Gavi and the Global Fund's Adoption of Eligibility, Co-Financing, and Transition Policies: An Assessment of the Need for an Improved Domestic-Financing Transition Framework Open Access

Jackson, Everett (Spring 2020)

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        Gavi and Global Fund are among multiple global development-focused organizations encouraging processes promoting “country ownership.” They stand out from the other organizations in that they are the only organizations to have introduced policies outlining a clear framework for this process as it relates to the finance of health programs and initiatives. Gavi and the Global Fund have introduced policies determining countries’ eligibility to receive funds, co-financing requirements for Gavi and Global fund supported programs, and transition processes to progressively scale countries’ domestic finance of those programs to 100%. These policies are uniformly applied to all eligible countries and are driven by a country’s GNI per capita and income level as determined by the World Bank.

           These policies have introduced a clear and structured framework guiding a country’s transition to being fully self-financed, and within this framework 14 countries in the 2010s successfully transitioned programs from Gavi support. As a new, diverse, and large cohort of countries are projected to reach eligibility thresholds in the 2020s, researchers have expressed concerns that this framework will be difficult to successfully apply in the future. A major concern is the new cohort are extremely diverse in their political, economic, and demographic features, and that the driving indicator for the transition process, GNI per capita, is insufficiently sensitive to these differences.

           The purpose of this paper is to better understand the historical processes leading to the development of these policies, examine how the policies operate, and assess how two distinct countries, Georgia and Nigeria, faced the transition process of these policies at the time of their introduction. This was done by a thorough review of the literature, the synthesis of the findings into clear summary tables and graphics, and the creation of two case studies to gain a clearer perspective of the policy mechanisms in real settings.

           The results of the critical analysis reflect changes in how countries and global health initiatives are likely to interact in future with the onus of financing transferring to countries. Economic shocks, like those experienced in the era of Covid-19, will undoubtedly interrupt the transition to domestic financing for all countries, and particularly those countries whose economic as well as health systems are fragile. The upheaval caused by the Covid-19 pandemic demonstrates vividly why relying on one economic indicator, GNI per capita, as a threshold indicator for domestic financing, is shortsighted and may be a barrier to the desirable goal of genuine partnerships in the global community.  

Table of Contents


1.1 Gavi and Global Fund’s Changing Policies on Finance 1

1.2 Research Question 3


2.1 The Gavi Vaccine Alliance 3

2.1.1 Gavi’s Eligibility and Transition Policy 3

2.1.2 Gavi’s Co-financing Policy 5

2.1.3 Significance of the Policies and Examination of Context 7

2.2 The Global Fund to fight AIDS, Tuberculosis, and Malaria 10

2.2.1 The Global Fund’s Eligibility Policy 10

2.2.2 Sustainability, Transition and Co-financing Policy 11

2.2.3 Significance of the Policies and Context 14


3.1 Research Question 15

3.1.1 Purpose 15

3.1.2 Rationale 15

3.1.3 Stated Aims 15

3.2 Data Sources & Literature Search 17

3.3 Methodology of Aims 19

3.3.1 Aim 1: Describe the Policies 19

3.3.2 Aim 2: Identify the Historical Basis for the Policies 20

3.3.3 Aim 3: Examine Transition Assessment Literature & Identify Transition Factors 20

3.3.4 Aim 4: Write a Case Study Analysis 21

3.3.5 Aim 5: Assess the limitations and strengths of the policies 22

3.4 Methodological Limitations 23


4.1 History of Global Public-Private Partnerships 25

4.2 Emergence of the concept of Country Ownership 27

4.3 Growth of Country Ownership and the Emergence of the concept of Domestic Finance 29

4.4 Implementation of Country Ownership and Domestic Finance Measures Post Crisis 32

4.5 Metrics for assessing beneficiary country contributions to domestic finance 33

4.6 The Growth of Middle-Income Countries (MIC) & The Challenges Faced in Transition 35

4.7 GNI as an inadequate indicator of capacity for successful transition toward domestic finance from GPPP support. 41

4.8 Moving forward – Gaps and Future Research 43

4.9 Results of Literature Review  46


5.1 Case Study on Georgia 49

5.2 Case Study on Nigeria 55



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