Cover image courtesy of Gavi, The Vaccine Alliance.
Written by Michael Cheng, The University of Oklahoma
The efficacy and course of action of Gavi, the Vaccine Alliance, will be under investigation throughout this analysis.
Abstract
Vaccinations are an important part of public health in preventing dangerous infectious diseases in a simple, safe, and effective way. Gavi, the Vaccine Alliance, is an international organization with the goal of creating equal access for vaccines to help immunizations in developing countries. They support the immunization of almost half of the world’s children and boast about having immunized over 822 million children which has resulted in preventing over 14 million deaths. Currently, Gavi has partnered and supports forty countries in Africa and has introduced nine different types of vaccines. Although Gavi claims to strengthen the health system, this article will investigate the methods and practices of Gavi’s humanitarian vaccination plan and explore how the strategy unintentionally affects local healthcare systems through placing a large emphasis on vaccines, creating financial burdens, and using a data resulting approach to tracking progress. Furthermore, those countries in agreement with Gavi must meet the health standards and numbers that are deemed appropriate to receive continued funding. These conditions often imply that “superior” Western knowledge should determine what is best for the African community. While Gavi does provide assistance through medical needs, it can be argued that this aid creates a dependency on Western humanitarian organization interventions in Africa and can create conditions that can cause more harm than good.
Introduction
Founded in January of 2000, with the help of a $750 million dollar pledge over a five years period from the Bill and Melinda Gates Foundation, the Global Alliance for Vaccines and Immunizations (GAVI), or now officially Gavi, the Vaccine Alliance, is an international organization with a mission of creating equal access for vaccines to help increase immunizations in developing countries. The Vaccine Alliance was created as a public and private global health partnership consisting of international health agencies, governments, private foundations and industries, large donors, and other groups concerned with the health of children in developing countries. Gavi seeks to address the inequity of vaccine availability, where children in rich Western countries have access to a multitude of vaccines resulting in lower child mortality; whereas children living in the poorest countries are denied basic vaccinations based on the cost of vaccines and access to healthcare services. While the region of sub-Saharan Africa has the highest birth rate in the world as well as one of the highest child mortality rates, Gavi has focused on combating those statistics by promoting health and increasing child survival rates through the power of vaccines [1]. Gavi has and currently continues to partner with and support exactly forty countries in Africa and has increased vaccination coverage that protects against thirteen common preventable diseases on the continent by introducing nine different types of vaccines. So far, Gavi has immunized more than 319 million children in Africa which has resulted in preventing over 7.5 million future deaths [1]. So how is Gavi, the Vaccine Alliance, able to pull all of this off?
Gavi’s Catalytic Funding and Vaccine Market Shaping Model
Gavi uses a catalytic funding model in which its main role in increasing access to vaccinations is to help finance, speed up, and rapidly scale up deliveries of the newest and improved vaccines to the developing world. First, there is an application that governments from countries with eligibility must submit to receive the initial financial support. This eligibility is primarily based on the average gross national income per capita over a three-year time period in which the threshold for eligibility is equal to or below $1,630 [2]. Right from the jump, countries are expected to co-finance a portion of the cost of the vaccine. But countries that are considered a “low-income country,” by the World Bank’s threshold of $1,045 per capita, can pay as little as twenty cents per dose [2]. As the participating countries’ national income rises, the co-financing amount rises as well. The objective of the co-financing policy is to prepare countries to take on the full cost of the vaccine. So once a country’s national income surpasses the eligibility threshold, the existing support phases rapidly decrease over a five-year period and the government must assume 100% of the vaccine cost [2].
