gavi.org
UPDATE ON COLLABORATION WITH OTHER
ORGANISATIONS
BOARD MEETING
Hope Johnson
Thabani Maphosa
6-7 June 2024, Geneva, Switzerland
2 Board Meeting, 6-7 June 2024
Keeping countries and communities central to our
collaboration
Guiding
Principles • Country led and demand driven
• Differentiated approach, leveraging the strengths of each Global Health Institution (GHI)
• Consideration for operating modalities of each GHI
High Impact
Workstreams • Malaria
• Health Systems Strengthening
• Country Engagement
Existing
collaboration • Investments and programming
• Legal, Audit & Investigation, Evaluations
• Resource mobilisation, communication, advocacy
Aligned
Communication • Consistent communication across Boards and Committees
• Clear narrative and strategic messaging to highlight distinct roles,
complementarities and impact
+ Enabling Functions (Gavi -Global Fund)

gavi.org
ROAD TO REPLENISHMENT
BOARD MEETING
Marie -Ange Saraka -Yao
6 -7 June 2024, Geneva, Switzerland
Protecting our future
Powered by
a unique and
innovative
model
Protecting
the World
Protecting
People
Protecting
Communities
Driven by
sustainability
• The African Vaccine Market Accelerator will build
resilience and support vaccine sovereignty
• Global health security preventing outbreaks and largest
investment in stockpiles against killer diseases like Ebola,
cholera and yellow fever
• >50% of Gavi’s vaccines will help countries adapt to the
threats of climate change and Anti -Microbial Resistance
• The widest portfolio in Gavi’s history with 24
life -saving vaccines for this generation of
children to be the most protected ever
• >100 million young women and girls
protected against cervical cancer , saving
1.5 million lives
• >50 million children will receive the new
malaria vaccine
• Gavi will facilitate 1.4 billion individual
contact points between families and
health services
• Gavi will strengthen health systems and
reach more women and zero -dose
children
• Over the next 5 years countries will fund
a record percentage of the costs of their
vaccines, contributing >US$ 4 billion
• By 2030, one in three of the 73 lower -
income countries originally supported by
Gavi will be fully funding their own
vaccine programmes
• Gavi will use its market power to pull
innovation form manufacturers
whilst reducing vaccine prices
across 50% of its portfolio
• Operational costs will stay lean: 97
cents of every $1 will go on buying
or delivering vaccines
* All numbers are provisional at this stage and will be
confirmed once Gavi 6.0 one -pager document is approved
2 Board Meeting, 6 -7 June 2024

Board -2024 -Mtg -02-Doc 10 -Annex A 1
Report to the Board
6-7 June 202 4
Annex A: Implications/Anticipated impact
The Vaccine Investment Strategy (VIS) facilitates strategic decision -making and is a
fundamental tool in fulfilling Gavi’s equity objectives . The rigorous process estimates
health and economic impact of the vaccines under consideration in Gavi -eligible
countries from 2026 -2040 and compares them to the expected impact of vaccines in
the current portfolio, thus providing a quantitative measure o f comparable anticipated
impact. The VIS process is meant to guide decisions for investment that could have
the highest public health impact in Gavi countries.
In this Governance cycle (PPC/Board in May/June 2024), final investment decisions
will be requested to be implemented from Gavi 6.0 subject to replenishment.
Investment cases include vaccines against endemic and epidemic diseases leading
to investments in routine/preventive programmes or stockpiles, respectively.
According to estimated timelines, the vaccines included in the investment cases would
be available for use by Gavi towards the end of the 6.0 period (Figure 1, Doc 10 ), thus
the recommendations presented to the PPC are for in -principle support. These in -
principle decisions allow Gavi to include the vaccine in the design of Gavi 6.0, identify
estimated costs for resource mobilisation and to provide a signal to manufactu rers and
countries regarding level of interest. The risks associated with these in -principle
decisions include the level of uncertainty regarding timelines, product characteristics,
supply and regulatory/policy recommendations. To mitigate these risks, the
Secretariat will continue to monitor the vaccine pipelines , potential demand and
progress of these products along regulatory and policy pathways to inform updated
investment cases that will go back to the PPC/Board for a final approval to start
planning and designing the vaccine programme/stockpile. Although Gavi could
consider deferring these investment decisions until information is more readily
available, this poses risks around funding not being available at the time of a future
decision, as well as negative impact on manufacturers’ continued inves tment in
development of new products and production scale -up that would impact the
timeliness and scale of supply availability and future market health.
Furthermore, the VIS recommendations from the PPC pose risks to countries , the
Alliance and vaccine development :
Impact on countries – Non -infant vaccines
• As more and more countries consider the introduction and sustainability of
additional vaccines outside the infant immunisation timepoint, it is important that
countries have sufficient financial support for their successful delivery. Vaccines
for dengue, tuberculosis and group B streptococcus target non -infant populations
(2yrs, 15yrs and pregnant women, respectively) and thus are expected to require
additional support to strengthen or d evelop additional immunisation touchpoints.
As products become available and updated investment cases are developed and
presented to the PPC/Board, t his additional support provided either by Gavi or
other stakeholders will need to be considered and weighed against other vaccines
and health interventions . If there is limited funding and appetite for this additional
support when these updated investment cases are reviewed there is a risk that

