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GAVI Update

Fifth GAVI Board Meeting, 21-22 June 2001, London, England


From the Department for International Development Fifth GAVI Board Meeting: Global Alliance for Vaccines and Immunisation – 21 June 2001

Clare Short, MP, Secretary of State for International Development

I want to make some remarks about GAVI and the remarkable lessons it teaches, and some of the lessons it teaches us about the proposed Global Health Fund. I am optimistic that we can get that right, but there are dangers that we do not get it right. If we build on what we have learned from GAVI, and we are all determined to do that, we are more likely to get it right.

I. Poverty and Ill-Health

It was in Lancaster House in London where we had that conference a couple of years ago, looking at the interaction between poverty and ill-health. We have all understood that human beings want healthcare and good health systems in order to have a better life. There was a prevailing presumption that countries needed to develop, and that as they got more resources they could afford better healthcare for their people. This was a shift in analysis that we all clarified for ourselves at the London conference, with the massive interaction between being trapped in poverty and ill-health. If you do not do something to provide people with better healthcare, they will not escape. As you know, the figures show clearly that the poor of the world struggle and work hard, harder than any of us. They often lift themselves up by their own efforts, but ill-health constantly throws them back: either the ill-health of the breadwinner, or of a child. Then a family will borrow and mortgage itself in order to get drugs or treatment. It is often very bad treatment, poor and inappropriate drugs, which throws the whole family back into poverty. Of course, good healthcare is good for people, but we have to do more to provide it and enable people to climb up and improve their lives and develop the economies of their country. It is not something that comes afterwards; it has got to come at the beginning to enable people to move forward. That was the thing that we really clarified at that conference. It is very important that we remember it clearly.

In an ancient place like this, such as the UK is littered with, it is good to remember history. When you read about the industrial revolution in this country, it began in the city that I come from and represent part of in the House of Commons, Birmingham, with the squalor and poverty, the child labour, the disease, all the things you can read about that inspired Dickens, and lots of anger. For a fifth of humanity, those are the conditions that still prevail in their lives. After all the wealth that has been generated, and technology and knowledge that we have, one in five of humanity is still living in conditions of poverty. As we have more knowledge, capital and technology, it is more unforgivable that it continues. Humanity has a capacity now that if we could put our resources together and have enough determination and united will, we could see over the next 20 or 30 years systematic improvement in poverty reduction, and the removal of that condition of abject poverty from the human condition, just as it has been removed from a country like this where it used to prevail.

II. Progress in Development

For too long in development we have been satisfied with one-off initiatives, gestures and doing some good. To make the systematic progress that is required, we have to be always looking to get all our initiatives to scale, to reach all and to be sustainable. This is a bigger challenge than some of the old efforts just do some good and have some good projects that we might fund here and there in the world. This requires us to collaborate in the international system in a way in which we have not before. Different countries, agencies and UN agencies have all gone out to do a bit of good here and there to the best they could. If we really mean to reach everyone in the world and get interventions that are sustainable, to get to scale and reach everybody, we have to group our resources in a way that we have not previously. It is a challenge to new ways of working. In all our government systems, in the international system and in the UN system, we see all the bureaucratic petty jealousies that mean we are less effective in our operations than we could be. It is our duty to be effective in order to give all those 1.2 billion of our fellow citizens some decent opportunities in life. My view on countries like my own, and public opinion, and the willingness to provide increased levels of ODA, is that we will win increasingly public support for these efforts as what we achieve is more effective and as people see that we know what we are doing, that we are spending the money well, that we are bringing about sustainable change and so on.

III. Responsibility

We carried out a survey after we formed our government just over four years ago in the UK. We won the election on a commitment to increase our work on development and our spending on development assistance. We then tried to get a baseline survey of public opinion to make sure we brought it with us. We asked the British public what they thought about aid, and they said it was a complete waste of time and money, and it all goes into corruption – a shocking, worrying result. However, we went on and said, ‘what do you think of these international development targets and the commitment to getting every child in the world into primary education, reducing infant, child and maternal mortality, and giving people access to reproductive healthcare?’ They said, ‘excellent; do it.’ That was really important learning for us: that is was not a lack of generosity of heart, it was not that people did not want to see their fellow human beings across the world having a decent chance in life, but that they had become cynical about the old procedures, and they wanted some new clarity and determination about achievement and objectives. This is the challenge of these times: we have more capacity, knowledge and capital technology that we have ever had, can we rise to it and collaborate to make all our systems more effective? Can we achieve more to keep our public opinions with us, moving the world forward in a way that is the most noble and morally important thing for humanity to do? If we fail, the catastrophes that are going to come and bite everyone, wherever they live, are going to be terribly serious for humanity in a 30-year timescale.

