From aid dependence to domestic ownership: Risks, challenges, and policy pathways for sustaining immunisation gains in lower-income countries.

Objective: Lower-income countries are increasingly expected to finance immunisation programmes as global health financing shifts from donor support to domestic ownership, in line with Immunization Agenda 2030 (IA2030). While rising domestic investment signals progress, concerns remain regarding whether countries have sufficient fiscal space and institutional capacity to sustain immunization gains independently. Methods: This commentary synthesizes published evidence from Gavi-supported and transitioning lower-income countries using literature available through April 2026 to evaluate financial, economic, and health system factors influencing the sustainability of immunization programmes. Results: Three interlocking risks are identified: limited fiscal space, rising vaccine and delivery costs, and macroeconomic instability linked to overlapping aid transitions. Persistent institutional weaknesses in procurement, budgeting, regulatory systems, and supply chain management further threaten sustainability. Evidence from past transitions shows mixed outcomes, with success associated with early financial planning, strong prioritisation of immunisation, and integration into national health systems. Conclusions: Although increased domestic investment is essential for country ownership, many lower-income countries are not yet fully prepared to sustain immunisation gains independently. A phased, risk-sensitive transition combining strengthened domestic financing with continued targeted global support is necessary to prevent reversals in coverage and equity.