This report describes the country-level experiences of applying for support from the Global Alliance for Vaccines and Immunization (GAVI) in Tanzania, Mozambique, Ghana and Lesotho; as well as early implementation experiences in the first three countries. The aim of the initiative is to raise immunisation coverage and introduce new and underutilised vaccines. The renewed focus on immunisations, strengthening of country immunisation coordination committees, introduction of Hepatitis B vaccine with safe injection equipment, and flexible systems support funding were all welcomed. All countries experienced the pace of the application process as too rapid, which contrasted with delays in the arrival of the vaccines. Support around technical issues, both within countries and from GAVI, was generally appreciated. However, donors – especially those
committed to sector-wide approaches – believed that the initiative took insufficient account of agreed mechanisms for country planning and prioritisation. The success of GAVI will be heavily dependent on the strength of existing systems delivering routine infant immunisations. In most of the study countries, fieldwork revealed serious systems weaknesses. These included low staffing levels, insufficient transport and fuel, poorly functioning cold chains and infrequent supervision. The low levels of systems support funding provided by GAVI to countries were unlikely to solve these problems. Inherently weak routine information systems in some of the countries will undermine GAVI’s ability to monitor and reward improvements in immunisation systems. It is unlikely that recipient countries could sustain the relatively high cost of the new vaccines, if GAVI funding ceases at the end of the five-year commitment, unless other sources of support are mobilised. Donor country-level advisers were much less optimistic than were ministries of health that such support would be forthcoming.