While countries with soaring cervical cancer rates would dearly love to offer citizens the HPV vaccine, their governments struggle most to afford it. In the poorest parts of the world, shortages, dosage costs, and barriers to distribution and delivery have made HPV vaccine access like winning a “life lottery” – garnering them no more than 13 percent of the global share. Despite the efforts of nonprofit agencies like Gavi – a vaccine-funding provider for the world’s poorest countries – this potent source of prevention remains elusive for “caught-in-the-middle” nations deemed above the funding cut-off. No such shortage exists in the United States, which pays $160 USD a dose and recently expanded vaccine eligibility in females up to forty-five, despite peak efficacy in teen girls. Market forces perpetuate the battle for this precious resource, even though widespread screening and pre-cancer treatment won’t be enough to stop the disease. In the absence of widespread HPV vaccination, global cervical cancer elimination remains a distant hope.

Chapter 5 presents the book’s second comparative case study, which examines four major global health agencies: the World Health Organization (WHO); the Joint United Nations Programme on HIV/AIDS (UNAIDS); Gavi, the Vaccine Alliance; and the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM). The structure of the examination is analogous to Chapter 4’s. After enumerating the characteristics on which the four institutions are matched, I chronicle how differences in their de facto policy autonomy have given rise to disparate performance outcomes: The WHO and UNAIDS have been characterized by relentlessly declining autonomy and performance over their life cycles, Gavi and GFATM by the opposite trends. I then delve into the operational origins of these differences, which, once again, defy a purely design-based explanation. Like Chapter 4, the case study draws on extensive interviews and archival material.