GAVI Immunization Services Support Funding: Evaluation of the First Five Years

Immunization Services Support (ISS) funding, provided by the Global Alliance for Vaccines and Immunization (GAVI), is an innovative performance-based funding mechanism that encourages countries to make investments to vaccinate more children. This strategy allows countries to spend ISS funds as they deem appropriate, but continued funding is based on increases in the number of immunized children. This study evaluates the impact of ISS funding on immunization performance (as measured by DTP3 coverage rates), and provides recommendations of alternative design and structure. This evaluation included regression analysis to test the effects of ISS expenditures on immunization rates, as well as in-depth study of three pairs of countries, using a modified case control approach. There were several important findings that have policy implications. We observed that Low Income Countries Under Stress (LICUS) tended to apply for GAVI ISS funding later than other countries, and were less likely to receive rewards. Performance-based funding, which by definition rewards better performers, may not be the most suitable for improving performance in LICUS countries. The data showed that ISS had a significant positive effect on DTP3 coverage rates from 2001-2005. A $1 influx of ISS funding per surviving infant increased the odds of immunization by approximately 10% in the year funding is received, and by another 10% in the next year. Our analysis does not confirm the finding by Lu et al. (The Lancet 2006) that ISS funding has no effect in countries with baseline coverage above 65%. Our model found that the cost of immunizing an additional child is approximately $23 at the lowest coverage rates, but increases to $53 per additional child at 80% coverage. The variables that proved statistically significant in influencing the ISS effect included GDP (negative effect), political stability (positive effect) and the presence of a current conflict (negative effect). The lack of correlation between specific types of expenditures and ISS effect suggests that, on a global level, it would be extremely difficult for GAVI to direct ISS expenditures toward relatively more effective uses. Our finding that the population growth rate alone explains 76% of whether a country receives rewards is cause for further examination of the reward system.