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GAVI The
Global Alliance for Vaccines and Immunization
As the
Alliance enters its third year, Carol Bellamy, chair of the GAVI Board
and Executive Director of UNICEF, explains how the immunization
initiative is moving forward
CAROL Bellamy is a realist. She knows what
it takes to work against donor fatigue and political apathy. So when she
sets out her vision for protecting more children worldwide against
killer diseases through immunization, it is clear that she believes it
can – and will – happen. Despite the challenges.
Why? “Because it is hard to find a better story, a better real story,”
she says. Immunization works. “It is highly cost-effective and there is
an increasing understanding that it plays a very important role in
reducing child and infant mortality…. This is a positive development
story that can really shoot a hole in development fatigue.”
As Executive Director of the United Nations Children’s Fund, UNICEF, Ms
Bellamy is also currently the chair of the Board of the Global Alliance
for Vaccines and Immunization. Two years after GAVI’s launch, she is
pushing ahead towards its goals, as well ensuring that the Alliance
builds on what it has learnt so far.
By the end of the five-year commitments made by GAVI, she hopes, the
health ministries in the poorest countries will have built stronger
infrastructures for immunization than ever before. A broader array of
vaccines will be part of routine immunization everywhere. And a new
mechanism of international aid pioneered by the Alliance – awards that
are made according to results – will be seen as a success.
How far has the Alliance progressed towards these goals so far? It is
still early days, says Ms Bellamy, because the first deliveries of
vaccines to countries have only recently begun. But no one doubts that
the pace so far has been fast: 53 of the 74 eligible countries – those
with an income per head of less than US$1000 – have already been
approved for support from GAVI and the Vaccine Fund.
Just as important, she says, the world has been sent a strong message.
The initial gift of US$750 million from the Bill and Melinda Gates
Foundation to the Vaccine Fund was “a much needed financial infusion at
a time of increasing ‘aid drowsiness’”, says Ms Bellamy. The new
private-public partnership drew attention at the highest political level
to a very efficient health intervention and it has attracted substantial
further donations from seven industrialized countries. So far, over US$1
billion has been committed to the Fund.
But Ms Bellamy is under no illusions about the tasks ahead. A key
challenge is to harness more money. The Vaccine Fund puts the total cost
of achieving the Alliance’s five-year goals at around $2 billion, so
another $1billion is needed. But the climate is tougher than at the end
of the 1990s. “We are now dealing with a much tighter global economy,”
says Ms Bellamy. She believes the Alliance partners need to work hard
with countries to explore different mechanisms, including allocating
debt relief in the poorest countries towards immunization. “Hopefully
countries will see this as a good opportunity for investing some of
these funds,” says Ms Bellamy. With evidence of such commitment from the
countries themselves, even at modest levels, she hopes that traditional
donors may be willing to come up with new support.
But funding is not everything: a critical requirement for success is
the commitment of each government to improving its own immunization
system. “There really has to be a buy-in at country level,” says Ms
Bellamy. In her visits to Mozambique and Cambodia, where the first GAVI
vaccines were delivered last year, she saw this commitment at first
hand.
This is also where the new approach to funding pioneered by GAVI comes
in. Hoping to increase political buy-in, the Alliance and the Vaccine
Fund award countries money to strengthen their immunization systems on
the basis of performance. From each country’s point of view, there is
greater freedom than in most international aid programmes: the
government can decide exactly how it will use the money to improve its
performance. In return, the Alliance focuses on results: if a country
increases its coverage (the percentage of children fully immunized), it
gets more money. If it does not – and the figures are independently
audited – the funding stops.
The brand-new mechanism is being evaluated now, as a high priority,
says Ms Bellamy. Outside GAVI, too, the idea has attracted interest from
other international development initiatives. “I think this approach has
the potential to be emulated elsewhere,” says Ms Bellamy, although she
cautions that definitions of the “results” of any health-related
investment need to be carefully thought out.
What has the Alliance learnt so far that could change its approach?
First, says Ms Bellamy, there has been an important recognition that the
Alliance needs to support countries in strengthening their routine
immunization services, as well as helping them to increase the number of
vaccines they provide. Initially, GAVI was criticised for allocating
less than one-fifth of its spending from the Fund to strengthening
immunization services, while spending most of the money on under-used
vaccines. Today, five-year commitments for strengthening routine
services have increased markedly, to some $269 million, just over
one-third of the total; in addition, more than $11 million has been
allocated over three years to help countries increase injection safety.
“Strengthening routine immunization has a multiplier effect and helps
the strengthening of the health system as a whole,” says Ms Bellamy.
There are several other key questions that the Alliance must ask itself
as it moves into its third year. First, how to ensure a steady supply of
vaccines in a market with few players. In the first two years of the
Alliance’s work, demand from the countries for certain combination
vaccines has far exceeded the available supply and countries have been
asked to accept alternative presentations of the vaccines. UNICEF, which
procures vaccines on behalf of most of the governments and the Vaccine
Fund, must work with the industry to find ways of making the supply more
predictable, says Ms Bellamy. She also wants to streamline the
procurement system itself.
The role of the vaccine industry within the Alliance itself has
attracted some critics who say individual companies should not have
seats on the Board because of the potential conflict of interest. Ms
Bellamy responds that the goal of the partnership – increasing
children’s access to immunization – is probably brought closer overall
by having the industry directly involved.
At all times, Ms Bellamy makes clear that the ultimate goal is better
immunization, beyond the lifetime of the Alliance itself. “Immunization
existed before GAVI and it will continue after GAVI,” she says. While
the Alliance partners will need to keep convincing potential investors
of the value of immunization, she says, governments’ own commitment will
determine whether sustainable funds can always be mobilized.
Equally important, she says, it is vital that all players face up to
the fact that there are “real costs” in bringing a broader range of
vaccines to a greater number of the world’s children. Immunization
cannot be done well on the cheap. But its costs are still relatively
small, she says, compared with the enormous benefits that the increased
investment will bring. Arguing that case effectively is a key task for
GAVI. “Let’s make sure we make a difference.”
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