UPDATE - July 2003
The Vaccine Fund's challenge
GAVI's fundraising arm has made a good start, but there is a lot of work ahead
WHEN GAVI and its financing arm, the Vaccine Fund, were born in 2000, their launch generated excitement and media coverage across the world. The Vaccine Fund was a new concept, and the generous gift it received from the Bill & Melinda Gates Foundation was on a scale unprecedented in public health. Three and a half years later, the excitement has been maintained, but there is also a growing recognition that raising new money may be more challenging than many expected. The Vaccine Fund now faces a substantial gap between its current income and the amount it needs to deliver the Alliance's longer term vision.
The early successes of the Alliance have been achieved at a brisk pace. By mid-2003, GAVI and the Vaccine Fund had committed almost $1 billion to countries over five years, for the purchase of new vaccines and to support improvements in immunization services and safety (1). By the end of 2002, an additional 10 million children had been newly protected against hepatitis B virus. Eleven countries have now been approved to receive Hib vaccination by 2004, newly protecting some 4 million children. Immunization has been raised back up the political agenda. What is more, the approach pioneered by GAVI and the Vaccine Fund -- which gives countries maximum control over resources, stresses accountability and rewards good performance -- is now being adopted by others outside the immunization field, such as the Global Fund to fight AIDS, TB and Malaria.
"The challenge for the foreseeable future is to close a funding gap of $150 million a year"
But if the Alliance is to deliver sustained improvements in immunization, the Vaccine Fund needs to dramatically increase its annual income (2). It has enough to meet its current commitments but needs much more. Plans for the mid-term future are currently being explored with countries and the partners to agree priorities and cost them.
Since the initial gift of $750 million from the Bill & Melinda Gates Foundation in 2000, nine industrialized countries have committed another $350 million in total. However, the Fund's President and CEO, Jacques-François Martin, says he needs to raise $400 million each year to fulfil GAVI's broad plans.
Another way to look at this is to view the Fund's income in annual terms. So far, its annual income has been around $250 million -- with $150 million a year for five years from the original Gates Foundation gift, and about $100 million a year so far from governments. Alex Palacios, who joined the Vaccine Fund earlier this year from UNICEF to head up the resource mobilization effort, says the income achieved so far is impressive. "I think it is unusual for a start-up to produce as much as we have,'' he says. "But the Vaccine Fund's challenge for the foreseeable future is to close a gap of $150 million a year. We have to reach a level of $400 million a year if we are going to achieve what we set out to do.''
In the longer term, the funding gap is growing greater. From about 2007 the requirements will increase as new vaccines come on stream and by 2011, the Vaccine Fund will need to raise about $1 billion a year to enable the Alliance to achieve its goals. 2011 is not far away.
The size of the funding gap may come as a surprise to politicians who had been lulled into believing that the generous initial Gates gift would somehow last forever. Yet, as Palacios stresses, the $1.1 billion raised so far is "an important down-payment, not the full mortgage''. Immunization is one of the most cost-effective health interventions available, but it is not free. It costs about $30 to fully protect each child for life with the six "basic'' vaccines (DTP, measles, polio and BCG) and two under-used vaccines, Hepatitis B and Hib. And, each year in the low-income countries eligible for GAVI support, there are almost 90 million new infants to immunize.
Although a large part of the Vaccine Fund's money has been spent on buying newer vaccines, GAVI policy is to improve countries' broader immunization services in a sustainable way and, under the current plans of the Alliance, strengthening these services is a one of the key priorities for the longer term. The estimated requirements over the next few years include more money to increase coverage to 80%, in line with GAVI goals, to improve immunization safety and to build up the capacity of national immunization teams. Also on the tab is the cost of work to accelerate the development of additional vaccines against two major killers, rotavirus and pneumococcus.