Another one of Gavi’s strategies to increase access to vaccines is their ability to reduce the vaccine prices to an affordable cost from manufactures and secure an increased amount of vaccines by shaping the vaccine market. Given that in a perfect vaccine market, the supply of vaccines should be consistent and precise with the capability of meeting demands in order to minimize the risk of over or under-producing costly vaccines, the market activity does not favor serving low-income countries because of the financial uncertainty and unstable demand for vaccines. These factors discourage vaccine manufacturers to provide vaccine shipments without a large price tag and often create a long time lag from when developed countries are first introduced to newer vaccines to when poorer countries receive the opportunity to obtain their own new vaccine shipments [3]. To combat these problems, Gavi has used different vaccine market shaping efforts to make vaccines and other immunization products more affordable by securing large supplies of vaccines from manufactures at a negotiated lower price. Without these efforts, there is a possibility that there could be a shift in the perspective of the vaccine market toward a more limited market where vaccine manufacturers aim their attention to the Western world and leave the developing countries behind [3].
It would appear from a policy and objective standpoint that Gavi is able to quickly and effectively carry out its goals, by working with participating countries’ governments to financially incorporate and support the integration of a vaccine program that eventually leads to the transition of vaccine self-sufficiency without the support of Gavi. This is all done while continuing to reduce the cost of vaccines and provide continuous supplies of vaccines to countries that need them. Additionally, each step of the two models that Gavi has implemented has clear and strategic stages in their ultimate plan that incorporates a holistic viewpoint to “reduce poverty and protect the world against the threats of epidemics” [4]. Despite many people only seeing Gavi as an effective party that assists in supporting the vaccination of millions of children, it is important to look at the unintentional consequences of such an ambitious plan and consider the risk of doing more harm than good due to underlying fundamental flaws.
Looking From the Top Down
As discussed earlier in the article, Gavi has brought together major players within the global health policy network such as the World Health Organization (WHO), World Bank, United Nations Children’s Fund (UNICEF), Bill & Melinda Gates Foundation, private pharmaceutical industry, and multiple donating Western countries, to work toward the common goal of increasing vaccination in developing countries. Although Gavi says that they work with developing countries, Gavi indicates a top-down approach to assistance where many of the major decisions are facilitated by top executives [5]. These decisions ultimately lead to a non-negotiable emphasis on vaccines that do not support broader systems objectives, which will be addressed later in the article, and undermines local support from the field workers and the developing countries’ government. Without true garnered local support, “pressure is placed on global organizers to seduce participants and manipulate enthusiasm rather than actually develop it” [5]. Although international health agencies typically are experts in big global situations, which in theory should allow them to see the larger picture of interventions, they often lack the ability to understand the cultural difference and problems that each developing country faces in detail. This structure plays into the all-too-common theme of paternalism in the humanitarian aid field, where Western countries, like the United States, often see themselves as the standard for modernization to which “undeveloped” African nations should look up to and strive for. In the West’s urge to help, they also see themselves as a guiding leader by deciding what is needed for poorer countries in their journey toward development, indicating that these developing countries do not know their own needs. Even an article published by the Center for Strategic and International Studies (CSIS) affirms how different aspects of Gavi’s efforts are consistent with the United States government goals for developmental approaches by focusing on “strengthening local capacities and accelerating enterprise-driven development”, which is the framework the United States would like to take instead of taking a country-specific objective approach for development [6]. The article continues to state how Gavi’s incorporation of United States-based vaccine manufacturers reinforce American global health security goals and is “consistent with U.S. diplomatic efforts to showcase U.S. based innovation and entrepreneurship abroad”, focusing more on how Gavi can help benefit the western world rather than actually benefitting those in need [6].
High-profiled global health intervention programs that receive large amounts of funding from donors all over the world, such as Gavi, can actually lead to overwhelming new developing countries that are to receive this funding. By quickly introducing protocols for planning vaccine procurement, management of a newly developed health system, as well as monitoring and evaluating those systems, these distractions can disrupt recipient countries’ governmental policy process of strengthening their own health systems that are in the process or have already been initiated. Jorn Heldrup, a bilateral donor for Dandida, which is a Danish foreign aid agency, is quoted saying, “[w]hat should be important is the countries’ own priorities and they’re looking at all the possibilities [available to them] and [then they’re] choosing priorities with the limited resources that they have. But that is not possible when these initiatives come down [from on high]” [5]. Heldrup is one of a few Western donors that have expressed their disagreement with the oppressive approach Gavi indirectly takes. Instead, the Vaccine Alliance stress stronger support for developing countries’ government to set their own priorities and try to avoid undermining the local decision process and planning at all costs, not only in the healthcare sector, but in other areas such as education, business sector, or housing as well [5].
