The most crucial part of next year’s federal budget

I enjoy plenty of government services (my library, my bus, the mail) but if I had to pick an absolute favorite thing the US government does, it might be “fund Gavi.”

Gavi is the international body, funded by rich governments and philanthropies, that bankrolls and organizes the distribution of life-saving vaccines in the Global South. Countries become eligible if their gross national income per capita is under $1,810. That’s lower than you might think — a lot of countries that we consider quite poor, like Bangladesh or Kenya, are too rich to qualify for Gavi support. Those who get aid are the poorest of the poor: Haiti, Liberia, the Democratic Republic of the Congo, and so on.

You might have heard of Gavi when it was co-leading Covax, the less than fully successful international effort to make sure poor countries got access to Covid-19 vaccines. But its bread and butter is funding the kind of routine vaccines given to infants in rich countries as a matter of course, like the polio vaccine or the measles and rubella vaccines. Its work has saved millions of lives.

Gavi, like many international organizations, is funded on “replenishment cycles,” in which every few years the group asks rich countries to pledge to fund it for a set period (usually about three to five years). It is currently asking rich country donors for $9 billion to cover its budget from 2026 to 2030. A huge chunk of that, over $1.1 billion, is set to fund purchases of newly approved vaccines against malaria, a disease that kills over a thousand children a day, most of whom are in some of the world’s poorest countries. Such vaccines have only become available in the last couple years, and their existence makes the case for generous funding of Gavi that much stronger.

At the same time, raising $9 billion is never easy, and Gavi has the misfortune of asking for funding during what experts are calling the “replenishment pileup.” A huge number of international humanitarian groups — the World Bank; the World Health Organization; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the Pandemic Fund; the climate-oriented Loss and Damage Fund — are all asking for donor funds at roughly the same time. That has fueled fears that donor fatigue and tight budgets will mean some, many, or all of these groups will fall short of their goals.

Luckily, Gavi seems likely to avoid that fate. The US has already pledged $1.58 billion of the $9 billion the group requested. And there’s bipartisan support in Congress — yes, the same Congress that can’t seem to agree on anything — for going even higher than that.

We know that vaccines in general are an incredibly effective way of saving tens of millions of lives, but Gavi in particular seems to be an effective way of buying and distributing them. For one thing, because it purchases so many vaccines in bulk, it can bid down the price, enabling more people to get immunized for less.

It has also played an unusual role in pushing the development of new vaccines. When the alliance started in 2000, the only available pneumococcal vaccine (preventing pneumonia, meningitis, and other diseases caused by the pneumococcus bacterium) targeted variants of the bacterium prevalent in the rich world, not in Gavi countries, where the disease is more common and more deadly. By setting up what’s called an advance market commitment promising to purchase en masse a vaccine that proved effective in poor countries, Gavi spurred the development of three effective new vaccines.

One recent paper studying Gavi's initial rollout from its founding through 2016 estimated that it saved about 9 million lives, at a cost of $118 each. Another paper using a different empirical strategy put the cost per life saved higher (between $4,265 and $17,059) but still very low in the scheme of things. Expanding Medicaid in the US, for instance, saves a life for about $5.4 million, or at least 300 times more than Gavi vaccinations.

Distributing vaccines in a cost-effective way isn’t always straightforward. A study by a team at the Center for Global Development found that Gavi funding for countries like Ukraine or the Philippines that were near its income cutoff often paid for vaccines the country would’ve paid for on its own anyway — but the authors are clear to emphasize that Gavi might have had a significant impact on vaccine coverage in very poor countries not near the cutoff and that, even for less poor countries, the aid might have helped them adopt newer, more cutting-edge vaccines and freed up government funds for other worthwhile social services.

This track record has resulted in “a long history of bipartisan support in Congress for Gavi,” per Adam Wexler, director of the global health budget project at the research group KFF. Through the Obama and Trump years, Congress consistently either met or exceeded the president’s pledged support for the group. In 2011, the US pledged $450 million in funding through 2015; Congress actually appropriated $733 million. In 2020, the Trump administration pledged $1.16 billion over four years, which Congress matched.

