Policy Analysis: Gavi’s ELTRACO, HSIS Policies, and Catalytic Phase Implications for Countries Like Nigeria

In 2018, as an epidemiologist intern in Ogun State, Nigeria, I had my first encounter with Gavi’s strategies while working alongside the State Ministry of Health and the WHO office. My role was to oversee the activities of Independent Monitors during outbreak responses and national immunization plus days. It was in this role that I began to appreciate Gavi’s efforts under its 4.0 strategy (2016–2020), which aimed to extend immunisation coverage in the world’s most vulnerable communities.

Fast forward to December 2024, Gavi’s Board approved updates to its Eligibility, Transition, and Co-financing (ELTRACO) policies, Health Systems and Immunisation Strengthening (HSIS) framework, and a Catalytic Phase for middle-income countries (MICs). These policies aim to balance sustainability and equity, enabling countries to strengthen their health systems while transitioning from Gavi’s support. For Nigeria, these policies present opportunities but also highlight the urgent need for domestic resource mobilisation (DRM) to reduce dependency on foreign aid, especially after the recent 90-day halt in external funding. Drawing on my experience and applying established policy analysis frameworks, I will explore the implications of these policies for low- and middle-income countries (LMICs), particularly Nigeria. Let's start with a summary of what the policies are.

The Policies, What's New?

Eligibility, Transition & Co-Financing Policy (ELTRACO)

At its core, ELTRACO helps countries transition from Gavi’s support to self-financed immunization programs. The 2024 updates introduced price-linked co-financing, where countries contribute a percentage of vaccine prices rather than fixed amounts. For example, HPV vaccines now have a co-financing rate of 4%, and pneumococcal vaccines are set at 7%. Currently, Africa produces only 0.1% of the global vaccine supply and to date, Nigeria has maintained a two-part financing mechanism for routine immunisation and vaccination and vaccine coverage. Despite this financing mechanism, Nigeria is still home to the largest population of zero-dose children (2.1 million) in the world and is still expected to transition from Gavi support by 2028.

Additionally, the eligibility threshold was raised to $2,300 GNI per capita, allowing countries like Nigeria to remain eligible for longer. Vulnerable countries such as Small Island Developing States (SIDS) receive an extended 12-year transition period with reduced co-financing obligations. Furthermore, countries experiencing conflict or disaster benefit from multi-year co-financing waivers.

Health Systems and Immunisation Strengthening (HSIS)

The updated HSIS policy consolidates seven funding streams into one cash grant, simplifying resource allocation. Funding now follows a formula prioritizing GNI per capita, vaccine coverage gaps (e.g., zero-dose children), and fragility multipliers for conflict-affected settings. Safeguards like minimum spending requirements for Cold Chain Equipment (CCE) and a 10% allocation for Civil Society Organizations (CSOs) ensure critical investments are not overlooked.

The Catalytic Phase

Designed for MICs, the Catalytic Phase prioritises the introduction of high-impact vaccines like HPV, PCV, rotavirus, and dengue. It also aims to prevent backsliding in vaccine coverage while supporting fragile and humanitarian settings. For Nigeria, this phase presents an opportunity to address significant gaps in vaccine access.

Understanding Gavi’s Approach

To unpack these updates, I turn to three key policy frameworks: Kingdon’s agenda-setting model, Shiffman and Smith’s network effectiveness framework, and Dahl’s theory of political assets. These frameworks provide insights into how policies are designed and implemented, and what that means for Nigeria’s immunisation journey.

Kingdon’s Agenda-Setting Model

Kingdon’s model highlights how the alignment of three streams—problem, policy, and politics—creates opportunities for policy change [1].

1. Problem Stream: Nigeria faces deep challenges in achieving equitable immunization coverage. Subnational disparities, particularly in northern states, persist due to infrastructure gaps and insecurity. These problems are further exacerbated by growing vaccine portfolios, which increase financial obligations for transitioning countries.
2. Policy Stream: Gavi’s updated policies address these challenges through innovative solutions. For instance, price-linked co-financing reflects a co-design approach, enabling countries to contribute in ways that align with their fiscal realities. However, translating these frameworks into practical, context-specific strategies will be critical for Nigeria.
3. Politics Stream: National and global political contexts influence how policies are adopted and implemented. Reflecting on President Trump’s 2025 executive order to withdraw from the World Health Organization (WHO), it is clear how political decisions can disrupt global health efforts [2]. Similarly, Nigeria’s fragmented health governance could undermine the effective implementation of Gavi’s policies if coordination between federal and state authorities is weak.

Shiffman and Smith’s Network Effectiveness Framework

Shiffman and Smith emphasise the importance of cohesive networks, effective framing, and strong leadership in policy implementation [3].