Case Study – Gavi’s Impact on Chad and Cameroon
In the case of the African countries of Chad and Cameroon, there was a study done that evaluated the impact that Gavi has provided in strengthening the health system in Chad and Cameroon by providing funds to the countries for the process of increasing and maintaining immunization coverage. To give some context, Cameroon requested a $14.4 million dollar health system strengthening grant in October of 2006 and had the proposal approved in August of 2007 for $9.9 million dollars over a five-year period by Gavi [7]. On the other hand, Chad also requested a grant for $4.9 million dollars over a four-year period and had the grant proposal approved in July of 2008. Gavi then made the first disbursement to Cameroon in November of 2007, and the first disbursement in Chad in September of 2008 [7]. The records go on to show that almost 60% of spending activities in Cameroon and almost 40% of spending activities in Chad were implemented outside the approved budgets and that little to no funds were spent toward the intended implementation [7]. This report led to Gavi conducting an audit and an investigation into the management of funds and later led to the eventual suspension of grant funds which resulted in the partial implementation of planned projects. Initial reasoning seems quite obvious that the fault for the failure lies with the recipient countries, since Cameroon and Chad were given grant money to improve their health systems to be in accordance with Gavi’s guidelines and procedures, and simply failed to follow through with the scheduled expenditures. But a closer investigation shows a different root cause for the execution challenges in Cameroon and Chad. As stated earlier, the period between the request and approval date in Cameroon lasted for ten months with an additional three months before funds were disbursed. In Chad, four months had passed before the country got approval after the submission of their proposal and had to wait an additional 2 months for the arrival of their disbursement. Both Cameroon and Chad considered these waiting delays to be too long and the planning process to be too fast and complex, causing unrealistic timelines for implementation. The countries felt obligated to spend the grant funds in a short period, often differing from what had been approved in their budget, as a result stemming not from the recipient countries, but from Gavi themselves and their delays [7]. This case study gives insights into Gavi’s fundamental weaknesses and challenges that limit their effectiveness, despite their perceived success in many other nations.
Data Resulting Approach
From a pure numbers approach, Gavi has had considerable success in the fight against preventable diseases through their alliance and vaccination plan since their conception in 2000. Gavi supports the immunization of almost half of the world’s children and in 2019 alone, they were able to immunize 65 million children and prevent 1.5 million deaths. Additionally, in Gavi-supported countries, there was an 81% diphtheria-tetanus-pertussis (DTP) vaccine coverage, which is a 22% increase since 2000 [8]. Overall, Gavi boasts about having immunized over 822 million children which has resulted in preventing over 14 million deaths and has introduced more than 495 vaccines in only twenty years [8]. However, while these data-driven accomplishments are a great testament to the massive resources that are available to Gavi’s global health interventions, it also has the unfavorable consequences of using statistics solutions and a business approach in the humanitarian field [9]. From their own webpage, it is evidently clear how important and fundamental quantitative data, and the overall quality of that data, is to Gavi [10]. One of the key indicators that Gavi uses to measures the vaccine coverage and progress in a developing country is how many children are receiving their third dose of the DTP vaccine (DTP3). The reason why the DTP vaccine was chosen as the main indicator is that three shots of DTP at different time points are needed to build a high enough immunological response against diphtheria, tetanus, and pertussis [11]. From this, if a high percentage of children are able to receive their third dose of the DTP vaccine, it suggests the ability of the country to maintain routine vaccination. Much of Gavi’s decisions involving allocation of funds, planning of vaccine programs, and evaluation of recipient government’s management are based on data, like the DTP3 data, they collect from participating countries [10]. Another reason why statistics and data collections are so important is due to the sheer numbers of donors and partners that contribute structurally and financially. Most donors and partners tend to focus on the statistical results, especially positive statistical results, as it allows them to justify their time, efforts, and expenses used on the organization as well as letting westerns play their part as “heroes”.
