Participation pathways in global vaccine partnerships and their implications for immunization systems: a comparative analysis of China and India in Gavi.

Background/objectives: As an increasing number of emerging economies move beyond a simple recipient role in global vaccine partnerships, their engagement with Gavi has become more diverse and institutionally layered. This study examined how different participation pathways in Gavi were associated with domestic immunization strengthening and roles in global vaccine procurement, using China and India as two comparable emerging economies with contrasting modes of engagement. Methods: A long-term qualitative comparative case study was conducted for 2000-2025 using a most-similar systems design. The analysis combined process tracing and structured cross-case comparison. Evidence was triangulated from institutional documents and public databases, Gavi and WHO materials, corporate disclosures and partnership records, peer-reviewed studies, and semi-structured interviews conducted between 2019 and 2025. The materials were manually coded around role evolution, participation mechanisms, pathway orientation, and outcome mapping. Results: Two distinct participation pathways were identified. China followed a state-coordinated pathway in which Gavi-related engagement was linked more closely to domestic system development, policy alignment, and selective donor-oriented repositioning. Corporate participation was limited and episodic, with the most visible expansion occurring during the COVID-19 period under government coordination. India followed a market-integrated pathway, characterized by sustained manufacturer participation in UNICEF-Gavi pooled procurement. This pathway was supported by WHO-prequalified products, technology-transfer arrangements, large-scale production, and cost competitiveness. The comparison suggests that China's engagement was more closely associated with domestic system consolidation, whereas India's engagement was associated with a stronger position in global vaccine supply but coexisted with more uneven domestic immunization-system outcomes. Conclusion: Emerging economies do not engage with Gavi through a single pathway, and these differences have important public health implications. For major Southern vaccine-producing countries, public health policy may need to better sequence global engagement with domestic system strengthening: first improving delivery, cold-chain, workforce, surveillance, and information systems; then upgrading regulatory capacity and WHO prequalification readiness; and finally linking industrial upgrading and procurement participation to equitable vaccine access.