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Okay, good afternoon. My name is Helen Gayle
and it's my pleasure today as the moderator of this panel
on replicating the GAVI success story. And we're going to get
into a lot more detail about GAVI and really have an exciting panel
but just to say, this is the 10th year anniversary of the launch of GAVI
and in the 10 years GAVI has had some incredible successes
that you'll hear about like the five million lives
that have been saved as a result of GAVI
and the 250 million children who have been immunized
in some of the world's poorest countries.
So today we're here because we want to talk
about some of the lessons that have been learned
through the experience with GAVI. Look at what this model offers us
and also think a little bit about whether or not this is a model
that might be useful for attacking some of the other health challenges
that we face around the world particularly if we look at
trying to decrease the disparities of health between rich and poor nations.
So let me just introduce our panelists and then we're going to see a video
that shows some highlight of GAVI and gives a background
and then we're going to get it right into the question and answer.
So first of all to my extreme left is *** Clark who is the Chairman,
President and CEO of Merck & Co. I'm sure everyone knows Merck
has made a substantial contribution as a pharmaceutical company
but one particularly that has had a strong focus on vaccines
for many years. Next, Melinda French Gates,
the Co-Chair of the Bill & Melinda Gates Foundation.
Bill & Melinda Gates Foundation has made a strong contribution
not only to GAVI and vaccines but to global health overall.
Nest is Julian Lob-Levyt who is the CEO of the GAVI Alliance.
And finally the honorable David Mwakyusa,
the Minister of Health and Social Welfare of Tanzania.
So we have a very distinguished who will be able to speak to this
from a variety of different perspectives. But before we start
with our discussion, let's go to the first video.
In the poor countries of the world my brothers and sisters
are dying needlessly. It's a tragedy for us, our families
and for our countries too. But it is a tragedy that vaccines can end.
Vaccines are a miracle thing.
GAVI, the Global Alliance for Vaccines and Immunization has the tall ambition
of protecting every child against killer diseases
and thus lays the foundation for personal development,
social development and eventually renewed economic development
for entire societies.
Vaccines first started to reach us in the 1970s.
Many children got immunized in the 1980s.
But the story has a twist. In the 1990s vaccination cover rate
started falling. Less children got immunized.
Millions of my brothers and sisters who died could have been saved.
To get our immunization back on track, a new idea was urgently needed.
We need cooperation from lots of groups. We need the governments
in the developed world to pitch in in order to make it all happen.
We need governments in the countries
where the vaccinations need to be delivered to pitch in.
We need the pharmaceutical industry. So we're just getting the critical math.
Everyone did pitch in.
Over the following 10 years, things got better.
And if we didn't know it before, we now know that the single
largest contributor to poverty and the single most vulnerable aspect
is in fact health. Is it better to treat people when they're sick
or is it better to try and stop them getting sick?
We need to make sure that we have the expertise and the capacity
and reach all of these children by bringing together those of us
who are on the ground, those who can make sure
that the quality and the overall policy is there.
Leaders of countries here is a broad-based strong alliance
giving a very high priority to this. We really can make a difference.
I don't think there's any doubt that as a result of undertaking
this initiative that there will be an increase
in the healthcare infrastructure and the primary care delivery system
that exists in every one of the countries that participates
and this is absolutely essential. We put together all of those elements.
I think that it will create a large market,
will draw in even more companies, more competition of ideas
and researched knowledge.
It's a real interest of investors to help and eradicate diseases.
So I think that creating conditions so that we bring in development
to the interest of everybody is very important.
You must have the political will in the countries to be able to deal
with these questions. You have to have the infrastructure.
You have to have the support locally. You have to have the focus on health.
In 2006, GAVI found new ways to fund vaccines enabling
spending on our immunization to double.
After 10 years, the numbers speak for themselves.
The alliance partners are delivering on their promises.
But our biggest enemies, pneumonia and diarrhea remain unconquered.
The demand is there and the vaccines are available
yet my brothers and sisters still die every year of diseases
that can be prevented.
Your children are vaccinated, why not ours too?
Great. Well I hope that sets the scene for the discussion
that we're going to have and I think that last question
in some ways really says it all. Before I go to Julian
who I'm going to ask the first question,
I also just wanted to mention one panelist who's not able to be here,
Margaret Chan, the Director-General of WHO
who really wanted to be part of this panel.
WHO is a strong partner in this but unfortunately
she had a death in her family so just to know
that she wanted very much to be here to represent the UN System
and their commitment.
So Julian, set the stage and give us a little foundation.
Say a little bit about what have been the drivers of success.
This video talks a lot about the things
that GAVI has been able to accomplish. What's been responsible
for some of those successes? What have been some of the factors
and what have we learned from the GAVI experience?
