Children in middle-income countries not eligible for support by Gavi, the Vaccine Alliance, are not receiving the immunization protection they need. Each year, 66 million children, half of all children globally, are born in these countries. Of these, 25% are not getting all the vaccines they need. By reaching 90% coverage of vaccines targeted by the Immunization Agenda 2030 (IA2030), tens of thousands of lives could be saved annually, and children’s health improved, in these countries. This brief highlights immunization performance in middle-income countries, from 2019 to 2022, visualizing a selection of progress towards IA2030 Impact Goals and Strategic Priority indicators. The brief also reviews four bottlenecks slowing progress and highlights major initiatives supporting middle-income countries.