New Models for Vaccine Delivery:
An Interview with Tore Godal
When the Global Alliance for Vaccines and Immunizations
(GAVI)was founded in 2000, it pioneered a new model for
accelerating thedelivery of public health commodities to
developing countries.Specifically, the Alliance seeks to increase
coverage of basicchildhood immunizations in low-resource settings
that have longlagged behind in being able to provide these
vaccines, whichinclude combinations like measles-mumps-rubella
anddiptheria-tetanus-pertussis (DTP), and hepatitis B. Working
withthe Vaccine Fund, a sister organization which mobilizes the
fundsto buy and deliver vaccines rapidly, GAVI supports programs
in 60of the world’s 74 poorest countries. Two years after its
launch,it is the elder statesman in a global health arena now
alsopopulated by similar new models, such as the
Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM).
Tore Godal is GAVI’s Executive Secretary. A
Norwegian-bornimmunologist, he is former head of the UNDP/World
Bank/WHO SpecialProgramme for Research and Training in Tropical
Diseases (TDR),and has also served as the initiating project
manager for the Roll Back Malaria
Project and as special advisor to Gro Harlem
Brundtland,Director-General of the
World HealthOrganization. In this discussion with IAVI Report
SeniorWriter Emily Bass, he describes what GAVI has learned
aboutestablishing effective vaccination programs in
developingcountries and how these lessons could apply more
generally toprograms that might follow in its footsteps, including
the GFATMand future AIDS vaccine distribution schemes.
Vaccine-Preventable Child Deaths
1.7 million children die each year from
Haemophilus influenzae type b (Hib)
(1,750: over 1/2 of all reported cases)
30-40 million children in the developing world are
notcovered by routine vaccination
* Data from the World Health Organization (WHO),
theGlobal Alliance for Vaccines and Immunizations (GAVI)
andthe Measles Initiative
In 1999, GAVI laid out several concrete milestones. How have
youfared in terms of meeting these goals?
We have the same milestones that were set in 1999--for
example,that by the end of 2002, 80% of the poorest countries
withadequate delivery systems will introduce hepatitis BB vaccine,
andby 2005, 80% will have at least 80% coverage with
routineimmunizations in all districts. [Editor’s note: Countries
aredeemed to have adequate infrastructure if they already provide
atleast 50% DTP coverage.]
We are pretty much on target. So far, 40 out of 47 countries
withadequate infrastructure are in the process of
introducinghepatitis B vaccine--that’s just over 80%.
That must be very gratifying.
It looks promising, I must say. But I’m sure that some
countrieswill not perform as they have laid out in their proposal
and5-year plan, and then we will have to take action based on that.
We’re now entering the implementation phase—a rather exciting
partof the process, where we will assess performance and act on
How will that be done?
We have selected one global indicator: DTP coverage. We assess
this based on what we call a Data Quality Audit [conducted
byindependent consortia that include the auditing firms
PriceWaterhouse and Deloitte and Touche], a process of
conductingvisits at a country level to gather data from the
primary place ofimmunization upwards through the system. We visit
randomlyselected sites, usually four districts in a country and
six healthfacilities within each district. Then we compare these
data withwhat the country is reporting in terms of their
Are there specific elements or approaches that make a
GAVI-fundedprogram likely to succeed?
We put our emphasis on countries’ achieving specific milestonesand
then give them complete freedom as to how they accomplishthis.
They can use the money they get from us however they want.What is
interesting is that they have all decided to get moneydown to the
district level as quickly as possible, because that isthe only way
to get increased coverage.
What are some examples of specific countries or diseases
whereGAVI-funded programs have been particularly successful?
One example is Tanzania, which was very systematic in itsapproach.
They decided to take districts that were performingpoorly, but
where they thought something could be done about it.The GAVI money
went for per diems to the health workers and forbicycles and
petrol, so that health providers could do betteroutreach.
In Ghana, they decided to spend the money on computers for
healthfacilities, so they could improve their record system
andimplement performance incentives for high-performing sites. And
inKenya, they decided to transfer the money directly from
theMinister of Health to the district medical officer and to adopt
aperformance-based payment system that bypassed the
normalgovernment channels, where money tends to get stuck
betweenNairobi and the districts.
Where has GAVI not had as much impact as it hoped for?