Yeah you've seen some of the figures in terms of the results,
the latest figures from WHO,
some five million children's future death has been prevented.
Those are very important figures and good contributions
to achieve the millennium development goals.
And I think it's quite interesting when you look at that video
from 10 years ago and not only to see how people have got more gray hairs
after 10 years but also those commitments that were made
at that time and how many have been met and some haven't
and some of those challenges still remain there
and I think I'm very interested in this debate
to go into some of those challenges. We'll come back to those.
I know you're going to - I hope you're press is on that.
But I think some of the factors in the success of GAVI have been -
and it was groundbreaking when it started.
We've forgotten ever since how the global fund for AIDS,
TB and malaria and others were sort of inspired by GAVI.
This very unique public/private partnership was created,
an alliance of the major actors involved in immunization
working together to a single mission on a single goal and delivering results
and attempting to build an organization that also worked in a different way
in that we can't say fairly lean structure and rely very heavily
on countries themselves and the part that is working in the country level
to then deliver the results that we've heard about.
And that's being challenging but I'm a large part has delivered.
I think the other thing that we've had in more recently
that's been made firmer is that as we build an alliance has gradually
got a clearer government structure and great accountabilities.
We're also beginning to see the importance of the private dynamic
in that debate. In our board
of our members come
from the private sector, people that come out of the financial markets.
They come with an independent and challenging mind
and bringing that dynamic is very vital. But also let's go back
to how it was started. I mean let's be honest,
without Bill and Melinda's contribution, GAVI would not have existed.
It required that vision to kick start a different way of thinking
and then to build and all the others gave their support since then.
In the announcements that you just made today
of another major investment in immunization more broadly,
$1 billion a year for 10 years, $10 billion is again in
to drive that momentum.
You touched on it but say a little bit about why it's an alliance,
who is it alliance of and just for people who don't know,
what does it really mean and who are the partners
because I think that's important.
I've been in this for so long now so I assume that everybody knows
what GAVI is. But GAVI is an alliance of the major multinational agencies,
principally WHO and UNICEF and the World Bank,
the Bill and Melinda Gates Foundation of course,
but also developing countries have a strong representation
of what are called the recipient countries, the partners actually
deliver the programs and the donors and industry
which was quite a breakthrough, having industry north and south
so from emerging markets, supplies, and then from the seat of industrialized
north added a new dimension to debate, civil society sitting with us,
and then lastly the sort of research creators I mentioned.
And so that's the kind of construction of this rather unique alliance.
I'll be honest, and again forgive me those of you that come
from some of these institutions, part of the downturn
that we saw in immunization coverage was partly it was
very individual-driven. Great leadership from an individual
such as James Grant in UNICEF and then when that man suddenly died
and priorities changed, it didn't turn out to be sustainable.
And I think that's what GAVI's brought and is bringing institutions together
with a more incremental approach rather than throw the money
and to get that huge picking coverage and not clear
how it's going to be sustained to build the necessary system,
not quite a different way of working. It also - alliance is not easy,
there's tensions in alliance as you've got to work at them,
you've got to build trust, you've got to have a common vision,
and it's not a given, and it's hard work.
And to sustain the lines for that kind of vision is important
but I think GAVI's made great progress in that direction.
Again, if I'm honest, there was competition between agencies,
that's gone, there's much clearer understanding of respective roles
and responsibilities of agencies therefore I think the -
add together some other parts and the whole is significantly greater.
And having that by and the alliance partners means that you kind of
keep the commitment strong and it doesn't rely on one organization
or the other to have that commitment. Melinda, a lot of deserved credit
has gone to you and the Bill and Melinda Gates Foundation
for the incredible, not only the financial commitment
but, as Julian said, the vision to make that kind of investment.
I also know that you don't make investments like that
without a lot of thought going into why this versus another.
Say a little bit about why early on you and Bill and the Foundation
took a big bet on GAVI and thought that this was something
that could make a difference.
Well when Bill and I were just very, very early thinking
about getting into the health arena and we were trying to learn,
we read this article that just really took as aback to be quite honest.
This article about half a million kids dying a year in the world of diarrhea
and you just say to yourself "Now wait a minute, I live in Seattle,
I travel to places like London or Paris, kids don't die of diarrhea.
How can this be happening? What is it that allows this to go on?
Why isn't somebody doing something about it?
There must be somebody tackling this" And the more we came to learn about it
and what the market failures were and why there weren't incentives
for the drug companies to actually create a vaccine
for the developing world we said there has to be something
that can be done about this. And we had this key dinner at our house
with some scientists where we just committed an amount of money
to do childhood vaccination because we were stunned also to see
that the vaccination rates and you had this system
but for whatever reason it was crumbling around the world.
