Gavi: The Inverted Pyramid of the Vaccine Alliance
Adaptive and innovative work increasing access to immunization across the world, from the safety of DC and Geneva
MISSION: Gavi is tackling a complex problem. Despite great progress and excitement in the 1980s, by the end of the 20th century, life-saving vaccinations were still not reaching 30 million children. In the world’s poorest countries, the most common barriers are cost and a lack of delivery infrastructure.
Founded in 2000, Gavi funds and facilitates the delivery of vaccines to children in countries where they would otherwise not have access. It has been successful in two significant ways: (1) it has saved, by its estimation, 7 million lives by vaccinating 500 million children to date, and (2) it has created a reliable market for vaccinations in developing countries.[i] Its success is impressive, given the complexity of the problem it is solving, and its operating model has contributed to this success in ways that differentiate it from other large multilaterals.
BUSINESS MODEL: Gavi’s business model has six pillars:
1. Get vaccines on the agenda: demonstrate the comparable cost-effectiveness of immunization versus other public health interventions
2. Secure predictable financing: use innovative financing mechanisms to provide long-term funding at scale
3. Put countries in charge: ensure country leaders and local partners run and manage immunization programs
4. Strengthen health delivery systems: support countries in tackling weaknesses to ensure coverage
5. Work together for healthy vaccine markets: ensure supply, reduce prices and incentivize new vaccine development to tackle the global disease burden
6. Obtain country commitment to co-financing: require that countries contribute to the cost of vaccines, increasing contribution to 100% over time[ii]
Their key challenge is to align public and private sector players around their goal of “increasing access to immunization in poor countries.”[iii]
OPERATING MODEL: Gavi’s operating model combines a requirement for broad reach with a lean internal organization structure. Its business model positions it as a facilitator more than an implementer. Gavi connects with, among others, private sector manufacturers to negotiate volume discounts and prove market sustainability, public and private donors to contribute funds, and governments to drive delivery. Its operating model reflects this strategic decision along three key dimensions: organizational governance, human capital management, and innovation.
Organizational governance: Gavi is a public-private partnership, and each partner delivers part of the value. For example, UNICEF procures vaccines, WHO develops quality and safety standards, country governments implement immunization programs etc. Gavi operates under a 28-member Board that directs strategy and funding policies. Board membership is a broad combination of representatives from stakeholder groups.
Source: Gavi website
The board’s diversity and decision-making power are key to the organization’s success. Including different representatives on the board gives them a voice in the strategic direction of the partnership, and leads to strong relationships with external stakeholders that hold very different interests.
Human capital management: Gavi runs a lean, top-heavy organization, combining public and private sector human capital to drive coordination across industries. It is not present in the 73 countries in which it operates, but works instead with government ministries, international agencies and civil society to build immunization programs. Offices for Gavi’s ~200 employees are in Geneva and Washington D.C., where small teams are organized around countries and functions. Employees are hired and trained to be versatile and able to work across sectors. The team set-up and culture promotes flexibility in response to partner needs. For example, if one country can pay more than another towards the vaccine program, or needs more investment in health infrastructure, the Gavi team will adapt their support to those specific needs.
Innovation: Gavi also creates value through innovative financing mechanisms to help develop the vaccine market. Two main innovative financing mechanisms have provided 31% of the ~$10B raised to date: Advanced Market Commitments (AMC) and International Finance Facility of Immunisation (IFFIm).
Source: Kaiser Family Foundation
IFFIm issues vaccine bond and securities, backed by long-term donor commitments.[ii] To facilitate this innovation, Gavi has created a separate IFFIm business unit that is encouraged to think about financing sustainability in new ways.
RISKS: Gavi’s model as a facilitator and innovator has helped it manage the complexities of vaccine delivery to countries with less developed markets and infrastructure. However, there are risks and downsides to its operating model. Other organizations in the immunization ecosystem express frustration with the “top-down globalism” that Gavi represents.[iii] Employees express frustration with the top-down organizational structure, and with the model that is inherently self-destructive if successful. These risks have not impeded its success to date, but whether they will become a bigger problem when Gavi starts to try to remove itself from countries with successful programs remains to be seen.
I think this is a really interesting post (and not just because it appeals to my public sector proclivities)! The main question I was left with upon reading it was about the order in which the business and operating models developed. On one hand, you could see a scenario where the business model is just the most strategic choice (because it doesn’t duplicate programs, or because it leverages existing partnerships, or because it creates a more sustainable local infrastructure for delivering vaccines, etc) and therefore that the business model must have come first, followed by an associated operating model. But I could also see it working the other way, where the realities of doing business in certain countries necessitate that Gavi structure itself this way. In other words, there might be some degree to which it would be very difficult for Gavi to run its own soup-to-nuts vaccine distribution and financing network in many countries, even if such a thing were (in theory) more efficient than this light-and-lean “facilitator” model. In that case, the operating model is really driving the business model. I think these things are difficult to untangle, but I find this a great example of the two being so tightly intertwined that it’s particularly hard to tell which is driving which.
Thanks Jennie! I agree that in this case they are very closely related. I think there was definitely an element of the business model that was purposeful, based on the competencies and connections of those who set it up. I also think the focus on innovative funding mechanisms and market development was deliberately chosen to drive sustainable vaccine market growth. But I also think your instinct may be right and Gavi may have recognized early that they would be better placed to scale across countries with different health and governance structures through a lighter touch model. Looking at other global health foundations originating in the US, the coverage is generally lower when the operating model is more hands on. For example, the Clinton Health Access Initiative has a strong footprint of country teams that work with national governments and existing health structures, but operates in 38 countries vs Gavi’s 73.
Good point re: Clinton Foundation! Makes sense it would shake out that way all things considered. Appreciate the thoughtful response 🙂