There are countries such as Laos, where preliminary data
suggestthat there may not be much progress. But we haven’t yet
done theData Quality Audit for this year, so we don’t have the
Overall, we’re changing our focus. For the first two years, it
wasa matter of receiving proposals. Now we’re setting policies
forimplementation. We will get information from countries on how
theyare doing, and we’ll respond depending on whether they
aresuccessful or have problems reaching the targets they set
This is a different phase for GAVI, with different
requirements.For example, it requires tighter management to ensure
that GAVIgrants bring added value to the projects they fund, and
lessinclusiveness in terms of who is involved in policy
discussions.How does GAVI balance the need to move quickly against
the time ittakes to build buy-in and decision-making structures
When GAVI started, the general picture was that aid moved
veryslowly. We would hear about big numbers of available dollars,
butwe would never see them. I remember the Minister of Health
fromMozambique at a meeting saying, In 1988 we asked the World
Bankfor a loan to the health sector, but we did not get an
In contrast, GAVI and the Vaccine Fund were launched in
January2000, and some countries received a first installment of
financialsupport later that year. In April 2001 we introduced
hepatitis Bvaccine in the first country, Mozambique. It’s true
that we imposesome time constraints, but this is necessary to
avoid having theprocess become too elaborate. Political leaders in
the receivingcountries were very keen to get the funds, so they
pushed to getthe technical assistance needed to develop their
This year, a report on four GAVI-funded programs was published
bySave The Children UK and the London School for Hygiene
andTropical Medicine. One concern it raised was that Ghana
waspressured to accept a pentavalent vaccine [containing hepatitis
B,Haemophilis influenzae type B (Hib) and DTP] which was not
theproduct they requested in their grant.
This is a case of inaccurate reporting. Countries have
criticizedthat study for rushing in, collecting data and not
discussing themwith authorities. Ghana’s Minister of Health has
explained thatthe country had been considering the introduction of
hepatitis Band possibly Hib for years, and that this pentavalent
vaccine wasa deliberate choice on their part. He also said that
Ghana isprepared to take over funding of the program after five
years,when GAVI support comes to an end.
But we have seen some problems. Many countries say they
wantcombination vaccines containing five shots in one, so they
onlyneed to give one injection. This makes delivery much simpler.
Whenwe started, we thought that obtaining these combination
vaccineswas only a question of financing—that if we had the funds,
then wecould deliver.
This has not turned out to be true. There is a limited
productioncapacity for the different combination vaccines. So we
had to makedecisions about which types of vaccines were given to
differentcountries, and these were not always the combinations
thecountries wanted. This created frustration. Countries thought
theywould get something they couldn’t get.
The positive side is that industry has now responded by formingnew
kinds of consortia and increasing production capacity. Butthis
takes time. We will not see the increased capacity beforenext year
or, more likely, 2004-05.
What kinds of consortia? What specifically is happening?
I can give you one example. Chiron, a multinational
company,produces Hib. Then there is Green Cross in Korea, which
haspatents and licenses for hepatitis B, and BioPharma in
Indonesia,which makes DTP. They have formed a consortium to
produce apentavalent vaccine containing DTP plus Hep B plus Hib.
Isn’t thata marvelous collaboration?
It certainly is. Where will the vaccine be made?
I think at BioPharma, but it is not completely clear. It’spossible
that the vaccine will be produced in bulk in all threeplaces, and
one place will fill the vials.
This type of partnership could be relevant to AIDS vaccines,
forexample if a biotech company without production capacity
developeda vaccine. This biotech could line up with a fairly
sophisticatedproducer in the South that has a good manufacturing
facility butno R&D capacity.
The London School report also raised the concern that GAVI is
notproviding enough support to health infrastructure.
It is fair to say that the infrastructure in many countries ismore
dilapidated than we had anticipated. For example, to deliverthe
more advanced new vaccines, there is a clear need for moresupport
to secure the cold chain [reliable storage facilities andtransport
mechanisms for vaccines needing refrigeration]. Nowpartners are
now coming in with this support as part of thealliance. GAVI
cannot cover all infrastructure needs—ours is moreof a catalytic
role. So UNICEF is stepping up its support for coldchains, and
bilaterals like the Japanese Institute forInternational
Collaboration (JAICA) are also stepping up.
In general there is more focus on immunization-related
activities,I think, thanks to the establishment of GAVI.
What is the best constellation of stakeholders to start
In my mind, we haven’t fully resolved the issues of
capacitybuilding and operational research needs for an activity
like GAVI.When we start doing disease-burden studies relating
topneumococcal disease, to rotavirus disease, it will be
anopportunity to build more long-term capacity. We’re
stillpondering how to do this. One thing I would like to see is
morepartnering between academic institutions in the North and
How does the Vaccine Fund buy its vaccines?
The Vaccine Fund [VF] is contracted with UNICEF for
specialprocurements on behalf of GAVI and the VF. Because this
involvespurchasing large volumes of vaccines, we’ve halved the
price ofhepatitis B vaccine, for example.
One of the lessons we learned is that if you can make
multi-yearcommitments to industry, you are likely to get better
prices andservices. We will now move into a multi-year commitment
toproduction. This means that if there is shortage of a
vaccine,[the purchaser] is guaranteed to get whatever cut of the
availablesupply was paid for—the industry partner cannot go and
sell thevaccine to somebody else who is willing to pay more.