And at the end of the dinner after a lot of discussion
about vaccines and childhood deaths I remember Bill leaving the scientists,
we thought we were done, and right after dessert
where everybody was ready to go he says "I just want to leave you
with one thought and that is how do we think big
about this problem?" When I think now about GAVI and what has been created
by this partnership the last 10 years and to sit and watch "Okay
this thing got launched 10 years ago" and say "This was thinking big,"
and it was thinking big about saying here's a goal
that we have as a world and let's pool the partnerships together
and let's figure out who can
in the different ways. So Bill and I initially thought "Okay, we'll make
this $750 million investment over five years"
but it went so honestly so well the first five years
and there were tweaks, there were things that I needed
to get reshaped but we had confidence and we put down a second bet
of $750 million over 10 years with the idea that we knew governments
were coming in and that our money may look big in this
but we have to be honest, it's not, it's government funding
and so many of the things that make this work
and now we've got this amazing rhotavirus vaccine that is just now
being delivered in places like Nicaragua
and that's going to spread all over the world and GAVI's been huge
and WHO and UNICEF all in partnership about getting the financing organized,
getting the technical approval, and actually getting it out
on the ground in the countries. We're going to bring down
the childhood death rate because of these vaccines.
So when you say that and you look at how inexpensive it is,
it makes us want to invest all the more.
It's an inspirational story and we're going to get back
to the story of Nicaragua and rhotavirus a little bit later
on in the session. Turning to *** Clark for a minute,
Merck has a long history of investment in vaccines
and it's really been laudable but GAVI has really been something different
I think in many ways. What were the kind of incentives
for you from an industry perspective that made you feel like GAVI
was a model that was worth being involved in
and what have you seen from your experience working with GAVI?
Well certainly, and it's already been discussed, the issue around it,
the funding capability and the reliability of funding,
the political will and the infrastructure
that you need in countries in order to deliver vaccines to the children,
the clinics has put in place. But the manufacturer's standpoint,
able to have reliable demand forecast, be able to go back into research
and plan, to be able to build vaccine facilities which takes years and years
and billions of dollars is very important to us
so that we can meet the demands of the developing world.
And with the advanced marketing commitment pilot, our ability
now to go back for a pneumococcal vaccine for example
and begin the planning and do it differently
so in fact we just signed an agreement, went Biological E
which is an Indian pharmaceutical company to have them think
about development and manufacturing for the developing world.
We would have never done it that far in advance if it wasn't for the success
of GAVI. When we formed the Hillman Institute which is joint venture
between Wellcome Trust and Merck to form a joint venture,
non-profit research capability in India and whether to start working
on developing world vaccines today and to optimize the current vaccines,
we would not have thought of that in the past. And so you have
to give GAVI and the inspiration and the mission they have
to really have the pharmaceutical companies think differently
about this and I think we're doing that.
So all of this doesn't really matter unless at the country level
it really is making a difference and it's really driving up
immunization rates and really changing mortality rates of children
in the community. So from a country perspective, Minister,
what has GAVI meant to you? What have been some of the lessons
and are there ways that you think GAVI could continue
to even more strengthen the ability to increase immunization rates
and save children's lives?
Well thank you Helen. Our country is committed to attain the NDG 4
and if things are going the way they are we certainly will.
There are the clients which are very encouraging.
If you look at the rates of 1999 and compare them with the demographic
and household savvy which we did two years ago,
there is a 38% drop of the mortality of the under 5s and a 41% drop
in the infant rate. We're not doing very well with the neonates
but that is probably related to the high mortality rate that we have.
These gains have been attributed to a lot of interventions
that we are taking place. We have vitamin A, IMCI, and so on and so forth
but the one we think that has really made the difference is immunization.
We have maintained a high immunization rate
and you'll find that some of the diseases which were common place
is difficult to find them there, In our main hospital we used to have
a measles ward and now we are finding it difficult to get
a measles patient to teach our medical students.
Even diphtheria, pertussis, or tetanus, they're also hard to come by.
So if the mortality has declined I think it's because of the cost
effectiveness of immunization and thanks to GAVI.
GAVI came on the scene I think in 2000. We're one of the first countries
to make an application and got funded in 2001.
And since then I think many such initiatives have to learn
from GAVI because their support is timely and predictable.
When you have an initiative like that, you think something
which is predictable and that is what we get from GAVI.
So we find that the immunization rates have been coming up and the least
of all is 84% and some of them we go right up to 80%.
But also when new vaccines came on the scene they were there to help us.
We've been able to immunize 88% of our kids with HPV
and what does it mean? Ten years down the line we are going
to get less and less hepatocellular carcinomas
and that is something to proud of. Last year we had haemophilus influenza
vaccine and we vaccinated 80% of our kids and it means
that the pneumonias which were taking our patients may be now they went
to common history. This year we are planning to put into our API
the pneumococcal and next year the rhotavirus.
