The Author’s Response

HAI very much welcomes the responses to its concerns about GAVI - from Tore Godal in his capacity as Secretary of GAVI,  Minister Els Borst-Eilers  (GAVI Board member) and  from James Lovelace (World Bank), to add to many informal responses received from concerned policy makers and international health experts.

The GAVI responses clarify some issues, such as explaining the origins of GAVI, and they reiterate GAVI’s equity objectives. They also point to areas where GAVI shares our concerns, such as those related to sustainability and governance. We appreciate Minister Borst’s  view that GAVI  is “receptive to critical voices”.  This reinforces our thinking that dialogue should be continued and is very useful: it keeps interested parties informed and may  lead to readjustments of objectives and strategies.

Some issues invite further debate.  Firstly, on the issue of inequity within countries:  Minister Borst and Tore Godal comment that this issue is  addressed through one of the milestones of the Alliance, which states that one objective should  be that “80% of countries should reach 80% coverage in all districts”. This is an enormously worthwhile objective, but how  can this be achieved if GAVI continues to spend around two-thirds of its resources on procurement and supply of new vaccines, rather than strengthening of existing immunisation services? It seems very unlikely that coverage will increase if new vaccines are introduced without accompanying efforts to strengthen immunisation services.  Under GAVI conditions, new vaccines are only introduced into countries which fufil the requirement of 50% DTP coverage, but 50% coverage is dismally low compared to the 80% which was achieved in the UCI campaign in 1990. The argument made in the original article is that without emphasis on the strengthening of health and immunisation services, the GAVI funded programmes must lead to inequities in countries: GAVI will contribute to the ‘have’s’ , receiving more vaccines and the ‘have-nots’ as a consequence receiving relatively fewer.

Numerous reports acknowledge that low vaccination rates in developing countries can be corrected only by a strengthening and expanding of the health care infrastructure which delivers vaccines. In 1997, WHO officials estimated that, on average, 43% of vaccines delivered to developing countries were not administered to children. Losses occur because many vaccines are left unrefrigerated for too long, because of limited shelf-life, and because of inefficient use of multi-vial doses[1] A 1998 special report by UNICEF found in eight countries in Sub-Saharan Africa that poor organisation and management in vaccine distribution, maintenance of refrigeration and immunisation scheduling resulted in an inefficient programme. The study found a shortage in trained staff. These factors were found to explain the low immunisation coverage.[2] Expanding coverage costs is also relatively expensive, because the under-served live in more remote areas where health care structures are especially underdeveloped and under-staffed. If the primary aim is to achieve equity in access to vaccines, it is very difficult to see how  a programme focusing on the introduction of new vaccines can be the  best way forward.  The resolution “Strengthening health systems in developing countries” adopted at the fifty-fourth World Health Assembly (21 May 2001), reaffirmed commitment to the objectives of the health-for-all strategy, in particular the achievement of equitable, affordable, accessible and sustainable health systems, and it calls on the international community and multilateral institutions to “provide support for efforts aimed at strengthening health systems in developing countries”. By paying more attention to the health system soft-ware than to the vaccine-hardware GAVI can contribute significantly to the achievement of these global health objectives.

Over the years, several bilateral and multilateral donor agencies have come to the conclusion that basket funding of the health sector in developing countries and so-called “sector wide approaches” are a better way of strengthening health systems than separate donor-driven vertical programmes, such as those supported by GAVI. They encourage governments to decentralise and reform health planning and management. Basket funding and decentralised health sector management are strategies to strengthen ownership. GAVI, as Tore Godal puts it, aims at “firmly putting governments in the driver’s seat”. In its guidelines for proposal submissions, however, GAVI sometimes appears to disregard existing organisational structures in developing countries. GAVI requires countries to develop plans according to GAVI guidelines and  set up a ‘fully functioning Inter-agency Co-ordination Committee’. These conditions disregard other ‘sector-wide’ mechanisms which may exist for planning, at other levels of organisation.

Tore Godal also commented on the Board composition, which in his view is appropriate because 12 of the 17 seats are for public sector representatives. The international pharmaceutical industry, representing the private-for-profit sector only has one seat. The problem with the Board composition is not its public-private balance, but that only a minority of members represent recipient country interests. The majority of the Board members are representatives of donors, making the Alliance a rather donor-driven initiative. The issues raised in the original article in fact go beyond board composition, raising issues on governance. The problem is that the board is not accountable to a democratic body. The advantage of UN agencies taking responsibility for global health programmes is that they are governed by assemblies, in which recipient countries have the majority of votes. Minister Borst in her response asserts that the critical issues raised in the article have been subject to discussion in the Board. This is reassuring, but only up to a point. The issue is not only what goes on during the Board deliberations, but how mechanisms can be established to ensure that the Board continues to listen, explain and justify its actions to the wider public, including end-users of vaccines, and recipient governments.

Others have expressed the same general concerns. The Norwegian Journal Development Today (June 2000) reports that the Norwegian UN delegation in Geneva has raised these same issues in the form of a letter addressed to the Norwegian Ministry of Foreign Affairs. The letter was based on an informal consultation with delegates from other donors during the 2000 World Health Assembly in Geneva. The letter notes that some other donors are concerned about “good governance”, “balanced participation on GAVI’s Board” and “transparency and accountability”. The letter also points to the need for clarity about management and control of public funds in alliances with industry, private foundations, non-governmental organisations and other players in the private sector.

Both Minister Borst and Tore Godal mention the positive results of the bulk procurement efforts by UNICEF.[3] The price of Hepatitis B has gone down to US$ 0.30 and contracts were awarded to producers in low and middle-income countries (South Korea, India and Indonesia). The lowering of prices of vaccines is an important positive achievement of GAVI and should be applauded. Also, it is good that developing country producers have been awarded the contracts. However, it should be noted that even at 30 cents, Hepatitis B is much more expensive than the traditional EPI  (‘penny’) vaccines. DTP costs only six US cents; and oral polio vaccine seven cents according to the UNICEF pricewatch presented during the GAVI partners meeting

. An interesting study in Addis Ababa calculated that the introduction of hepatitis B would increase the costs of the immunisation programme by about 30% (including all recurrent and non-recurrent costs). The bulk of additional costs are related to the cost of the hepatitis B vaccine (the estimated cost per dose at the time was US$0.50).[4] Hepatitis B has high prevalence in some countries, and related health risks are serious. In settings where health budgets are limited, health policy makers need to make choices, with an aim of achieving equity. The additional 30% could perhaps be better initially invested in strengthening an expanding the health care infrastructure . When the majority of children are reached with existing ‘penny’ vaccines,  inclusion of new ‘dollar’ vaccines makes sense.

Even, then countries need to consider sustainability. Can they continue to pay for the additional 30% when GAVI has run out of resources? How long will the Fund be able to pay for the vaccines? The World Bank has prepared a very interesting paper on this issue for GAVI. The paper outlines various dimensions of financial sustainability of immunisation systems, falling into the categories efficiency in the supply chain and reliable and sufficient revenues through appropriate funding structures.  It points to the potential of sectoral (rather than immunisation specific) programmes, which have tremendous potential to contribute to sustainability, and the need to set targets for financial sustainability in a participatory fashion with full input from experts and policy makers in recipient countries.[5]

Overall what appear to be needed is some independent monitoring and review of GAVI actions, in order for timely adjustment of strategies, and to formally measure its effectiveness in achieving equity aims. Also more emphasis is needed on the development of mechanisms for accountability and transparency in decision-making towards the major stakeholders in the process, including recipient governments and consumers of vaccines.

Anita Hardon