAVI is at capacity for their implementing their primary activities of directly increasing basic immunization coverage. An additional, ~30% of GAVI's funds go to cash or in-kind donations for vaccination materials. ~20% goes to flexible money for health system strengthening. < 10% goes to GAVI's "flagship" ISS program.
Roughly 60% of these funds (and all of the funds that go to the external intiatives) come through a mechanism know as the IFFIm (more at http://www.iff-immunisation.org/index.html). It's not totally clear whether it's appropriate to treat these funds as funds given to GAVI through other channels. I've contacted someone at GAVI to ask about this issue. Details on their spending are below.
Assuming that the IFFIm funds are conceptually separate from general spending, we might still assess GAVI on the basis of its non-IFFIm spending, which leads us to question 2.2. How do countries utilize GAVI's funds? GAVI's NUS and INS programs provide either a) in-kind donations of vaccines and related materials or b) cash to purchase these materials. GAVI's website says that GAVI requires a relatively high standard of evidence that countries use the funds provided to purchase the expected materials (see http://www.gavialliance.org/support/what/nvs/cofinancing/index.php).It's not clear that GAVI monitors that these materials are ultimately used properly (as opposed to sold by the countries for cash, which is a concern we've read about). However, they do a) use WHO data to track the number of people immunized and b) perform data quality audits (DQA) to assess that the data provided is accurate. Assuming that GAVI funds/materials account for a substantial portion of the people immunized in a country, these two checks together would provide a relatively strong case that GAVI funds are used for immunizations. To check this, we'd need to look at a) the number of immunizations GAVI expects to provide and b) the number of total immunizations implemented in that country.
The HSS funds are a different case. These, which account for ~20% of expenses, can be used for many uses. I didn't see a summarized report on what countries used these funds for. (It may be - and I haven't yet checked - in the individual country-level reports -- though, as far as I know, GAVI does not perform any monitoring of these reports aside from the DQA, so it's unclear how trustworthy these are, on their own.)
Details on GAVI spending:
- Total program expenses: $1.1 billion (Audited financial
- "Investment cases": $428 million (GAVI Alliance Progress Report 2007, Pg 77).
- New and underused vaccine program: $345 million (GAVI Alliance
Progress Report 2007, Pg 77 for IFFIm money and subtracting cumulative
spending through 2006 (2006 Progress Report, Pg 32 available at
cumulative spending through 2007 (2007 Progress report, Pg 9). [I
wasn't able to find annual spending broken out by area.]
- Health systems strengthening: $206 million (Same as above)
- Immunization services support: $92 million (Same as above)
- Injection safety and support: $11 million (Same as above)
- Investment cases: in 2007, these consisted of a $190m to the
Global Polio Eradication Initiative, $139m to the Measles Initiative,
$49m to the Maternal and Neonatal Tetanus Initiative, and $48m to the
Yellow Fever Initiative.
- New and underused vaccines: (NUS) "provides support to developing countries to introduce the following vaccines and associated vaccine technology. GAVI's support aims to accelerate their uptake and to improve vaccine supply security. "
- Immunisation services support: (ISS) "flexible cash which countries can use as they choose to improve immunisation performance." Funding comes in two phases: an "investment" phase of two years granted on the basis of an approved application and a "reward" phase, where funding is continued on the basis of meeting pre-defined targets for immunization coverage.
- Injection safety support: (INS) funding used to purchase equipment which increases vaccination safety for a pre-determined set of vaccines.
- Health system strengthening: (HSS) funds used for non-vaccine-specific health services aiming to ultimately increase immunization coverage
- Total program expenses: $1.1 billion (Audited financial statements: http://www.gavialliance.org/resources/GAVI_2007_financial_statements___non_A_133.pdf, Pg 3)