How are vaccine prices negotiated?
It’s an open, competitive process among the manufacturers.
Is the process different for new vaccines which have not
yetrecouped development costs?
The process is similar, although the prices would be
higher.Whether this will stay the same in the future or not is a
topicfor more discussion among the manufacturers and purchasers.
What practical advice do you have for AIDS vaccine stakeholderswho
are thinking ahead to possible procurement schemes?
You need to define the specific countries for which your
reducedprice procurement is valid. We have defined it as the
world’spoorest countries, and we then say to industry, ‘We are not
goingto interfere with the prices of this vaccine in middle or
higherincome countries.’ We are not trying to set a price standard
forthese other markets—we’ve explicitly agreed to segmented
marketsat different prices.
How do you think a future AIDS vaccine be financed?
The Vaccine Fund is seen by donors as the global
commodityfinancing mechanism for vaccines. We have learned from
vaccineprocurement so far that it is advantageous to have a
singlemechanism for securing the desired products at the best
prices ina timely fashion.
Will GAVI play a role in distributing an AIDS vaccine?
We see the most strategic role for GAVI as preparing the groundfor
a future AIDS vaccine. Countries need to strengthen theirhealth
systems today to ensure rapid delivery of an AIDS vaccineas soon
as one becomes available. And the global community needsto be
convinced of the high value of vaccines in general, so theywill
commit the necessary resources for development and
eventualpurchase of an AIDS vaccine.
Finally, GAVI is focused on the development and introduction ofnew
technologies that will improve access to vaccines—such asreduced
reliance on the cold chain and, ultimately, eliminatingthe use of
Are there efforts underway to help countries make plans for
howthey will sustain GAVI-funded vaccination programs after
theirfive-year grant ends?
After five years GAVI and the VF would like to move on to
financenew vaccines that come on the horizon, including an AIDS
vaccine.So it is important that countries take on the financing
for basicvaccines now covered by GAVI. We have guidelines for
countries onhow to develop sustainability plans.
One thing we try to do is to link countries’ immunization
needsinto broader initiatives like poverty reduction strategies.
Forexample, in Tanzania, the budget for immunization is being
tripledover the next 2 years, thanks to a link with a poverty
reductionstrategy that includes immunization coverage as an
Have there been changes for GAVI since 9/11, for example, in
thearguments you make, or the questions you need to answer?
Yes, 9/11 has meant some changes for the vaccine field. One isthat
there is now development of vaccines against bioterror. Thiscan
threaten some of the capacity for producing routine vaccines.I
think it is only limited competition, but it has been flagged asa
The second point is that eradication goals have been weakened.
Ithink the possible reintroduction of smallpox vaccination
willinfluence decision-making, for example about polio—there
areincreasingly arguments that we should continue to vaccinate,
evenafter polio has been eradicated—or about whether we should go
On the other hand, all this opens up new opportunities
fortechnology development, and for the delivery of vaccines.
GAVI is working on two projects that will create resources for
thefield--an immunization financing database and a ‘Lessons
Learned’study. Can you describe these projects?
The idea behind the Lessons Learned study is that we want togather
the lessons from each individual step. For example, we wantto
learn from the first procurement round so we can do better inthe
next round, which is coming up next year.
The Lessons Learned study also provides more detailed
informationabout the vaccine industry, including earnings,
markets, andactivities of producers in the North and South. We had
only astudy from 1993 to build on. So it was important to get
The immunization financing database will be an important guide
towhat we can ask in terms of country-level and
internationalsupport for immunization programs. And it will be
helpful to showhow we fare in relation to mobilizing general
support forimmunization services.
How is GAVI working with the Global Fund to Fight
AIDS,Tuberculosis and Malaria?
We have been participating closely in the development of theGlobal
Fund, though not everything we proposed has taken hold.
We suggested that it would be good to have a defined number
ofcountries. But that was not accepted. Another suggestion was
tohave clearly defined criteria as a baseline against which
tomeasure progress. And we proposed that there be a short list
ofbasic indicators like those developed by other programs, such
asUNAIDS, Roll Back Malaria or StopTB. That was not approved
either.I think this will be a challenge to the Fund—they want to
beperformance-based, but they didn’t make the hard decisions
neededto actually make it performance-based. But with Richard
Feachem onboard [as the Fund’s new head], I’m sure things will
How important is political will in the work that GAVI does?
One of the gratifying things about the whole process has been
thepolitical commitment, both in the North and in
developingcountries. It’s amazing. Vaccines are now seen as
something likewater and sanitation they should be available to
Copyright 2002 International AIDS Vaccine Initiative