A new charismatic CEO, Dr. Seth Berkley will soon take up his position with the Global Alliance for Vaccines and Immunisation (GAVI) Alliance, the aim of which is to save children’s lives and protect people’s health by increasing access to immunisation in poor countries. Can Berkley see through the spin at global health cocktail parties? Get dirt under his fingernails to discover the real customers? Grasp immunisation as part of broader health systems? Negotiate with pharma for lower prices? Get non-Gates donors to open their wallets? And all at the same time?
Craig Burgess, Chief of Child Survival and Development of UNICEF Vietnam and a former employee of the GAVI Secretariat, shares what Berkley will need to do to make this happen.
The Gates Foundation, US-based institutions and the Global Fund to Fight AIDS, TB and Malaria (GFATM) blogs are celebrating.
A US-national and not short on charisma, Berkley’s joins the GAVI Alliance with an epidemiological career predominantly based on single diseases. His appointment is a major coup for institutions and individuals who have built up reputations based on discovery and development of disease specific ‘upstream’ research and policy agendas for new technology introduction (often funded by the Gates Foundation). They expect renewed focus on discovery and development of vaccines against Human Papilloma Virus (HPV), HIV and malaria.
Despite the praise and adulation, here are five reflections that should also reach him before he takes up his post:
1. Resolve issues between disease-specific interventions and health systems strengthening.
An immunisation system (if there is such a thing!) does not deliver the discovered and developed new vaccines in isolation. Vaccines do not appear miraculously in the hands of a nurse midwife!
Introduction and delivery require careful reviews of regional and national disease burdens, socio-economic contexts, cost effectiveness, human rights, and strong health systems to absorb and deliver increasingly expensive new technologies.
Yet the last thing the world needs is yet another new vaccine-specific initiative. Separate ‘project management units’ for each individual new vaccine tend to grow lives of their own, becoming resource intensive and aiming to survive forever.
GAVI Alliance board documents suggest that health systems costs account for 20-50% of overall new vaccine introduction costs, making sustainability a serious undertaking. Most vaccines are delivered at routine immunisation sessions with other maternal, neonatal and child health (MNCH) interventions. Yet the links between the new vaccines and health systems communities remain fragmented at best.
The previous GAVI CEO and newly-appointed head of the Partnership for Maternal, Neonatal and Child Health (PMNCH) provided leadership for the Health Systems Strengthening (HSS) and harmonisation and alignment agendas. This helped the vaccine community, though often controversially, to be more aware of necessary downstream linkages with delivery of other MNCH packages.
There is considerable support for joint the World Bank – Global Fund – GAVI health systems strengthening platform. Mainly due to institutional politics, this has stumbled and faltered, despite considerable funding being earmarked, which could be made available for countries.
Unfortunately, the issues between disease-specific interventions and health systems strengthening are as polarised as ever. It is divided geographically between groups residing on opposite sides of the Atlantic Ocean. It also revolves around tensions between the need for attribution of specific results with the call to reduce the transaction costs of application and monitoring processes inflicted on countries by various global health initiatives by improving harmonisation and alignment.
There is currently a leadership vacuum in the GAVI secretariat on these issues. But they will not disappear quietly without strong direction.
2. Listen to and understand GAVI’s customers. Find the truth, not the ‘spin’.
Both GAVI and GFATM’s powerful advocacy machines play important roles in prioritising their institutional agendas and raising issue-specific funding. “Never let the truth get in the way of a good story” was a recurrent quote in this area of work.
Berkley has the kudos and sound epidemiology training to look past the ‘feel good’ stories, glitzy secretariats, and cocktail parties to get closer to the ‘truth’ of how best to use GAVI’s resources.
Regular exposure to downstream implementation issues will help keep things in perspective. It is important to understand the needs of GAVI’s ultimate customers needs, as well as the environmental complexity facing country decision makers and beneficiaries every day. Strengthening relationships with GAVI’s direct customers, i.e. Ministries of Health, and indirect customers, i.e. women and children living in hard to reach areas, need to be prioritised.
A large dose of humbleness and humility go a long way, despite the pressure Berkley will face from key donors and industry for vaccine introduction. Supporting internal decision-making processes must be a reality and not rhetoric.
Also, there are very good reasons why some countries cannot and should not introduce vaccines offered on the GAVI menu in the foreseeable future. Traditional studies compared cost effectiveness of vaccines costing several cents a dose with other MNCH interventions. With new vaccines now costing several dollars per dose, disease-specific lobbyists have shied away from comparisons. When compared to breastfeeding or oral rehydration therapy interventions for example, new vaccines may not be seen as favourable option from a cost effectiveness perspective. However the new CEO should not shy away from promoting better information for national policy makers to make informed decisions or encourage rights-based approaches so effectively used for anti retro viral therapy introduction.
