Evaluating Country Performance After Transitioning From Gavi Assistance: An Applied Synthetic Control Analysis

After transitioning from Gavi support, most countries in this analysis maintained or improved key outcomes compared to expected performance. Transition planning should include assessing risk factors and engaging country actors for post-transition assistance. Key Findings Despite context-specific differences in vaccination coverage among countries after transitioning from Gavi assistance, most countries successfully maintained or further improved key outcomes compared to their expected performance. Unstable or decreasing vaccination coverage before becoming fully self-financing may be considered risk indicators, particularly among countries facing governance challenges. Annual fluctuations in vaccination coverage may have a limited impact on the overall trajectory of post-neonatal mortality when the rate is relatively low. Key Implications Synthetic control, a quasi-experimental method, can be used to evaluate large-scale global health program transitions. The results can inform approaches to safeguard and further gains achieved with external financial assistance, thereby maximizing the potential for success. International donors should assess contextual externalities and risks to potentially slow down the process of transitioning countries from assistance when needed. Country actors can leverage mechanisms for post-transition technical assistance and accountability and provide guidance to transitioning countries. Gavi can systematize post-transition assessments and evaluations that engage the expertise and experience of countries that no longer receive its support. ABSTRACT Introduction: Over the past decade, international development assistance for health has slowed. As donors seek to increase domestic cofinancing and ultimately transition countries from donor aid dependence, COVID-19 has severely constrained public budgets. The evaluation of sustainability and longer-term impacts of donor withdrawal is increasingly important. We assess vaccination coverage and post-neonatal mortality to estimate country performance of these outcomes among countries that no longer received assistance from Gavi, the Vaccine Alliance (Gavi) between 2000 and 2018. Methods: Using data from all countries receiving Gavi support between 2000 and 2020, we employed a synthetic control method to generate a pre-transition counterfactual with the same characteristics as the observation of interest to predict a future that empirically never existed. The synthetic unit is constructed from the weighted average of other units with good fit to the unit of interest before transition but did not transition. Results: We found substantial heterogeneity after transitioning from Gavi assistance. China, Guyana, and Turkmenistan overperformed their expected coverage rates; Albania, Bhutan, China, Guyana, and Turkmenistan maintained coverage over 90%; and Bosnia and Herzegovina and Ukraine reported precipitous drop-offs that fell well below their synthetic controls. We also observed a vaccination coverage decline in 2020 for several countries after transitioning and most synthetic controls, which we attribute to COVID-19-related service disruptions. Conclusions: We recommend that Gavi adjust its transition model to systematically assess contextual externalities and risk. In addition, countries that no longer receive Gavi assistance can leverage technical assistance and communities of practice to mutually assist each other and other countries advancing toward transition. This could also foster intracountry accountability after transition. We also recommend that Gavi systematize post-transition assessments and evaluations that leverage the expertise and experience of graduated countries to encourage cross-learning.