But they've also helped us with immunization support
in terms of training and logistics and even vehicles.
They have helped us and also the injectional materials
to have a new type of injections which is very important in our area
otherwise you are going to transmit *** or other diseases
if you're not careful with injections.
that you can only do one here.
One and you can't use it anymore. And also we have an ongoing
what we call the "reach every district strategy"
or "reach every child strategy." When we do the vaccination
and go back to see how we have done, we find there are some districts
which are less performing so we go back to revaccinate
and that has helped us a lot. Also in the financing,
the country also does - for every initiative that we do,
anything that goes into my budget there is a budget line
from the government and I would like to see that increasing every year.
For instance when we had the pentavalent vaccine in 2008,
we spent $1 million and that's no little money for a country like mine.
So we make sure that we are not completely reliant
so that one day GAVI will say "You go on your own way"
we should not be left in a vacuum. So we are grateful to GAVI very much
so because of this sustainable type of support.
Our appeal is that when new vaccines come on board they take too long
to reach our countries. Just like the pneumococcal for instance.
Studies were done in Africa but we are the last to receive them.
So we should think about that. And also you visited our country,
we've been talking about immunizable diseases,
some of you may not know that cancer of the *** is a big killer
in my country, actually 47% of all the cancers, children, male,
female is cervical cancer and we know what causes cervical cancer,
we know we can immunize, we know we can - we have serological tests
so my appeal is we need to find some mechanism to help us.
We are the needy but we are the ones who are least prepared actually
to handle a situation like that.
And we may want to come back and talk about the situation
of HPV but this has been some kind of a GAVI love fest.
It has been great and there have been some incredible successes
but obviously this has also had some bumps along the road.
Julian say a little bit about some of the things,
as you look back, that could have been done differently.
What are some of the lessons that are learned,
things that you think could have improved
how GAVI functions and things that you're thinking about moving forward?
I think one of the areas that perhaps we underestimated in the early days
was the speed by which vaccines could become affordable
because our first set of vaccines that we introduced were quite pricey.
The Minister has pointed out, this isn't a free lunch,
and the way GAVI works is that countries
is according to our ability to pay. But over the short timeframes
that we had it was rather uncertain about what was the exact strategy
and was this going to be feasible? Was this sustainable?
Where are we putting budgetary time bombs into the government of Tanzania
putting in a vaccine and GAVI wouldn't be there
three or four or five years later and then who's going to pay
for the vaccine now?
We learned about that and I think one of the things we have done
is that we've taken a much longer timeframe, a longer vision
so commitments of 10 years of financing again
from the Bill and Melinda Gates Foundation
but also the International Financing Facility for Immunization
which came on the stream three years ago and innovative financing instrument
that gets long term, legally binding, predictable financing from donors.
We raise it from the capital markets as bonds but it allows us to enter
into multiple agreements with governments
and if I was a Minister of Health or a Minister of Finance
I would be enormously reluctant to take on somebody's products
unless I knew this was not a fly-by-night project.
And I think in the early days of GAVI there was some uncertainty.
would we be here in the long term? And I think that's completely changed
and therefore allows ministers of health to have ambition and to scale up
but also I think for industry. Industry now sees that a market
has been created as one they can have confidence and that you can have
the confidence to invest in and to go forward. And I think
we're still unpacking some of those dynamics,
how can we shift prices in those kinds of areas.
I'll stop there because I think those are some of the key issues
that we struggle with. The other though has been perhaps about understanding
what is the necessary platform
everybody talks about health systems and everybody either falls asleep
or says "What are you talking about?' it's a big black hole.
I tend to talk about what is the delivery platform
for an intervention. But at the end of the day it's going to be the same
3, 4, or 5 health workers in the district
and they go to do the antenatal care, they have to do the ***,
treat the malaria, they have to do the vaccines.
How can we more effectively think about what are those delivery platforms
because that's part of the sustainability answer.
We need those kinds of platforms to ensure the vaccines
continue to get out. And many times we did have successes but in others
it remains to me uncertain whether that sustainability will be.
Yeah and I think it raises a good issue that some of the critique
or at least observations about GAVI is that this is based
on a very product-driven health intervention.
Is the rest of what needs to happen to increase immunization rates
actually happening? Is GAVI the right mechanism for the system's piece of it
and what can GAVI contribute to it and where does that stop
and then how do we make the links to the rest of what needs to be done
for health system strengthening?
And maybe you might want to comment on that, Minister?
If I heard you correctly you said it's a product-driven initiative.
I'll say it's not purely product-driven because what I was saying
a few minutes ago they have helped us with
to try to get the vaccines in cold chain.