The ‘truth’ is based on reality. Reality is where the action is.
3. Strengthen partnerships with implementers and look at strengthening ownership of monitoring systems.
As CEO, Berkley will provide leadership for the GAVI secretariat and help inform the board to make decisions. Implementation of GAVI Alliance activities and achieving results depends mainly upon ministries of health and advice given by technical partners. Strengthening relationships with constituents involved with other MNCH initiatives (such as UNFPA and the PMNCH) and those with an in-country presence, working on a daily basis with ministries of health, will be crucial.
Measuring the impact of the GAVI Alliance’s work will depend not on other global institutions funded by the Gates foundation, using postdoctoral students to hoover and analyse data to publish in journals. Instead, impact measurement will need to be generated from and by countries through partnerships that build national capacities to measure and use reported and survey-generated data at all levels, local to global.
The private sector and civil society in countries can do a significant part of the job. Prioritise them! Over 50% of vaccines are delivered by NGOs in some African countries and there are some good examples of civil society helping to increase the accountability of government and bi- and multi-lateral institutions. However, compared to the GFATM, GAVI has only one civil society board seat and is still struggling to agree on the best way of engaging civil society at sub-global level. This constituency needs to be listened to and nurtured.
4. Influence industry prices and encourage ethical marketing processes.
Some would argue that the GAVI Alliance is one of the best marketing machines ever devised by industry and partners, stimulating demand and shaping pricing mechanisms. The GAVI business model helped increase the numbers of vaccine manufacturers in the market and there has been a small decrease in the price of tetravalent (DTP-HepB) vaccines over time.
However the business model that promised so much in terms of price reduction for other new vaccines seems to be stuck. Pentavalent (DTP-HepB – Hib) vaccine prices have remained static or increased slightly and there are major supply issues. Who knows what lies ahead for pneumococcal and rotavirus vaccine behind-the-scenes price negotiations?
As part of their sales strategies, manufacturers have made ‘donations’ of new vaccines such as HPV and others to countries. They have also, together with some key donors, stimulated creation of NGOs focussed on lobbying influential individuals to speed up government introduction decisions. This brings into question the issue of ethics of big pharma’s market penetration processes.
Challenging the industry publicly or privately seems off limits for discussion, adding to the ‘smoke and mirrors’ perceived relationship that GAVI has with pharma. The new CEO will need to take a firm stance on this – putting these issues on the table for frank discussion!
5. Recruit and reward the ‘right’ skills and stimulate creativity.
The GAVI and GFATM secretariats and the Gates Foundation currently have staff of approximately 120,600 and 600 people respectively. Recent staff increases are predominantly armed with MBAs, experience in academia, private sector or communications and advocacy.
These, debatably, are the skill sets for well-oiled communication and fundraising machines, but there appears to be little emphasis on experience in actually understanding and implementing global health policy at sub-global levels. These skills, together with large doses of common sense can provide the substance (aka ‘truth’) and an important dose of on-the-ground reality. Groups with these skills sets are rare. Berkley must find them and nurture them.
Newly qualified graduates with a masters degree can now command annual salaries of US$100,000 or more tax free from these impressive Geneva and Seattle institutions. This is obviously very attractive, but tends to favour candidates of certain nationalities and cultural backgrounds, which can be problematic when compared to the terms and conditions of colleagues working for bilateral donors, government ministries, or civil society.
As a self-proclaimed maverick and thought leader, Berkley will need to enable creative and innovative thinking that actively challenges the GAVI ‘group think,’ which so often creeps into organisational strategy and senior management. Strong leadership is needed to allow open dialogue exploring new research and development and delivery ideas, which may run contrary to senior management.
One question remains: Will Berkley have the integrity, willingness, and boldness to stimulate this type of thinking and free dialogue between GAVI, the Gates Foundation, GFATM, and Alliance stakeholders on service delivery?
Craig Burgess is an advocate for the introduction of disease-specific interventions for developing countries, based on consideration of national priorities, long-term financial implications, and a primary healthcare philosophy. Craig is an ex-GAVI secretariat employee with extensive multilateral and NGO experience. He reminds us, “These views are my own and do not reflect those of my current or previous employers. I realise that by contributing to blog sites may adversely affect career progression, the consequence of not using appropriate protocol or diplomatic channels!”
But he did it anyway! Thanks for sharing your expertise and ideas with how-matters.org, Craig!
This article is cross-posted on Global Health Sushi.