Dutch Ministry of Health, Welfare and Sport

Dear Ms. Hayes,

Thank you for your letter and the attached critical article on the Global Alliance for Vaccines and Immunization. During the 16 months that I have participated as GAVI Board member I have found both the GAVI Secretariat as well as the Board receptive to critical voices. Many of the issues identified by Anita Hardon have been topics for lengthy discussions in the GAVI Board--resulting most of the time in adaptions to policies and criteria. In her article Anita Hardon raises some critical issues, however the article also contains some untested assumptions and misconceptions that are unfortunate.

As you will be aware Tore Godal, Executive Secretary of GAVI, has given a very detailed reaction to the article, to which I would like to refer. However, I would like to highlight some of the issues raised by Anita Hardon that I consider of specific relevance.

It is essential to be absolutely clear that the Global Fund and GAVI were NOT created when the Bill and Melinda Gates Foundation made a US$750 million donation for the immunization cause. The discussions leading to the creation of GAVI started in March 1998 after a call by Worldbank President Wolfensohn to the international community to address the obvious deterioration of immunization programmes as well as the market failure to deliver more recently developed vaccines to countries that would need them most. Consequently a number of regional consultations were organized and finalized with a meeting in Bellagio, Italy, in March 1999. This process resulted in a proto board meeting in July 1999 and finally the official launch of GAVI in January 2000. It was during the launch that the Bill and Melinda Gates Foundation announced their contribution of US$750 million.

The balance between applications for new and underutilized vaccines vis-a-vis applications for strengthening immunization services has been discussed several times in the GAVI-Board, and I am confident that the proposed measures that have been taken to tackle this potential threat will be effective. I do not agree on the statement that GAVI reflects a general shift away from equity. Apart from the points mentioned by Tore Godal in his reaction, namely that an immunization coverage of over 80% in all districts is an explicit GAVI-milestone, I was somewhat surprised by the tone of the discussion. Statements like "By introducing a hepatitis B vaccination in these countries, children who are already being immunized with the traditional EPI vaccines will be protected against yet another disease" seem to imply that this is a bad thing to do. Given the fact that we are talking about poor countries and a proven cost-effective protection against an important cause of morbidity and mortality, this could hardly be the case. I would prefer addressing the equity issue by simultaneously improving coverage as well as introducing new vaccines. Withholding cost effective health interventions to all might be seen as promoting an equity perspective, however I'd rather look at this from a less cynical angle.

The balance between commercial interests of the private sector and public health interests have featured prominently as a topic of discussion during the GAVI Board meetings and within the various task forces. I can assure you that many critical questions have been asked regarding this balance, not in the least by myself and I can tell you that all Board members were anxiously waiting the results of the first tendering procedure. Apart from the fact that prices were much lower than expected, it was a pleasant surprise to see that producers in lower and middle-income countries (South Korea, India and Indonesia) got six 6 out of eight contracts. Skeptics had expected that multinational companies would have been the winners, which proved not to be the case.

Finally, about the Board's chairs. Already at an early stage, at the Bellagio meeting in March 1999, it was decided that the chair would rotate among the heads of WHO, UNICEF and Worldbank. It is indeed true that Carol Bellamy, Executive Director of UNICEF, will succeed Gro Brundtland, Director General of WHO, as chair, who in turn will be followed by the President of the Worldbank, whereafter the Director General of WHO is supposed to take over again. In my opinion there is absolutely no lack of clarity whatsoever, as is suggested in the article.

Yours sincerely,

E. Borst-Eilers MD PhD
Minister of Health, Welfare and Sport