We have a fantastic opportunity and an enormous responsibility. Making progress in healthcare for the poor of the world is key to giving them the chance to develop their lives and gain the benefits of learning, knowledge, and technology that globalisation is making available in greater abundance for the world.

IV. GAVI’s Role

In this effort to have a step change in the way we work and the way we collaborate in our ambition and effectiveness, GAVI is a very optimistic new baby. It shows all the signs of a new way of working: much more flexible, lighter in its bureaucracy, inclusive, willing to be open and learn, not being bureaucratic and slow and ponderous, using resources effectively, seeking to work in partnership and bring people together, and not having prima donna issues. This is all enormously important. It is important the GAVI goes on and builds on that and does better, and that we learn from the best of GAVI in the launch of this proposed Global Health Fund. I want to make a few remarks about the interface between the two, and the lessons we can learn.

GAVI has led the way in a willingness to work with a diversity of partners, public, private, multilateral and NGO; an aspiration and reality of swiftness of action; the openness to suggestions and new ideas; a responsiveness to the concerns of partners and agencies in developing countries rather than the arrogance that can sometimes come from the centre; and a willingness to be flexible in response. These things are admirable, and you are all to be congratulated. They need to be held onto, as often new organisations are flexible and then we all get sclerotic as we go on.

GAVI is good, but must never be complacent, and some of these qualities must be maintained and driven forward. On the Vaccine Fund, of course, it is my view that we could have, after the UNGASS that is coming up on HIV/AIDS and the G7, a fund for commodities and organisations to get better treatment of HIV/AIDS, malaria and TB. This could leverage further improvements in the way that GAVI has trailed. On the other hand, we could have a series of bureaucratic conflicts, the thing collapses and we do not really get it. We must make sure we get the good outcome, and that we do not have people trying to play games in order to make announcements.

V. Resources

International development is full of ponderous conferences, with lots of bureaucratic preparation, the launch of funds that are a gesture for the media – and then we move on. For example, not that long ago we had the conference in Dakar delivering the 2015 target to have every single child in the world in primary education. There was big pressure for a fund. The next year there might be a pressure for a health fund, the next year it is a forest fund, and the next a desert fund. Everyone pretends it is new money, but really it is the same old ODA, and it is a shrinking pile. Someone sets up these bureaucratic funds and there is a great dance of international meetings. Little bits of good are done, but it is not real, sustainable change country by country.

We have to make sure we have proposals for a fund here that can leverage the kind of change that is needed to bring in better drugs, encourage research, get the commodities and encourage countries to put in place the basic healthcare systems and delivery mechanisms that are absolutely key. Otherwise, it does not matter how cheap the drugs are, the bulk of the poor will not receive them. We have to make sure that both GAVI continues in that spirit, and that the new Health Fund is structured in that kind of way. The structure and governance needs to be inclusive but light and non-bureaucratic, the secretariat light and effective, both for GAVI and the new Global Health Fund. We have to always be looking for sustainability.

We know that ODA and very generous donations like that of the Gates Foundation – and I was just thinking, that if one of the most successful businessmen in the world is willing to support an initiative it must be good; I was thinking ‘yes, and if his father agrees it must be even better,’ as the person who gave birth to the man. I think it is a delight that not only the funding is there, but your personal engagement and commitment, and what you said about the kind of satisfaction of working in areas of this kind of importance, and some of the idealism you meet, is very nice to hear.

The big additional resources that in the end have to be there to get scale and sustainability are out of the economies, revenue systems and improved organisation of the countries themselves. The ODA and the other donations are leverage to build up the systems. You can only get sustainability if countries can be helped to have the expertise to grow their economy and get the efficiency into their health departments and the training of their own people. This means you really have got sustainability, and that the economy itself can continue to provide a decent service for their people. This is what we are always looking for, so if GAVI and the Global Health Fund can help to leverage that kind of change, that is wonderful, but unless we have leveraged that kind of change everywhere, we have not got sustainability or scale, and we are not reaching everyone. Those are very big objectives and we must hold onto them.

VI. Markets

Clearly, GAVI has taught some very important lessons about commodity markets and price. We all know that there is a real problem in the world’s pharmaceutical industry, which is overwhelmingly in private hands with some of the best brains in science in the world. It is driven largely by where the markets are. Even in a country like India, where a third of the poor of the world live and which now has a very large pharmaceutical industry, only 10% of its research is done for the diseases of poverty. The poor do not generate a market, and therefore cannot buy products without some intervention.