One of the ways how Gavi attempts to ensure that supported countries achieving their immunization level goals is through a performance-based funding approach. Participating countries are required to input vaccine coverage data in their annual report they submit to Gavi for assessment. The report must meet satisfactory conditions, determined by Gavi, to continue to maintain their support from Gavi [7]. These conditions often imply that “superior” Western knowledge has the right to and should be allowed to determine what is in the best interest of the “inferior” African community. As a result, misreporting and misrepresentation of data by African national agencies as well as international agencies were often caused by these incentives in order to exaggerate the developmental progress of African countries and receive funding [7]. In a statical investigation conducted by Justin Sandefur and Amanda Glassman, they suggest the same outcome of how “misrepresentation in data reflect the incentives provided by governance and funding structures of these ministries” when they reviewed a policy where Gavi offered eligible African countries a cash incentive for every additional child that received the DTP3 vaccine [7]. This policy induced a bias that overestimated the DTP3 coverage rate in each national administrative data system by at least 5%. The minor discrepancy in the data is not a major concern of Gavi as there is an assumption that more money and better technology that are becoming more advanced will eventually provide higher quality data and resolve the problem [10]. However, using a data-driven approach is only really useful in indicating the possible success and progress of a program, but reliance on only using data to assess and track the results of Gavi’s programs could lead to a focus on improving the numbers on paper and not the living quality on the ground.
Only Vaccines
Vaccinations play an important part in public health in preventing the infection and spread of dangerous infectious diseases in a simple, safe, and effective way. That’s why Gavi utilizes the foundation of routine immunizations from vaccines as a platform to strengthen the healthcare system as well as improve developmental goals, but as Gavi primarily focuses on the immunization of children, vaccines remain largely an individual intervention that improves healthcare one at a time instead of implementing change through wide socioeconomic factors or addressing the root of the problem [11]. The main reason why the state of health of people in Africa is so detrimental is simply that a significant percentage of the sub-Saharan African population live in poverty and are unable to escape the poverty trap [13]. The concept of the poverty trap is an intergenerational self-repeating cycle or system that makes it difficult and almost impossible to escape poverty without being given sufficient aid to gain a foothold out of poverty. Health aid programs like Gavi solely provide funds only for the specific and technical interventions of administering vaccines that do not directly aid in the fight against poverty. In fact, with the vaccine plan, Gavi expects developing countries to eventually take over the massive financial burden in full for the cost of vaccines. As a result, participating countries will have a massive expenditure in the government’s future budget for vaccine supplies and must provide support for future vaccine initiation instead of addressing the extreme poverty that mainly contributes to the poor state of health in Africa [13]. The large and special emphasis placed on vaccines by Gavi perpetuates the idea that vaccinations are the best, greatest, and most important interventions that developing country governments need to take in order to build up their country. These ideas frankly distort local priorities, undermine local advancements, and ignore the global, political, economic, and structural issues that lead to reasons why poverty and inequality continue to grow and worsen in Africa.
