Gavi needs a ‘new playbook’ to deliver impact, experts say

Gavi, the Vaccine Alliance’s new CEO Sania Nishtar has her work cut out for her, even before she takes the helm of the organization later this month. The multilateral organization is operating in a landscape where countries are faced with competing needs and funding constraints, and difficult environments for vaccine delivery and immunization. These conditions pose challenges to its ability to introduce current and upcoming vaccines to as many people as possible. The 2023 midterm review of its current strategy found that rising country debt and lower economic growth are affecting some countries' ability to transition from Gavi support, and increased pricing for newer vaccines is "putting pressure on the sustainability of Gavi’s co-financing model." At a Center for Global Development event last week, a group of experts said Gavi remains one of the most impactful global health initiatives, but it needs to adjust its priorities and operating model to continue to deliver impact. The advice is timely as the global health initiative is currently developing its next five-year strategy, Gavi 6.0, which is expected to be approved by its board in June. It is also launching an investment case for its next replenishment during the same period. The experts want Gavi to: • Revise its eligibility policy for countries, which is currently based on gross national income. • Establish a standalone subsidiary focused on operating in conflict-affected and fragile settings. • Prepare for the introduction of more vaccines targeted at different age groups. • Strengthen integration with other global health institutions, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. • Place a significant focus on strengthening health systems. • Recalibrate the regional-global balance in vaccine manufacturing and procurement. • Drive more country ownership by changing the way it offers and finances vaccine programs. Orin Levine, a nonresident fellow at CGD who served as a Gavi board member for nine years, used the potential introduction of a TB vaccine within the next decade as an example of why these shifts need to happen. The TB vaccine, when it becomes available, will need to be administered to adolescents and young adults, who have not typically been recipients of Gavi vaccines. It also needs to be provided in countries with the highest TB disease burden. However, at present, some of them — such as Indonesia and the Philippines — do not meet Gavi’s eligibility criteria but are eligible for support from the Global Fund. A CGD policy paper, “A New Playbook for Gavi,” also noted that the creation of a subsidiary “with high-risk appetite and greater agility” could “further enhance speed, agility, and scope for partnerships with nongovernment entities required to effectively deliver vaccines in the face of conflict and instability.” The paper highlights the decline of routine immunization rates in Myanmar, from 87% in 2020 to 45% in 2021, as a result of the ongoing humanitarian crisis as one of the challenges Gavi is currently facing. Another is the outflow of refugees from Syria to nearby countries such as Jordan and Lebanon, which aren’t eligible for Gavi support. This shows the need for greater operational flexibility, it states. Justice Nonvignon, head of the health economics program at the Africa Centres for Disease Control and Prevention, said country ownership is also important. He underscored the importance of “going beyond words” to strengthen country and regional systems, citing recent initiatives such as the African Vaccine Manufacturing Accelerator that Gavi launched in December. “We know that one of the goals of [the] African Union is to ensure that by 2040, 60% of the vaccines used in Africa will be purchased from African manufacturers. So let’s go beyond the AVMA and see how the Gavi 6.0 clearly articulates … this too,” he said, adding support should not just be on setting up the continent’s manufacturing capacity, but also sustaining it. Johannes Ahrendts, director of strategy, funding, and performance at Gavi, said the recommendations, which are also in the CGD policy paper, “have already informed the design of Gavi 6.0.” He said they recognize the opportunities to save more lives by covering more age groups, the need to evolve the way they work with fragile and conflict-affected countries, and be more country-centric, and the challenges that countries face that make it difficult for them to transition successfully out of Gavi support, but they don’t as yet have all the answers to these challenges. “We are cognizant that there are many funding constraints from our donors. So our board will need to take some important decisions here about priorities, and a successful replenishment will be more important than ever,” he said. Kate O’Brien, director of WHO’s Department of Immunization, Vaccines and Biologicals, and a current Gavi board member, said one of the struggles they’re dealing with in developing Gavi’s new strategy is finding the balance between equity and efficiency. “Those two are in tension with each other. And so the question is really going to be where on that trajectory between efficiency … and equity is the board going to land in this strategy,” she said. Another decision that the board, and Nishtar, have to make is the degree of change Gavi would be willing to make in a changing landscape, Levine said. Nishtar and the board “have to think about to what degree do we change and to what degree do we stand still,” he said. “Standing still in a rapidly changing environment can be wise sometimes, and it can be risky. Changing is also risky. And so she’s gonna have to come up with those balances.”