Board -2024 -Mtg -02-Doc 06b -Annex A 1
Report to the Board
6-7 June 202 4
Annex A: Implications and Anticipated Impact

Risks and mitigation:
• Risk of insufficient or slow operationalisation of HS Strategy shifts by the
Alliance , including in -country stakeholders and partners. This is exacerbated by
the interdependencies with other important changes being introduced in Gavi 6.0
including implementation of EVOLVE (Doc 10a) and potential redesign of Gavi
policies, funding levers and processes. To mitigate, an implementation and
socialisation plan will be co -developed with Secretariat teams and Alliance
partners as part of operationalisation of the HS strategy.
• Risk that resources and capacities are inadequate to achieve all results:
There remains considerable risk that countries will not be able to accelerate
progress on all Gavi 6.0 goals given the projected reduction in the HSS funding
envelope compared to the original Gavi 5.0 budgets and constrained capacities at
the country, Alliance, and Secretariat levels. This will be particularly true if funding
efficiencies anticipated through funding levers consolidation are not materialised .
Without additional investm ent in vaccination touchpoints beyond infancy, it is also
likely that coverage rates will not reach levels of other Gavi -supported vaccines
and there is a risk that coverage of HPV vaccine may decline wants countries fully
utilise the vaccine introduction grants and campaign operational costs available in
the early years following introduction . Countries will need to mobilise domestic
resources for these efforts or leverage funding from other donors. The Alliance will
seek to mitigate this risk through the proposed approach to differentiate and
prioritise objectives across countries, and through enhanced partnership and co -
funding with other stakeholders.
• Risk that some shifts cause unintended reputational or programmatic
consequences , including in instances where Gavi significantly reduces a
country’s HSS ceiling or seeks to reduce support for recurrent costs (e.g., in
transitioning countries ), which could result in backsliding of immunisation
performance or pressure on other donors to support these costs in the absence of
government financing . Gavi intends to rol l out shifts in a phased approach and
prioriti se programme learning which will partially mitigate these risks and ensure
new approaches and policies do not credit undue complexity or harm towards
countries.
• Measurement risk and potential for misalignment of expectations with the
Board and key stakeholders: Even with greater investment and focus on
measurement, results of Gavi’s health systems investments will not always be
immediate, nor will they always be demonstrable through available data systems
or methods. Mitigation of this risk will require greater t ransparency and
communication from the Alliance on available data and causal pathways from Gavi
support to intended outcomes, as well as constructive and o pen dialogue with the
Board on reasonable expectations and outcomes from Gavi’s health systems
investments.

Board -2024 -Mtg -02-Doc 06b -Annex B 1
Report to the Board
6-7 June 202 4
Annex B: Gavi 6.0 cash funding and implications for countries
In Gavi 6.0 funding for ‘other cash -based programmes’, defined as the support that has
historically been provided for health systems through HSS, CCEOP, and EAF funding levers,
may be reduced by approximately 15% from the originally planned Gavi 5.0 level, based on
the indicative guidance from the Board during its April 2024 retreat 1. This reduction is driven
by two factors (and illustrated in the slide below) :

1. Efficiencies in the use of Gavi ’s cash grants through the anticipated consolidation of
funding levers , with the expectation this will allow countries to plan more strategically ,
better allocate resources and reduce duplication between funding levers. Costing for
Gavi 6.0 assumed this will allow countries to achieve the same results with a 10%
lower ceiling.
2. Board guidance to reduce support for higher performing countries .

In addition, the Board chose not to make additional investments in health systems to
strengthen touchpoints beyond infancy or strengthen delivery of integrated primary healthcare
services as part of the zero -dose agenda.