Our people live out there in the villages
and to get the vaccines in the slum is not getting the vaccine
to the people who need it. So they'll provide us with vehicles
plus training our people so what I would say is much like
we were talking with the global fund, there are disease-specific
but we took them on board to come and talk
about health system strengthening. I think GAVI are doing that as well.
And I think that's a piece that often gets forgotten,
that in fact GAVI is not just a funding mechanism,
it's not just about getting a vaccine to the place
but it's really looking at the whole piece in the system.
Yes I just wanted to add and echo the comments that are being made here.
I just was in Malawi, actually in Benin earlier this week and in particularly
Malawi I went out to see several things because of some of the great work
they've done to get their childhood deaths of kids under 5
has really been - they've been ticking away at it year after year after year
and they're one of the only two countries in Africa
that's likely going to meet the millennium development goal
of reducing childhood deaths by 2/3 by 2015
and so I wanted to understand better what they're doing
and see some of the partners work. And when you get out there
and see what they're doing, so this is a country that's
one of the bottom 10 countries in Sub-Saharan Africa
in terms of GDP per person, about $770 per person,
so very, very poor country. But the government,
they've applied to GAVI, they've gotten GAVI financing
over time, they've committed 5% of the money to the pentavalent vaccine
and what that has allowed them to do is at the same time
the government recognized the issue that they had to train
health surveillance assistance very inexpensive people to work our
in the village. They've now trained 11,000 of them. They work out
in the remote rural villages which is where 85% of their population lives,
they have a population of about 13 million people.
Well these health surveillance assistants work three weeks
out in the rural village and then they move into the clinic
and the nearby hospital and work one day a week out of there.
So they're doing the immunizations one week in the clinic or hospital,
they're doing a few out in the village but they're in - they live out
in the villages so they're in constant communication with the mothers
and the parents in the village and so they can reinforce
all kinds of things, not just getting the basic immunizations
which is really, really important for the childhood under 5 deaths
but when we look at these childhood deaths and we say "Okay, in the 1960s
there were 20 million childhood deaths."
We're now, as of 2008, are down to about 9 million childhood deaths.
Of those 9 million, 4 million are the deaths of under 5
or the neonates, the first 30 days. These house surveillance workers
can really be out in the villages giving the messages to the moms
"You have to get to the clinic four weeks ahead" which is what
the moms are doing now "to deliver your baby. Yes you wait
around for 3 or 4 weeks but the difference between a mom
being in the clinic to deliver her baby is literally the difference
between life and death for her and that newborn.
So you can link up everything that's happened from the immunization
goes all the way back out in the rural villages
so they're going to start to be able to bring down
the maternal death rate and their neonatal death rate
and that's when you see the system working all the way through.
And if you say "If it can be done in Malawi it can be done
in a lot other countries."
I think it's an incredible example of how one intervention
can really be used to spur changes across the whole health system.
So it will be great to hear from others also.
This has been a very particular experiment. It's been focused
on getting vaccines out, strengthening the systems.
It has a fairly focused approach and a focused agenda but as you said,
Melinda, it's a way of actually also having broader impact.
Does this model, the GAVI model, what aspects of it would work
for other health challenges?
What pieces of it have we learned that we could possibly use
for whether it's maternal mortality, non-vaccine preventable diseases
and also from an industry perspective, I'm just going to ask you all the -
chime in when you want, from an industry perspective,
what does the GAVI model say to you about ways in which industry can engage
in some of these big health issues? Take it away.
I think that one of the important things we have learned over the years
and I'll go back to the Botswana experience where Merck
and the Gates Foundation worked in Botswana for over a decade now
and it was easy to get the product to the country, what wasn't easy
was building the infrastructure like Melinda said.
Whether it's free clinics, whether it's education,
whether it's healthcare professionals, whether it's teachers,
that took a long time to do and I think those experiences
will help us with the GAVI experiences particularly as we go forward with HPV,
I think that's going to be important sequencing to get that right
as we move forward. But now if you think longer term with chronic diseases
and where we're headed with obesity and hypertension and issues like that,
to use this type of model to take that on as a potential new frontier
to try to get ahead of all of that and get into preventiveness
and wellness and all the adults standpoint and the elderly standpoint
would certainly have an impact not only the wellbeing and health
but the issue around the healthcare cost within these countries
to be able to bring out - sorry, I think that's important.
From an industry standpoint, industry engagement is critical
and I think one of the successes we've had with GAVI is to bring
the industry in earlier to have those dialogues and debates
and discussion so that we're able to get that idea and that strategy
and that long term planning done correctly because we truly want
to be at the table and we all have the same missions and values.
An issue that still is a concern to us is tiered pricing.