To understand how large organizations that primarily focus on explicit goals, such as Gavi, affect local communities and health systems, a story done by the Los Angeles Times exposes and illustrates representative outcomes of the unintended negative consequence on real-world individuals. In the case of Natsepang Nyoba, a 30-year-old female with acquired immunodeficiency syndrome (AIDS), she had a baby girl that died in the “roach-infested maternity ward of Queen Elizabeth II” [14]. Her newborn girl did not die from AIDS, but instead due to the lack of staff, supply, and equipment in the medical setting. Large organizations, like the Gates Foundation, have donated billions to fund the prevention and treatment of diseases like tuberculosis or AIDS, and are the main reason Nyoba is able to obtain her expensive AIDS medications. In addition to funding the needed medicines, agencies will pay an increased salary for healthcare providers to administer antiretroviral drugs to AIDS patients, which increases the demands for AIDS staff and diverts doctors and nurses from primary care positions [14]. These changes were meant to improve health systems, but the opposite seems true as evident in the short life of Nyoba’s baby girl. In another example, Mamoraturoa Polaki dragged her small and frail son, Huku, to receive his measle shot at a clinic provided by Gavi. However, Polaki’s main motivation was to ask clinicians about the health of her weak appearing son, but received no answers and was left unaddressed after her son’s vaccination [14]. Despite Gavi stating that immunization is the only intervention that brings individuals into contact with the health system five or more times, offering more opportunity for communities to have additional primary health care services, Gavi discourages medical screening to deter “raising expectation” and “overburdening the campaign” as Dr. Peter Salama, UNICEF’s chief of health section, states [14]. The attention to the high-profile disease and strict adherence to organizational goals distracts from the basic needs such as food and transportation, and the overall weakening of the local health systems.
Conclusion
Gavi, the Vaccine Alliance, has set out on the ambitious mission to save lives, reduce poverty, and protect the world against dangerous infectious diseases through the increased access to vaccines in poor and developing countries. On the outside, Gavi seems to have strong partnerships with a well-thought-out and meticulous plan that has been able to reach extraordinary accomplishments in their first 20 years. However, a closer look into Gavi’s structure, policies, and results paint a different picture. The unintentional consequences of Gavi’s effects have negatively impacted the health systems in participating countries, a complete contradiction of Gavi’s goal to improve the health system. Gavi should truly place a larger emphasis on allowing developing countries’ governments to set their own priorities and decisions. Officials and donors must also step away from perceiving the African population as numbers on statistic sheets that achieve their humanitarian objectives. Instead, they should more closely consider an overall more collaborative system and integral efforts to create an environment where African countries can truly develop and grow.
This post may have been edited by admin for clarity and length.
Bibliography
Primary Sources
“About Our Alliance.” GAVI: The Vaccine Alliance, February 18, 2021. https://www.gavi.org/our-alliance/about.
“Facts and Figures.” GAVI: The Vaccine Alliance, February 18, 2021. https://www.gavi.org/programmes-impact/our-impact/facts-and-figures.
“Gavi in Africa Since 2000.” GAVI: The Vaccine Alliance, January 2020. https://www.gavi.org/news/document-library/gavi-impact-africa.
“How Good Quality Data Is Vital to Saving Lives.” Accessed April 14, 2021. https://www.gavi.org/vaccineswork/vital-quality-data.
“Immunisation: Strengthening Primary Healthcare for Universal Health Coverage.” GAVI: The Vaccine Alliance, September 2019. https://www.gavi.org/news/document-library/immunisation-platform-universal-health-coverage.
Kallenberg, Judith, Wilson Mok, Robert Newman, Aurélia Nguyen, Theresa Ryckman, Helen Saxenian, and Paul Wilson. “Gavi’s Transition Policy: Moving From Development Assistance To Domestic Financing Of Immunization Programs.” Health Affairs 35, no. 2 (February 2016): 250–58. https://doi.org/10.1377/hlthaff.2015.1079.
“Supply and Procurement Strategy 2016-20.” GAVI: The Vaccine Alliance, January 2016. https://www.gavi.org/news/document-library/supply-and-procurement-strategy-2016-20.
Secondary Sources
Bliss, Katherine E. “Sustaining U.S. Support for Gavi: A Critical Global Health Security and Development Partner.” Center for Strategic and International Studies (CSIS), 2020. https://www.jstor.org/stable/resrep22399.
Muraskin, William. “The Global Alliance for Vaccines and Immunization: Is It a New Model for Effective Public-Private Cooperation in International Public Health?” American Journal of Public Health 94, no. 11 (November 2004): 1922–25. https://doi.org/10.2105/AJPH.94.11.1922.
Sandefur, Justin, and Amanda Glassman. “The Political Economy of Bad Data: Evidence from African Survey and Administrative Statistics.” The Journal of Development Studies 51, no. 2 (February 2015): 116–32. https://doi.org/10.1080/00220388.2014.968138.