1. Cohesion: Gavi’s policies exemplify alignment among donors, technical agencies, and recipient countries. However, Nigeria’s fragmented health system often lacks this cohesion, especially between federal and state health authorities. Decentralised models, like those used in India, demonstrate how localized governance can strengthen vaccine delivery [4].
2. Framing: Gavi frames its policies around equity and sustainability, presenting immunisation as a global public good. However, using national metrics like GNI and vaccine coverage risks obscuring subnational disparities. Highlighting local stories of underserved communities could build stronger public support. While humanised framing is a valuable communication tool, it should complement rather than replace data-driven and systemic analysis. Combining compelling stories with broader evidence ensures that emotional resonance is grounded in factual context, leading to more balanced and informed policymaking.
3. Leadership: Gavi’s leadership is evident in its ability to mobilise stakeholders around shared goals. In Nigeria, local leaders—particularly in civil society—can play a crucial role in ensuring these policies are implemented effectively. The COVID-19 pandemic underscored the importance of community-led vaccine campaigns in reaching marginalized populations.

Dahl’s Political Assets Framework

Dahl argues that power in policymaking depends on resources such as wealth, knowledge, and access to decision-makers [5].

1. Application to Gavi: Gavi’s partnerships with WHO and UNICEF amplify its influence, but prioritising donor-selected vaccines like HPV may sideline locally urgent issues, such as yellow fever.
2. Implications for Nigeria: The 90-day halt in foreign aid highlighted the vulnerability of relying on external funding. Nigeria must prioritise domestic resource mobilisation to secure its immunisation programs. Building fiscal resilience through increased health budget allocations and improved tax systems is essential.

Implications for Nigeria

Gavi’s updated policies present both opportunities and challenges for a country like Nigeria. Price-linked co-financing offers a more equitable method for Nigeria to share the financial burden of immunisation, but it also risks straining a budget that is already under pressure from competing health priorities. As vaccine portfolios expand, fiscal space may not grow quickly enough to keep pace with rising costs, potentially delaying critical vaccine introductions.

The raised eligibility threshold ensures that Nigeria continues to benefit from Gavi’s support, providing more time to strengthen its health systems. However, national metrics such as GNI per capita often obscure significant subnational inequities within countries. For Nigeria, this implies that regions such as the conflict-affected north could remain underserved, even as national-level indicators improve.

The Catalytic Phase provides a pathway to introduce high-impact vaccines, but donor priorities must align with Nigeria’s urgent health needs, such as yellow fever and meningitis. Interruptions in foreign aid highlight that local ownership and domestic resource mobilisation are the only sustainable solutions.

Consolidated HSIS grants simplify funding processes, but weak governance and accountability at state and local levels could hinder their impact. Strengthening local capacity and ensuring transparent resource use are non-negotiable for success.

Recommendations

To maximize the impact of Gavi’s policies, Nigeria & LMICs should:

1. Focus on Domestic Resource Mobilization: Immunisation funding must be integrated into Nigeria’s national budget with clear allocations for vaccines, infrastructure, and workforce development. The recent halt in foreign aid shows self-reliance is critical.
2. Strengthen Local Governance: Empower state and local governments to address regional disparities and improve service delivery.
3. Prioritize Equity: Ensure funding and resources target underserved areas, particularly in the north, to close regional gaps.
4. Leverage Community Partnerships: Work with CSOs and local leaders to adapt Gavi’s policies to Nigeria’s context and improve vaccine uptake.
5. Align Donor and Local Priorities: Advocate for flexibility in donor-driven vaccine choices to better reflect Nigeria’s disease burden.

Conclusion

Gavi’s policies aim to balance sustainability and equity, but their success in Nigeria depends on domestic action. The temporary halt in foreign aid is a wake-up call for Nigeria to take charge of its immunisation programs. By prioritising DRM, addressing regional disparities, and leveraging local partnerships, Nigeria can build a more resilient immunisation system.

From my first exposure to Gavi's policies in 2018 till date, it is clear that sustainable immunisation requires national ownership, not just global strategies.

There is a whole lot in the policy updates, you can access the documents here.

References

1. Kingdon J. Agendas, Alternatives, and Public Policies. Updated Second Edition. Harlow: Longman Classic; 2010.
2. The Guardian. Trump executive order: WHO withdrawal. Available from: https://www.theguardian.com/us-news/2025/jan/20/trump-executive-order-who-withdrawal. Accessed January 2025.
3. Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. The Lancet. 2007;370(9595):1370–9.
4. Buse K, Mays N, Walt G. Making Health Policy. Maidenhead: Open University Press; 2012.
5. Dahl R. Who Governs? Democracy and Power in an American City. New Haven, CT: Yale University Press; 1961.