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
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. GAVIs 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.
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.
Clearly, GAVI has taught some very important
lessons about commodity markets and price. We all know that there
is a real problem in the worlds 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, it
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.
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.
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.
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.