Jacques-François Martin acknowledges that it has been more difficult than expected to find new donors to contribute. "I think it is clear that we all underestimated the difficulties that we would face when we started,'' he says. In general, the Vaccine Fund's mission is well received among potential donors, he says; few argue with the basic principle that immunization is a comparatively straightforward, cost-effective way to save lives. "But in order to translate sympathy into hard cash, we have to overcome some problems.'' One is the mistaken perception of some governments that the initial gift of the Gates Foundation was big enough to let everyone else relax. "We have not communicated clearly enough that Gates challenged the world to match this initial contribution,'' he says. Also, he says, some countries delayed contributing to the Fund, particularly in Europe, because they did not feel involved in the initial formation of the Alliance. Gradually, these attitudes are changing and there is an increased sense of ownership of the GAVI initiative, says Martin, but the process takes time. In the case of one industrialized country, representatives of nine different ministries and national political bodies held a total of more than 40 meetings with the Fund before the government agreed to commit money.
Since 2000, also, economic conditions have deteriorated, while other global health initiatives have been launched, some with a higher profile than GAVI and the Vaccine Fund. Everyone is competing for limited resources. "We need to increase our political visibility,'' says Martin.
We need to capitalise on our extraordinary start. We don't normally get such an opportunity
Palacios is upbeat. When I came here I was impressed by what has been achieved so far,'' he says. "I had expected that there would be much more initial groundbreaking to be done but the fact is, it has already been done. This organization has been in existence for only a bit over three years, and we have had to live with an extraordinary period in history.'' After the terrorist attacks of September 11, many people did not travel for months, reducing the opportunities to network. War, the threat of bioterrorist attack, and even the media obsession with severe acute respiratory syndrome (SARS) have kept children's immunization off the political radar for longer than expected. But now is the time to act. "We need to capitalize on our rather extraordinary start. We don't normally get such an opportunity.''
Several changes have been made. The staff of the Fund is to increase from just a dozen to about 20, with more individuals dedicated to full-time fundraising. And there will be an increased emphasis on communicating the achievements of countries supported by GAVI and the Fund, in order to attract new donors. Both Martin and Palacios believe that more sceptical donor governments need to see hard data that demonstrate the positive impact of the Alliance. Those data are starting to emerge. For example, says Palacios, Uganda has reportedly increased its immunization coverage by 10% in a year. "I believe that there are number of governments that have been taking a close look at the information we provide, and that they will soon join the mix,'' says Palacios.
He argues the case for immunization as a practicable way to help halve child deaths, as governments have pledged to do as part of the Millennium Development Goals. Thanks to the basic foundation laid by the Expanded Programme on Immunization, vaccines already save about 3 million lives a year. If existing vaccines reached more children, another 2 million lives could be saved. With the development of the newer vaccines against major killers such as rotavirus and pneumococcus, yet another 2 to 3 million lives could be saved. "That's half of the 10 million child deaths,'' says Palacios.
The Vaccine Fund is also exploring new types of donors. Palacios wants to build better relationships with nongovernmental organizations and advocacy groups. "For example, I think it is very important to make sure that Oxfam understands that this is an effort that they are also involved in.'' Martin also describes ideas for attracting new privatesector donors, and simple donation schemes that would strengthen solidarity between vaccine users in the rich countries and their peers in poorer countries.
In the longer term, more innovative financing mechanisms are being explored. One idea is that the Fund could "buy down'' loans made to a country by the International Development Association (IDA), the World Bank's softloan arm, on completion of a specific immunization goal. Because the loans are effectively zero interest, each $1 spent would unlock at least $2.50, maximizing the efficiency of donor support. This approach has already been used to pay for polio vaccine (3). Martin says the Vaccine Fund is also exploring various mechanisms involving the financial markets, and the options for the Fund itself to borrow money. "But it is very early days,'' he says.
The Fund's aim has always been to catalyse funding from other sources, and GAVI's policy is to encourage governments and their partners to take over responsibility for financing their own immunization services at the end of the Fund's support. But, says Martin, the Fund's support for specific activities will not stop suddenly; rather, it will be tailed off gradually over several years. By the time this happens, new sources of funding for immunization must be in place: the challenge is to build close partnerships with those new sources now.
- See http://www.vaccinealliance.org/home/Support_to_ Country/Country_Status/index.php
- Vaccine Fund Strategic Plan 20022006. Available from the Vaccine Fund www.vaccinefund.org
- World Bank news release April 29 2003 (2003/304/S) at www.worldbank.org
Immunization Focus July 2003 - Contents