These calculations do not yet reflect changes to the eligibility, transition and co -financing
(ELTRACO) policy which may mean countries becoming newly eligible or having an extension
of eligibility for HSS support in Gavi 6.0. This is partially accounted f or within the costing of the
proposed changes to the ELTRACO policies but early analysis based on the PPC
recommendations suggests that some share of these changes would also need to be
1 Actual disbursement has been lower than planned due to disruption caused by the COVID -19 pandemic but this
was more than offset by US $ 1 billion in COVID -19 delivery support projected to be disbursed in Gavi 5.0 / 5.1.
This has been used to fund many health systems priorities including cold chain equipment ; demand -side
interventions; strengthening leadership management and coordination; and service delivery including for the Big
Catch -Up. If CDS is included, the reduction in available resources is significantly larger.

Board -2024 -Mtg -02-Doc 06b -Annex C 1
Report to the Board
6-7 June 202 4
Annex C: Health systems strategy problem statements and key questions

Board -2024 -Mtg -02-Doc 06b -Annex D 1
Report to the Board
6-7 June 202 4
Annex D: Draft framework for differentiation and programmatic sustainability


ISF = initial self -financing ; PT = preparatory transition

Board -2024 -Mtg -02-Doc 06 b 1
Report to the Board
6-7 June 2024

Subject Health Systems Strategy
Agenda item 06 b
Category For Guidance

Executive Summary
The purpose of this paper is to request Board guidance on the emerging direction
of Gavi’s first Health Systems (HS) Strategy. The final HS Strategy will come to the
Programme and Policy Committee ( PPC ) and Board for decision at the end of 2024.
Given the growing importance of health systems to many aspects of Gavi’s mission,
Gavi needs a clear HS Strategy that defines investment priorities and tradeoffs in
line with the Gavi 6.0 strategy and sharpens fo cus on the specific interventions
required to enhance immunisation delivery within a primary healthcare (PHC)
approach . This paper provides an overview and lessons from Gavi’s health systems
investments to date, and early thinking on a set of key shifts to address the problem
statements which were discussed with the Board in November 2023 . This paper has
been informed by guidance received from the Programme and Policy Committee at
its meeting on 15 -16 May 2024 , early direction from Gavi’s new CEO and by
consultations with countries and partners . It has been co -developed with the HS
Strategy Technical Advisory Group (TAG), which includes representatives from the
Bill & Melinda Gates Foundation, civil society organisations (CSOs), US Centers for
Disease Contro l (CDC), the Global Fund to Fight AIDS, Tuberculosis and Malaria
(Global Fund), UNICEF, the World Bank, and the World Health Organization (WHO).
The Health Systems Strategy has been an integral part of the Board’s deliberations
on Gavi 6.0, including through, a ‘virtual Board/PPC mini workshop’ in October 2023,
a Board/PPC Technical Briefing in November 2023, a Gavi 6.0 costing deep dive in
April 2 024, and the Board retreats in December 2023 and April 2024.
Action Requested of the Board
The Gavi Alliance Board is requested to provide guidance on early thinking on the
HS Strategy as described in this paper, including the proposed objectives , approach
to differentiation and to measurement .
Next steps/timeline
Following Board guidance on this paper, the Gavi 6.0 HS Strategy will be developed
in close consultation with the HS Technical Advisory Group and other stakeholders
as part of the Gavi 6.0 operationalisation process and will be brought to the October
2024 PPC meeting and to the December 2024 Board meeting for approval. The
strategy will be operationalised in 2025 for implementation starting in 2026 .