Clearly, in these globalising times we need to look at the world and see what the public sector can bring. We need to get some sort of order and structure into our global arrangement, and to use the science, technology and capacity of the private sector to make the kind of partnerships and interventions that make sure the drugs are delivered to the poor of the world, and the research is being done. GAVI is trailing big enough orders that begin to make the pharmaceutical companies of all kinds bring down the price and bring reliability of supply. They see that the orders are going to be there and hopefully, as we go on, leverage the research that is not being done to produce the products that the poor of the world need to have better health. That is the promise we have here, and it is fantastically important. If we can build on what GAVI has achieved in this direction and go onto drugs on a bigger scale for malaria, TB, HIV and so on by the way we structure the Vaccine Fund, that will be a very big prize. We are starting to get a world then that looks at the needs of its people and its capacity, public and private sectors together, to deliver an outcome for everybody. We are on the brink of being able to think in that way, of managing the whole world and its people in a way that in the past we have not been able to do. We must build on that.

VII. Additionality and Partnership

I have made the point that everybody pretends these new initiatives are additional funds, but whenever ODA is being committed, i t is not additional. The money would have gone into some other ODA spending, unless we can get enough effectiveness into the system that our public will vote for growing budgets – and I do believe these things are linked. Every time we set up a new initiative, it is a duty not just that it funds itself, but that it brings improved performance into the whole system. Then we have real additionality, and the improved capacity of developing countries themselves that I have always talked about.

This is why the spirit of partnership is so crucial. Partnership is not just a good word, although it is a good word, describing the fundamental equality and mutual respect you need to share knowledge and do good development work. It is no good experts from countries with much more capacity, training and skilled human resources rushing in and telling developing countries what to do. They also have to be able to listen well enough to where the blockages and problems are and share the knowledge and investment, training and skills that enable the partner country to take on that knowledge and apply it.

This spirit of partnership is absolutely crucial to effectiveness. I am told that GAVI has to watch for this, as there is such efficiency in the organisation, and such enthusiasm, there is a danger that the patience to listen and learn back, and hear from the partners what the blockages are and why something did not work disappears. There is always a danger there that we do not listen and we do not get it completely right.

VIII. Outputs

We must measure performance, and be clearer about outputs. I have no doubt about that. The whole world of development since the Second World War has been obsessed with inputs and how much was spent, with far too little stress on what was being achieved, measuring progress, learning from success and from failure and adjusting what we do, too much gesture spending and people boasting about what they are spending, rather than what they are achieving.

We must – and GAVI is – make sure that the new Global Fund looks to an output-based system. We must be careful that the targets do not make us have numerical incentives, and that we do not only supply to those who are easiest to reach. We need outputs, but of course the poorest and the people living in the most remote communities and the people with the greatest difficulties are going to be more difficult to reach. If we just go with numerical targets and do not somehow take account of that it could distort what we do. I say this as someone who is dedicated to getting the international system to work on output-driven targets, so it is a mea culpa too, and we all must keep both these things in mind: reach the people with the greatest difficulties, but also measure our progress and success, and learn from errors and success.

IX. Challenges

The is the biggest challenge of all is that we need global efforts, where we come together in partnership and create a new energy and a new enthusiasm, but we have to leverage the building of basic healthcare systems that reaches everybody in a sustainable way, in the poorest countries where they do not exist at the moment. We know that in the poorest countries, the poor are spending more on their healthcare – often more than much better off people – totally ineffectively on poor treatments and bad drugs. They are spending enormous proportions of their very low income on very poor quality healthcare. If we could only break through this, we could get an enormous improvement and use some of the resources that they are already putting in.

It is easier to talk and think about this than to do it in practice. I know GAVI has in its structure – and we have to get it into the Global Health Fund – the back up and technical capacity to help countries deliver not just the immunisation systematically, which is the beginning of looking for system-wide improvements, but also to build basic healthcare systems that can provide all the things that people need. If we can get the two structures working side by side, leveraging that sort of roll forward of improvement, that really will be a very important opportunity. It is there on the tips of our fingers, if we can get both these things right.

X. Conclusion

I am delighted to be joining the GAVI board for the reasons I gave last night and this morning: you have been pioneers. There is something very creative and important going on here. GAVI is also new and pioneering and we have to make sure that spirit is maintained, all its ambitions are delivered, that we get the same spirit into the Global Health Fund and the collaboration between the two, and that we do not waste and duplicate resources. I commit my department and the UK government, as a member of the Board, to do its very best to ensure that GAVI never ceases to be a learning organisation, and that the lessons from GAVI are widely shared for the benefits of all. We are planning a multiyear donation, but I have to manage my money properly, and I am not, unfortunately, announcing it this morning. We will, I promise.


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