Sanders, D. M., C. Todd, and M. Chopra. “Confronting Africa’s Health Crisis: More of the Same Will Not Be Enough.” BMJ 331, no. 7519 (October 1, 2005): 755–58. https://doi.org/10.1136/bmj.331.7519.755.
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Other
Bowman, Andrew. “The Flip Side to Bill Gates’ Charity Billions.” New Internationalist, April 1, 2012. https://newint.org/features/2012/04/01/bill-gates-charitable-giving-ethics.
Piller, Charles, and Doug Smith. “Unintended Victims of Gates Foundation Generosity.” Los Angeles Times, December 16, 2007. https://www.latimes.com/nation/la-xpm-2007-dec-16-la-na-gates16dec16-story.html.
[1] “Gavi in Africa Since 2000.” GAVI: The Vaccine Alliance, January 2020. https://www.gavi.org/news/document-library/gavi-impact-africa.
[2] Kallenberg, Judith, Wilson Mok, Robert Newman, Aurélia Nguyen, Theresa Ryckman, Helen Saxenian, and Paul Wilson. “Gavi’s Transition Policy: Moving From Development Assistance To Domestic Financing Of Immunization Programs.” Health Affairs 35, no. 2 (February 2016): 250–58. https://doi.org/10.1377/hlthaff.2015.1079.
[3] “Supply and Procurement Strategy 2016-20.” GAVI: The Vaccine Alliance, January 2016. https://www.gavi.org/news/document-library/supply-and-procurement-strategy-2016-20.
[4] “About Our Alliance.” GAVI: The Vaccine Alliance, February 18, 2021. https://www.gavi.org/our-alliance/about.
[5] Muraskin, William. “The Global Alliance for Vaccines and Immunization: Is It a New Model for Effective Public-Private Cooperation in International Public Health?” American Journal of Public Health 94, no. 11 (November 2004): 1922–25. https://doi.org/10.2105/AJPH.94.11.1922.
[6] Bliss, Katherine E. “Sustaining U.S. Support for Gavi: A Critical Global Health Security and Development Partner.” Center for Strategic and International Studies (CSIS), 2020. https://www.jstor.org/stable/resrep22399.
[7] Sandefur, Justin, and Amanda Glassman. “The Political Economy of Bad Data: Evidence from African Survey and Administrative Statistics.” The Journal of Development Studies 51, no. 2 (February 2015): 116–32. https://doi.org/10.1080/00220388.2014.968138.
[8] “Facts and Figures.” GAVI: The Vaccine Alliance, February 18, 2021. https://www.gavi.org/programmes-impact/our-impact/facts-and-figures.
[9] Bowman, Andrew. “The Flip Side to Bill Gates’ Charity Billions.” New Internationalist, April 1, 2012. https://newint.org/features/2012/04/01/bill-gates-charitable-giving-ethics.
[10] “How Good Quality Data Is Vital to Saving Lives.” Accessed April 14, 2021. https://www.gavi.org/vaccineswork/vital-quality-data.
[11] “Immunisation: Strengthening Primary Healthcare for Universal Health Coverage.” GAVI: The Vaccine Alliance, September 2019. https://www.gavi.org/news/document-library/immunisation-platform-universal-health-coverage.
[12] “How Good Quality Data Is Vital to Saving Lives.” Accessed April 14, 2021. https://www.gavi.org/vaccineswork/vital-quality-data.
[13] Sanders, D. M., C. Todd, and M. Chopra. “Confronting Africa’s Health Crisis: More of the Same Will Not Be Enough.” BMJ 331, no. 7519 (October 1, 2005): 755–58. https://doi.org/10.1136/bmj.331.7519.755.
[14] Piller, Charles, and Doug Smith. “Unintended Victims of Gates Foundation Generosity.” Los Angeles Times, December 16, 2007. https://www.latimes.com/nation/la-xpm-2007-dec-16-la-na-gates16dec16-story.html.