We have a very serious concern over making sure that the GAVI countries
get the lowest possible price, none for profit-type price
and then you have middle income countries wanting that same price
as well. That's a threat and we have to be able to solve that quickly
in order to keep that sustained movement towards the proper relationship
between the industry and GAVI.
I think one of the characteristics rather than saying product-driven
I would say results-driven and I think that one of the lessons
for other partnerships and organizations is
'Okay you have the delivery platform but what is it there to focus
on deliver with a series of results that's going to maximize
health impacts?" I think that remains absolutely valid and I think
how you're going to measure that result remains a challenge.
I think there's more that we need to do there. And particularly
as we begin to move more into results-based financing
where we're through as GAVI did in the early days and continues to do,
how do you reward excellent performance and begin to intensify
management systems and delivery systems to do that. And I think
there's a lot of potential there but I really would like to echo
creating these broader partnerships as early as possible
where the key stakeholders can make a difference.
vital thing about GAVI and is a vital thing about other interventions
whether in maternal, health, or in other areas of child health.
These are not going to be solved by one act,
I think that's one of the things we've learned from GAVI,
bringing together stakeholders and then getting it country driven,
having the ministers. And that's been the success of GAVI.
The success of GAVI is not the funding, it's not the product,
it's actually the countries from the south that take ownership,
leadership and use GAVI.
Finance and the products were able to supply.
Two deliver results to that people and be able to demonstrate that
they're making progress.
And I think it's an important point because again there have been critiques
that GAVI is too top down, doesn't involve the countries
as we're all partners and I think that kind of examples that you've given
in fact show how that partnership - maybe it didn't start perfectly
but how that really has emerged over time. Melinda, you look like -
Well I was just going to say I also think the model of GAVI
and people seeing this public/private partnership really work
even in the early days and there were things to work out.
I do think it was an inspiration for the global fund
and I think in the whole mechanism for public/private partnership
to the global fund and then working with country coordinators and countries
up to applying to the fund and the funding going out.
And then again your
looks at and they don't structure it in the same way but they say
"Okay GAVI's done this very innovative type of financing, what can we do
that's innovative kind of financing that will support global fund
either through the global fund or on the side of global fund
that will give money." So global fund is focused on AIDS,
tuberculosis, and malaria just like GAVI,
they've got a very specific mission and goal and I think seeing that
a public/private partnership can work made people willing then to -
again large scale government investments willing to invest
in something like the global fund.
Do we need GAVI as in global fund for every health issue
we're trying to tackle? How do we use what we have
from these new mechanisms that can really help extend
our ability to make an impact more broadly?
I don't think that we necessarily have the resources or the appetite
for having a GAVI or a global fund for every single disease
that we're trying to tackle?
Yeah I don't either. I think particularly
in these times of recession when all government budgets
are facing pretty large crises, the message to them is the institutions
that have been set up are really working.
We need to keep the funding as is or increase slightly, not decrease.
I think that's going to be very difficult in the next 5 years.
So to go and ask for a new type of fund I just don't think is realistic
but I think trying to show - get the success messages out
of where this has worked and then talk to the countries.
They're great countries doing also specific -
this is all multilateral work, but doing some bilateral work
around specific goals maybe around maternal and child health
that are in conjunction with the work that's happening
with global fund or with GAVI. I think that may be the way to go
on maternal health. I don't think we have that solved yet but I think
we have to be very realistic about where governments are today
with their financing.
I would say the sheer number of institutions like GAVI
is not very important. I think what we should be talking
is that any major disease should have a funding mechanism
like we have in GAVI. Like *** said just now on Wednesday
we are talking about chronic diseases and someone remarked that in the MDGs
chronic diseases don't appear anywhere. And the suggestion that came out
which I agree with is either we start a fund, a stand alone fund,
or we can make it to some other funds which are there. What we want is
to give a focus to those diseases which there is little
that is being done in terms of financing
and get the global community to support particularly
the underserved countries like mine.
Yeah Julian go ahead.
I think another approach is the more coordinated harmonization
of different efforts led by national strategies
and I'm being very careful that everything that GAVI does
or the global fund does isn't undermining or distorting
priorities at the country level. It is actually reinforcing
or integrating ways and we can do that and as you know
the global fund, GAVI, and the World Bank have come together
to see how can they better coordinate
their efforts around some of the platforms of system building.
And I think that's another way forward because I think the Minister
might be being quite polite here as well but I know that many ministers
suffer from 200 visits a year from different institutions
and initiatives and NGOs which can itself be paralyzing
and I think we've got to change the way we do that business.
So I think the more that GAVI, global fund and those can be sensitive
to those issues and structure our finance and our support
country level in our case so that the UNICEF has a vital role
in ensuring that our support is supported or what's going to happen
to maternal health and not undermining the resources that we're providing
as supporting initiatives in that particular area.
