Last week over 300 people from across the Gavi Alliance came together in Abu Dhabi to discuss progress and challenges at the mid-point of Gavi’s 2016–2020 strategy. As well as the Gavi Secretariat, delegates included representatives from governments, civil society, donors, technical agencies and the private sector. Many of Gavi’s successes and impacts were raised during the two day mid-term review meeting. The numbers speak for themselves – Gavi has helped protect nearly 127 million children against vaccine-preventable diseases in low-income countries through routine immunisation, averting around 2.5 million future deaths.
However, the meeting wasn’t just about celebrating successes. As Reina Buijs from the Netherlands Ministry of Foreign Affairs reminded participants, “We also need to critically look at challenges.”
Gavi Board Chair, Dr Ngozi Okonjo-Iweala, recognised that “we still have a long way to go… Despite improvements in vaccine coverage, it is not accelerating as fast as we would like.” We need to push progress further. A number of critical issues and challenges emerged during discussions, many of which we raised in our accountability briefing and scorecard on Assessing Progress on the Pathway to Universal Immunisation Coverage, published in the lead up to the meeting.
Ensuring immunisation is in reach of all children
Gavi’s current strategy has equity at its core. However, it is clear that much more is needed to reach every fifth child in Gavi countries who is still missing out on immunisation. Progress on coverage has been slow with only a one percentage point increase between 2015 and 2017. Just over half of Gavi-supported countries with available disaggregated data (29 out of 55 of them) show poor performance in terms of equity. As Ola Rosling highlighted, three main groups of children are being left behind in:
- remote areas
- informal urban settlements
- conflict-affected countries.
Increasingly, inequalities aren’t just due to geographic distance, but also social distance, UNICEF’s Chief of Immunization, Robin Nandy, pointed out.
Countries must prioritise universal immunisation coverage, turning political commitments into action. Gavi and Alliance partners must continue to improve support to countries if they are to reach their coverage and equity goals, including through improved technical and capacity assistance that really responds to countries’ needs and builds national capacity. Civil society has a critical role to play in driving equitable progress – supporting service delivery, demand generation and accountability – and thus improved independent support for civil society organisations is needed to help them deliver on this role.
Sustainability and transition
Sustainability is the essence and key measure of success of Gavi’s model. Gavi support should be catalytic and time limited, supporting countries to make immunisation gains, while preparing them to carry that progress forward as they transition away from that support. Transition was certainly a hot topic at the mid-term review meeting. Gavi talked of a shift from fiscal space for vaccines to fiscal space for vaccination and health. This is definitely a welcome move: we have continued to argue that, while co-financing should be a minimum requirement, this is insufficient to ensure sustainable transition. Countries must increase domestic investment to strengthen immunisation programmes as part of growing investment in primary healthcare.
Gavi and development partners must support this with the right financial, technical and capacity support – this must be catalytic to support countries as they move towards universal health coverage, aligning this support behind national priorities and plans. This was emphasised by development partners at the meeting. Chris Elias from the Bill & Melinda Gates Foundation talked of helping countries to drive their agenda – building strong primary healthcare systems that form the foundation of universal healthcare coverage. Harriet Ludwig, from the Federal Ministry for Economic Cooperation and Development , Germany, talked of the critical importance of health system strengthening and domestic resource allocation as the foundation for sustainability.
Vaccine affordability must be improved so that immunisation gains can be expanded and sustained. Despite this topic (disappointingly) not being given space in the mid-term review programme, it was nonetheless flagged by participants – for example, Mahamadou Issoufou, President of Niger, spoke of the critical challenge faced by countries due to high vaccine prices. Vaccine supply concerns were also identified. Gavi CEO Seth Berkley talked about how important it is that when countries introduce a vaccine, they know that vaccine will be available. The recent worrying news on rotavirus supply illustrates just how real this issue is.
There must be a healthy vaccines market with sufficient and genuine competition to ensure supply security and help drive down prices. Gavi and Alliance partners – with their extensive market-shaping expertise and occupying a substantial space in the vaccines market – must do more to help shape the market, including through mechanisms that encourage new market entrants. They should also help build countries’ procurement and price negotiating capacity. Critically, we must be doing more to hold vaccine manufacturers to account for their commitments and to children.
Charting the way forward
What the mid-term review meeting was missing was a thorough discussion on how to chart the way forward. I suppose this is the challenge of such large gatherings – you don’t get down to the nitty gritty. During his concluding remarks, Seth Berkley laid out the future immunisation landscape and potential direction for Gavi 5.0. As future strategy discussions intensify in coming months, let’s hope they include a thorough assessment of past progress and challenges, and deep reflection on key issues that emerged during the mid-term review and that are raised by various constituencies – including the ultimate beneficiaries for Gavi support, civil society.
And importantly, let’s hope that this is done through an inclusive and genuinely consultative, bottom-up process, looking at how best to address challenges during the remainder of this strategy and looking forward to Gavi 5.0.
We have many of the ingredients of what must feature in Gavi’s future strategic direction. Now we must turn them into action.