GiveWell started supporting vaccines in 2015 and has made over $160 million in vaccine-related grants to date. With strong results from past work in this space, we’re now exploring how to reach more people with vaccines in low- and middle-income countries. This post discusses our current thinking on vaccines grantmaking and our key hypotheses about where to focus our efforts going forward.

Where are we now?

Before this year, our grants for vaccine programs focused on (a) increasing uptake of the vaccines given to children in the first two years of life, and (b) speeding up the rollout of malaria vaccines.

Relative to other global health approaches, vaccines garner a lot of attention. Governments in high-income countries contribute to Gavi, the Vaccine Alliance, which heavily subsidizes the purchasing of vaccines in the world’s poorest countries and provides cash assistance to help these countries deliver them. The Gates Foundation is also a major contributor to vaccine programs. These efforts have been fairly successful—in 2022, 81% of children in the 57 low-income countries supported by Gavi had received the DTP3 vaccine, which protects against diphtheria, tetanus, and pertussis (DTP3 coverage is often used as a benchmark for progress on vaccination).

This provides both a challenge and an opportunity for finding cost-effective giving opportunities. On the one hand, thankfully, the people who are easiest to reach with vaccines are already being reached, which means more expensive or innovative methods are needed to expand coverage. On the other hand, we can build on the extensive knowledge and infrastructure that already exists.

We’re pretty unsure how those factors will balance out and whether we’ll find many funding opportunities above our cost-effectiveness threshold (i.e., that are competitive with the cost-effectiveness of grants we’re making in areas such as malaria, nutrition, and water). But we think it’s worth exploring the space more deeply than we have in the past because the basic case for vaccines is strong, and we’ve identified a few highly cost-effective funding opportunities (e.g., New Incentives in Nigeria, IRD’s vaccination incentives and reminders in Pakistan), which suggests there may be others.

What’s next?

We aim for our work to be a constantly evolving set of hypotheses, rather than a set strategy. One of the main ways we’ll test and change our hypotheses is through making grants and learning from them over time.

Hypothesis 1: Focus on young children

Our primary hypothesis is that, within vaccine programs, many of the most cost-effective opportunities involve increasing the number of vaccines delivered to children under the age of two. This includes vaccines for tuberculosis, diphtheria, tetanus, pertussis, measles, pneumococcal pneumonia, diarrhea-causing rotavirus, malaria, and several others.

Children under two years old are a particularly vulnerable group for which there are many opportunities to deliver a set of interventions as a bundle. There are large benefits (because this age group has high mortality rates) at modest cost (because delivery costs can be reduced through bundling). The bundles include multiple vaccines delivered at the same time, and could also include other useful services, such as oral rehydration solution and zinc to treat diarrhea, vitamin A supplementation, breastfeeding promotion, and malnutrition screening and treatment.

Hypothesis 2: Focus on making vaccination easier

A related hypothesis is that, for the most part, caregivers who are not currently vaccinating their children fully would choose to do so if it were easier. We hypothesize that strongly held objections to vaccination play a much smaller role.

Some of the interventions we’re particularly interested in learning more about are:

• More/better outreach services. In places with low vaccination coverage, sending vaccinators to communities, rather than relying on parents and children coming to health facilities, may be an effective strategy for increasing vaccination rates.
• Demand incentives. Evidence indicates that giving parents small amounts of cash if they vaccinate their children can increase vaccination rates. We’ve funded two demand incentive programs to date: New Incentives provides small cash stipends, along with support to the public vaccination system, in northern Nigeria; and IRD provides small mobile cash stipends in Pakistan.
• Reminders by phone. The vaccine schedule for young children involves several visits at irregular intervals, and sending reminders by SMS has been shown to increase vaccine uptake. We’ve funded two reminder programs to date: Suvita in India, and another IRD program in Pakistan.
• Adding additional interventions when vaccines are delivered. This year, we’ve funded a study adding the distribution of oral rehydration solution and zinc to treat diarrhea and chlorine to treat drinking water to vaccine delivery, and we’ve also supported work by New Incentives to screen for malnutrition during vaccination visits.
• Reducing shortages of vaccine stocks. Vaccine uptake will likely be higher if caregivers are more confident that vaccines will be in stock when they bring their children to be vaccinated.

Hypothesis 3: Make exceptions to hypothesis 1 for diseases with very high numbers of deaths

Human papillomavirus (HPV) vaccines are the main exception to our focus on young children. In low- and middle-income countries, HPV vaccines are typically given to adolescent girls, ages 9 to 14. HPV vaccines are very effective at preventing cervical cancer, which kills about 350,000 each year. In 2020, we wrote that cost-effectiveness was potentially high but vaccine supply was a limiting factor; the supply has now expanded, and we are looking into possibilities for strengthening HPV delivery. However, HPV vaccines are a priority for the Gates Foundation and Gavi, so we’re not yet sure if we will have a useful role to play.

Looking ahead, there may be a window of opportunity over the next few years to support the development and deployment of tuberculosis vaccines for adolescents. Tuberculosis kills more people each year than malaria. There are multiple vaccine candidates being tested.

Hypothesis 4: Investigate funding outside of Gavi’s remit

Gavi’s remit in vaccination for low-income countries is quite broad, so we think this is a less promising hypothesis to pursue than the three above, but we’re open to working on:

• Funding research, spanning from “upstream” work in vaccine development (which Open Philanthropy has funded and continues to believe is highly promising) and efficacy trials (as we did for combining malaria vaccines with another malaria program) to “downstream” work in testing different approaches for improving access to vaccination services (as we did for New Incentives)
• Funding advisors to aid ministries of health with the many-step process for introducing new vaccines to a country (as we have for malaria vaccines)
• Market shaping (e.g., supporting new low-cost suppliers and supporting Gavi and countries to switch to those suppliers)

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Our team’s hypotheses will guide us in identifying and funding cost-effective interventions to increase vaccination rates for children under two and target more high-mortality diseases through vaccines. By continuously testing and refining our hypotheses as we deepen our vaccines portfolio, we believe these programs will expand access and provide life-saving vaccines to some of the world’s most vulnerable populations.

If you work on vaccine research or distribution in low- and middle-income countries, particularly if you have suggestions for ways to test the hypotheses above or things we are missing, we’d love to hear from you. Email us at info@givewell.org.