That continues today. Bipartisan resolutions have been introduced in the House and Senate this spring supporting high funding levels for Gavi, as have bipartisan “Dear Colleague” letters calling for $340 million in annual funding for the group. That implies $1.7 billion in funding over five years, or substantially more than the Biden administration’s $1.58 billion pledge. When announcing the pledge, the administration was careful to call for “at least $1.58 billion,” leaving the door open for Congress to exceed that amount.

The House Appropriations Committee recently passed a funding bill on a party-line vote including some serious cuts, like zeroing out support for the World Health Organization entirely. But even the Republican-backed package included $300 million for Gavi — not the full $340 million advocates wanted, but consistent with the Biden pledge. Colin Puzo Smith, director of global policy at the pro-aid advocacy group Results, told me that the $1.58 billion is meant to be distributed as $300 million in the first year and $320 million in the subsequent four, meaning the House bill keeps things on track.

The funding isn’t finalized yet, and the House and Senate appropriators will surely clash over other components of the package. But so far, at least $300 million in Gavi funding in 2025 looks like a sure thing.

I’m sufficiently jaded by American politics that whenever I see that both parties want to give serious funding to a good program, that’s enough to get me excited. But there’s a real case that appropriators should be aiming much higher.

Recall that there are not one but two new vaccines available for malaria. RTS,S, which has been in development for decades, is quite expensive to produce, but R21, the second approved vaccine, is not. RTS,S currently costs around $10 per dose, while R21 costs $3.90 per dose. Once manufacturing has ramped up, GlaxoSmithKline, which makes RTS,S, estimates it can produce 15 million doses of it a year; the Serum Institute, which makes R21, estimates that it can currently make as many as 100 million doses a year. Both because it’s less than half the price and because it can be produced in much greater quantities, R21 is the vaccine to watch here.

A full course of either vaccine requires four doses, meaning that we could theoretically produce enough to vaccinate about 29 million children a year. That’s not enough to cover every child at risk of the disease, but it’s a huge number. And right now, the Gavi budget isn’t sufficient to reach that target. It projects immunizing 50 million children from 2026 to 2030, or 10 million a year. That’s less than half the number that could theoretically be vaccinated if Serum and GSK’s total production capacity were reached.

In the nearer term, the situation is bleaker. The advocacy group 1DaySooner has been pushing a goal of vaccinating 50 million children this year and the next (2024 and 2025). That takes 200 million doses, which Serum claims it can produce. But Gavi only projects a total of only 2 million immunized children from 2021 and 2025, or 25 times fewer children than theoretically could be vaccinated with more funding.

The rollout of R21 has faced resistance from some quarters in public health in a way I find frankly baffling. It is not, to be clear, sufficient to wipe out malaria, the way the smallpox vaccine eventually wiped out that disease. The largest study I’ve seen estimates that it’s 68-75 percent effective in the first year, which is very good but not as high as some vaccines, like that for measles. It’s better to think of it as one tool among several, and a tool that can be replaced if we develop yet-more-effective malaria vaccines, as I think we will. (If you live near Baltimore, you can help and join a trial of one candidate right now!).

The R21 vaccine is still an incredibly cost-effective way to prevent malaria infection and death. One recent analysis found that distributing R21 saves a year of a child’s life for about $39. Anti-malaria bednets save a year of life for about $38. Bednets are among the most cost-effective public health interventions known to mankind, so being roughly as cost-effective as them is hitting a very, very high bar. If Gavi were able to buy it in much greater quantity and bargain down the price, it would be more cost-effective than bednets, and even more of a no-brainer.

So while the bipartisan support for Gavi is a great thing, I think there’s a strong case that donors like the US should be pledging a significantly higher amount to make sure every single dose of RTS,S and R21 that can be bought and used to prevent malaria is. Funding the standard vaccines is great. But every 100,000 kids vaccinated with R21 means 629 fewer kids dead from malaria. The 48 million kid gap between 1DaySooner's vaccination goal and Gavi's current plans for this year and next, then, represents about 300,000 additional dead kids. Those are lives we can save with sufficient investment.

As Jacob Trefethen, a funder of global health research at Open Philanthropy, recently asked, “Are we, as a country, as a world, really going to let money be the blocker to kids getting a malaria vaccine?”