1 Report to the Board
6 - 7 June 202 4
Appendix 2: General Overview: Forecast Process and Governance including
anticipated impact
Impact on countries
Approval of the Financial Forecast enables funding to be allotted to programmes in
accordance with the Programme Funding Policy.
Risk implication and mitigation, including information on the risks of inaction
Determination of Gavi’s financial capacity to approve the recommended decisions
relies on the Financial Forecast.
Macro risks that may impact the reliability of the financial forecast are described below,
as well as the mitigation strategies in place to address these risks. Please refer to the
main paper for detail and range forecasts of specific risks and opportuniti es to the
forecast.
One of those risks arises from exposure to foreign currency exchange rate
fluctuations. In the forecast, non - USD pledges are valued at their USD equivalents
using the Bloomberg spot exchange rates when compiling the forecast (consistent with
the approach a greed with donors) or, where hedged, at the hedge rate. Pledges are
hedged progressively in accordance with the Board approved Treasury policy.
Gavi’s Cash and Investments Reserve provides a cushion for adverse fluctuations in
resources and expenditures. Gavi can also decline or defer funding requests based
on resource availability.
Risks associated with the financial forecast and mitigation
Factors that may impact the expenditure forecast include:
Demand volumes can vary significantly based on small changes in country
introduction assumptions. While the introduction assumptions made in the current
forecasts leverage the information readily available, there remains an inherent high
degree of uncertai nty on these assumptions. In addition, the assumptions on
introduction timing are often dependent on projections of when a country will no longer
be eligible for new Gavi support. This forecast represents the application of the current
Board approved Eligi bility and Transition Policy. Changes or exceptions to this policy
could vary demand significantly.
The expenditure forecast adjusts for performance risk at the portfolio level reflecting
the Secretariat’s current estimate of overall needs based on historic trends and
forecast country absorptive capacity. However actual expenditure could be higher or
low er than the financial forecast depending on actual country demand. Should
performance risk be lower than forecast, Gavi can decline or defer funding requests
based on resource availability.
Doc 07 - Appendix 2

Board -2024 -Mtg -02-Doc 0 6a 1
Report to the Board
6-7 June 2024

Subject Future of Gavi’s Eligibility, Co-financing and Transition M odel
and Middle -Income Countries Approach
Agenda item 06a
Category For Guidance

Executive Summary
This report provide s an overview of the key shifts considered for the
enhanced eligibility, transition, and co -financing model (ELTRACO), and the
Middle -Income Countries (MICs) approach in Gavi 6.0. Gavi’s ELTRACO model
is widely regarded as a success story, with nineteen countries having transitioned
out of Gavi support to date. In response to the e volving context marked by a
challengin g macro -economic outlook, growing risks of unsuccessful transition of a
subset of countries, and growing inequities in access t o immunisation in lower
middle -inco me countries, the Board as part of the design of Gavi 6.0 1 has explor ed
opportunities to improve Gavi’s approach to building programmatic and financial
sustainability of immunisation programmes in the next strategic period . It provided
guidance that successful transitions should remain a cornerstone of the Gavi model
in the next strategic period and beyond, and therefore to significantly enhance the
current ELTRACO model and MICs approach. The enhanced model introduces six
main shifts to mitigate the risks of countries defaulting on their co -financing
obligations ; to slow down the acceleration of co -financing obligations 2 in Gavi -
eligible countries ; and to ensure successful transitions. The current MICs approach
becomes the new post -transition Catalytic phase of the ELTRACO model to improve
immunisation outcomes in a subset of Former - and Never -Gavi -eligible countries.
Lastly, a learning agenda is developed to test some elements of a transition by
vaccine model. At its May 2024 meeting, the Programme and Policy Committee
(PPC ) largely supported and further concretised the general ‘direction of travel’ from
the Board discussions , pending further detailed design deliberations as part of the
upcoming Funding Policy Review (FPR) , in particular on updating Gavi’s eligibility
indicators and threshold in Gavi 6.0 .
Action Requested of the Board
The Gavi Alliance Board is requested to :
a) Provide guidance on the additional recommendations provided by the Gavi
Alliance Programme and Policy Committee in May 2024 as an input into the
Funding Policy Review .
1 The future ELTRACO model and MICs approach in Gavi 6.0 have been an integral part of the Board’s
deliberations on Gavi 6.0, including through, a ‘virtual Board/PPC mini workshop’ in October 2023, a Board/PPC
Technical Briefing in November 2023, a Gavi 6.0 costing deep dive in April 2024 and the Board retreats in
December 2023 and April 2024. In addition, an informal Gavi 6.0 Board Task Team was established to shepherd
the development of the ELTRACO/MICs approach from January to March 2024. 2 Co -financin g in this document refers to co -financed and fully self -financed Gavi vaccines programmes by Gavi -
eligible countries , provid ing an overview of overall country financing .

Board -2024 -Mtg -02-Doc 06a -Annex B 1
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6-7 June 202 4
Annex B: Definition of Gavi’s objectives and principles for the enhanced ELTRACO
and MICs model
The definition and prioritisation of the objectives and principles were reviewed by the
Board Task Team and endorsed by the Board at its retreat in April 2024.

Board -2024 -Mtg -02-Doc 06a -Annex C 1
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6-7 June 202 4
Annex C: Overview of the impact of different eligibility thresholds on countries’
eligibility status and transition pathways in Gavi 6.0