The global locus of undervaccination is increasingly shifting from the poorest countries in the world—which are eligible for support from Gavi, the Vaccine Alliance (Gavi)—to middle-income countries (MICs) that do not qualify for traditional Gavi support. Given these growing challenges, Gavi must rethink its engagement with those MICs that are ineligible for traditional support. Although this engagement is intended to be “catalytic” and has been intentionally targeted to country needs, it also has been relatively small-scale and ad hoc. Gavi’s next five-year strategic period from 2026 to 2030, known as “Gavi 6.0,” offers a window of opportunity for its board and leadership to consider new and different ways for Gavi to engage with MICs to advance global vaccine access and improve vaccination outcomes. To have the greatest impact in this context, Gavi must lean into its comparative advantage in market shaping and demand consolidation to drive its contributions to global vaccination efforts with finite resources. We offer recommendations for Gavi to operationalize broader engagement with MICs, specifically by enabling an expanded cohort of MICs to access more affordable prices for both newer, costlier vaccines and future vaccines via opt-in framework agreements and by supporting a global coordinating hub to shape a forward-looking immunization innovation agenda.