I think as the governments, just as you're saying,
when you go on the ground in Ethiopia, again a lot like Malawi,
they have 20,000 of these health extension workers
and they literally have a framework as does Malawi now,
to help slot the partners in to say "Okay, this is who's already
on the ground working in x number of our districts
and these are the places that would be helpful as you come in
as a bilateral donor to really fill out our framework. This is where
we still have holes that need to be filled in."
It absolutely though has to come from the governments, I completely agree.
So more funding, more focus, more results, but not necessarily
more mechanisms to figure out how we'd do a better job of integrating
what we have but make sure that the resources are there
and do what we need to do to create those kinds of resources.
Yeah, Julian.
And I think also I understand what are the - I don't like the word
but I'm going to use it - comparative advantages
of different institutions. GAVI was very much set up to welcome
global public goods to work with industry and the market,
to shape new products coming in faster, better prices. So understand that
as a separate added value at the global level
which I think is a good rationale for GAVI's other separate role.
Great. I'm going to switch gears for a moment. We're going to show
another very short video and this is one - we've been doing
a lot of talking about mechanisms and how things work in institutions
but what we really want to do is to show a little clip of a film
that the Gates Foundation produced that shows the evolution
of a new vaccine and this is the rhotavirus vaccine
that Merck was able to develop and make available. So we want to show
a little bit about that and then we want to open it up to the audience
for question and answer and I have a couple of people
I want to call on particularly. I'm going to start with you Ian Smith
from WHO because unfortunately since Margaret's not here,
we would like to hear about WHO's view of this
as the World Health Organization and how a mechanism like GAVI
helps or doesn't help what you're trying to accomplish.
All right, let's see the video,
Three years ago we had high rates of diarrhea and severe dehydration.
We had so many cases that we'd have two babies sharing one bed.
And it was hard to loose so many of our kids to rhotavirus.
My daughter's name is Scarlet Sarah Alvarez.
She is my princess. We are here because she's sick.
She's vomiting and has diarrhea.
As a dad I work to protect my kids but sometimes I worry.
We started working on this in 1980. It took us about 10 years to figure out
how to make the strains that ultimately became the vaccine.
In 1990 we went to Merck and they did the research
and development over a period of about 16 years.
The trick is being able to get that vaccine from, in this case,
this manufacturer in the United States, into the mouths of children
in the developing world and that's hard.
The rhotavirus vaccine needs to be refrigerated.
It needs to be refrigerated on the way to the country.
It needs to be refrigerated while it's being delivered to the clinic
and then it needs to be refrigerated really right up into the time
that it's given to the child.
When this vaccine arrived in Pantasma,
the number of cases of diarrhea dropped.
Today, we don't have a single child that made it into our rhotavirus ward.
We are going home today. If she hadn't been vaccinated,
she'd be a lot worse. She's two years old and I hope
she grows to be a strong and determined woman,
a superstar, right my love?
Hard not to feel good about that. So I'm going to turn it over
to the audience but I would like Ian, if you want to say a couple of words
from the standpoint of WHO and how has GAVI fit in to
what WHO is trying to accomplish in child vaccinations.
Thank you very much and thank you for the discussions
so far I've been very, very interesting and Dr. Chan sends her apologies
that she's not able to be present. She would have loved
to have joined this and I know she would have wanted to send
her congratulations to GAVI on the 10 years
and also to warmly applaud the extraordinary announcement today
from the Foundation. I also know that what she would have liked
to have said would have been to say how we've learned from the experience
with GAVI over the last few years and what are the key lessons
that I think - not just WHO but the world has learned
from this experience. Perhaps just focusing on three specific ones.
Some of it just came out already but perhaps not entirely.
First of all the value of partnership, interestingly partnership
has been critical to vaccination even before GAVI.
The '80s and the '90s partnership has always been a fundamental element
of success in immunization. But we've not always done it very well,
there have been mixed experiences with partnership over the years
and I think what we've learned through GAVI is ways of doing
partnership well and that's been really critical to the success.
A second thing we've learned I think is the value of innovation
not just innovation in terms of product, new tools
but innovation in different ways of working, innovation in ways
of financing, in getting additional resources,
innovation in ways of working to increase access to vaccines
to be added, for example, in the past, the perks and results.
All of these innovations are now being used as we've mentioned.
And perhaps the third thing that's been so critical
has been the value of delivery systems and I think immunization programs
are often the backbone of health systems in many countries.
They're not just delivering immunizations,
they're not just delivering vaccines, they're the basis
on which many families, many children get micronutrients, get mosquito nets,
get all sorts of other - antibiotics, etc.
It's often been the backbone of development in the health system
and it's contributed to better health planning, better surveillance,
better monitoring, better laboratory standards etc.
