Q&A: How Gavi can adapt to tackle equity and conflict

WASHINGTON — Gavi, the Vaccine Alliance, is gearing up for its third replenishment cycle and rolling out a new strategy — Gavi 5.0 — that aims to reflect a new era of global health and development. Devex spoke to Anuradha Gupta, Gavi’s deputy CEO, about what internal policy changes will be required for Gavi to ensure its immunization efforts reach underserved communities. “What is really coming out of the board retreat that we had to think about Gavi 5.0 in the last week of March in Ottawa, was to say very emphatically that equity should be the organizing principle of Gavi support to countries in Gavi 5.0,” Gupta said. “That means that we are going to challenge ourselves to first talk about, who are the children we are missing,” she added. Immunization serves as a proxy indicator for other aspects of poverty and marginalization, Gupta said, which can reveal pockets of exclusion — even within countries whose overall immunization rates are relatively high. That variation, coupled with increasing challenges presented by fragile and conflict-affected states, is motivating Gavi’s leaders to revisit how the institution determines where to work, how to allocate its resources, and what kinds of partnerships to pursue. “If you really want to incentivize health workforce to go and serve in those areas, sometimes at the risk of their personal lives, how do you compensate them for that?” --— Anuradha Gupta, deputy CEO, Gavi “We have to segment countries much more deliberately and not treat all countries as one amorphous whole. That means that there is going to be a huge shift from one-size-fits-all approach, to saying, okay, let's look at this country context,” Gupta said. This interview has been edited for clarity and length. It's one thing to recognize those differences at the subnational level. It's another thing to be an organization that can actually change and adapt itself to be able to implement according to those differences. Operationally, how do you take that knowledge and incorporate it into the way that you are structured and into your funding processes? It would mean that we challenge ourselves on the kind of operating models that we have today. For example, funding policy. At this point, funding is allocated to countries based on a three-pronged criteria — [gross national income] per capita, the overall size of the birth cohort, and DTP3 [diphtheria-tetanus-pertussis] coverage ... A question that we would be asking ourselves is whether we should allocate funding based on the number of unimmunized children. That's a funding policy decision that we would take, and it's not hard, but it would mean that we have to start thinking differently about how do you allocate those resources. The second is remote, rural, or conflict settings where operational costs are much higher, because these are typically the areas where you don't have a health workforce. If you really want to incentivize health workforce to go and serve in those areas, sometimes at the risk of their personal lives, how do you compensate them for that? That could mean our funding policies would not just need to think about new allocation formulas, but would also need to think about how do we provide enough flexibility and nimbleness to actually allow us to adapt and deliver support to these countries. The third important dimension would be the mix of partners. We are an alliance, and WHO and UNICEF are our core partners. We provide technical support through our partners, but we have started to expand the mix of partners already. In humanitarian settings this is going to be a very different approach, but we don't, at this point of time, work directly with international NGOs, or those other nonstate actors that may have a very strong presence, that may have the trust of armed groups. What is going to be that new operating model that gives us the ability to actually start to partner with some of these organizations that have stronger presence and that actually are delivering. “We never funded entities outside the government.” --— What inhibits that flexibility right now? Is that a statutory issue in terms of what Gavi is allowed to do or not to do that would have to be changed? Our strategy is to work through country governments. This is what has worked extremely well, because Gavi is known for its model to bolster country ownership and promote sustainability, and that's what we have done extremely successfully, because of the fact that we rely on country governments and we don't create vertical parallel systems or financing. We never funded entities outside the government. We have encouraged countries to start taking ownership of their vaccines as their GNI levels go up and we have been hugely successful. And that's where the whole development world wants to go, right? In places where there is not a government partner to work with. … Working through country governments is going to be the model that we continue to follow. But the point is — how you create additional space for new partnerships, while not undermining the country ownership and country systems is going to be a question. Do you anticipate that revisiting the eligibility formula would allow for the flexibility to work in countries that may have been middle income but are slipping back, not necessarily economically, but in terms of their health systems? Venezuela, for example. There's a health crisis that is one of the worst that this hemisphere has ever seen. Gavi can't work in Venezuela. That's a question that we are trying to address in Gavi 5.0. First of all, in the beginning, we treated co-financing as an important ambition for sustainability … What we are now going to do in Gavi 5.0 is to bring much more forcefully the notion of programmatic sustainability into the equation. Though 20 countries will transition out of Gavi support by 2020, in many cases where you have commodity-driven economies, there has been a very steep increase in GNI — [for example in] oil-driven economies. When you see that kind of spike in GNI, it's not necessary that your health systems will be able to keep pace. That has been a challenge, for example, in Congo Republic ... What happened was that we suddenly saw a steep increase in the GNI to $3400 per capita. As oil prices crashed in 2014, soon enough [GNI] started to tumble, and now it is $1360, which means that they have become re-eligible for Gavi support. But there is an intervening period where the program could actually get into a state of shock, because the GNI data may not be available real-time, and at the same time the country starts to struggle. The board is saying that GNI is an important threshold to apply, an important filter to apply. However, we are also invested in successful transition, and we should monitor very carefully, and if we think that there are certain factors, which are happening which can actually threaten a successful transition ... then that's the time when we should have the flexibility to adjust. We don't want to not encourage countries to take ownership of the financing of vaccines. Outside the financing of vaccines ... there could be technical support that they may need — and even in Gavi 4.0, the board made this a flexible ad-hoc provision to support countries post-transition with technical assistance ... So you make very time-limited, but targeted catalytic investments by way of technical assistance. What do you think are going to be the biggest challenges in driving the next replenishment cycle? It's a very competitive time for global health funding. How do you think about positioning Gavi in a way that's convincing, but in a way that's also building towards a broader coalition for global health investment? It is important for us to remind ourselves and the world that prevention is really the best course of action if the world is serious about primary health care, universal health coverage, and global health security. Today, 65 million children are being reached every year with Gavi support ... and you have population or birth rate still going up in several Gavi countries. Between 2000 to 2015, [we saw a] 40% increase in the size of the birth cohort in African countries that Gavi is supporting … So it is not that you can vaccinate these children and then say the job is done. Every year you have new children. The second is protection. Global health security is becoming a challenge … Antimicrobial resistance is becoming a challenge ... and then there are emerging risks like climate change. If you have climate change, you have new pathogens, you have new diseases, you have all these migration patterns ... If the world is futuristic and they want to really invest in ensuring a safer future, then that's the second argument. And the third big thing for us is prosperity, because it is a highly pro-poor intervention. The rich can protect themselves better. They have access to social determinants of health, so their children may not be at equal risk of some of these diseases, and then they have access to health care. If we remind ourselves that 100 million people slip into poverty every year because of catastrophic medical expenses, then I think vaccination is really a sure way of ensuring that the poor are given that protection. So that is our case.