So I think we've learned a huge amount through immunization programs
and through the support that GAVI has provided to them.
But as we look to the future, I think there are again perhaps
two or three challenges that lie ahead and some of them
have come out already. One of them is this issue
of well we dearly need resources in other areas other than just vaccines
and ***, TB and malaria so how do we take the lessons of GAVI
and replicate them not in creating new funds, new global funds
but how do we get the existing mechanisms to get more funds
but also to then address other critical issues
like maternal mortality and CDs and so on. The second challenge
is how to move from a dependence on donor resources to country-owned,
country-resourced programs where not just the products
are being bought by the countries through their own resources
but in some cases in being produced by the countries,
the transfer of technology that's needed in the countries.
How can we facilitate that in the longer term?
And then finally how can we - we've made great progress
but we've clearly got a lot further to go.
We've got nine vaccines out there but we've got at least another 10
that are not really widely used. And obviously we need to be
not just sustaining the current achievements,
we need to be going way beyond them and what's that going to take?
So there's a number of challenges that lie ahead.
Lots to be thankful for.
Lots to celebrate but also a lot more to do in the future.
Great. Thank you. We have about 10 minutes for questions
and I would like people to keep questions as brief as possible
so that our panelist have a chance to respond adequately
so I'll take the first question here and yes.
I have a comment and then a question. This is in support of what Mr. Clark
and the honorable Minister mentioned about
the chronic disease management. More than 505 of people
in emerging markets die of chronic diseases today.
It was earlier only developed countries
and this can be prevented and reduced enormously through education,
through communication and also a low cost, early diagnosis.
So I think it is an area which has not been there
in any of these health management programs and the kind of impact
it can make in reducing health costs and saving lives has been enormous.
So my thought for you is that is there another model
if you're looking at in the future in the next 10/15 years?
Is this an area one should look seriously in terms
of doing chronic disease management? That's the question I would like to ask.
I think broadly speaking I think the question of how does this model
potentially can it be extended for other things like chronic diseases
which we know are clearly causing a huge health burden
in emerging markets and emerging industries?
Truly I know the governor's healthcare committee and conference of CEOs
across the world are taking this on as a primary project, as a pilot
to think about chronic diseases in many of the emerging markets
so we certainly don't have a solution yet but we're taking it on
as a project and ideas about what the future should be
and certainly looking at the successes of other organizations
and other funding mechanisms. In the infrastructure
you need to be able to accomplish this, something we're taking into impact
so hopefully by next year at this conference
we actually have some updates on that.
Next question. Feel free to say who you are and -
I'm Justin Picardo with advanced.
My question is on the problem of counterfeit medication.
You have some countries now with 50% counterfeit medications
or medications that don't heal or can kill the patient.
You have an estimated 700,000 people dying because they have been treated
with counterfeit medication for malaria and tuberculosis.
There starts to be evidence that counterfeit medication promoted
more resistant strains for malaria so that could make it more difficult
to eradicate this disease. So my question to the panel
is is it a concern for you and what are you trying to do
to address this problem which is growing and growing every year?
I think on the vaccine side it's a rather different market
that you're dealing with and we haven't in GAVI faced
any of those types of problems but that doesn't mean to say
we won't in the future but one of the ways we manage this
is pre-qualifies manufacturers
so that we know we're getting quality products.
UNICEF does most of our procurement and therefore they really ensured.
What we can't have as a single bad vaccine in any country in the world.
The ramifications are enormous as we know here in the west
but everywhere else so we pay very close attention.
Hello. Jamie Germont of the Global Anti-Poverty Organization.
Some of the statements up on the screen behind you duly implied
that GAVI's fully funded through to 2015
and hero commitment this morning by the Bill and Melinda Gates Foundation
would also suggest that this issue is well financed and in fact
that commitment should be matched 10 more by governments.
Maybe you could articulate exactly how much you need.
What is the financing gap? Where is it going to come from?
How can groups like one who things GAVI's amazing help?
And before you start, Melinda would you just,
for those who haven't heard your announcement from this morning,
would you just repeat what you actually - the wonderful announcement
you and Bill made this morning.
Yes. Bill and I made an announcement that we're going to commit
$10 billion over the next decade to basic immunizations
to get the basic packages out there and also to get new vaccines created
and out to the developing world.
Fabulous. Fabulous announcement.
Notwithstanding that generous contribution to vaccination broadly
there is a real challenge, you're quite right Jamie,
to be absolutely clear about this.
GAVI is sufficiently financed, you're quite correct.
for our existing programs that we've committed to countries.
This is very important, this is part of our long term
sustainable commitments. But all our ambition for the future
whether it's pneumococcal vaccine, whether it's diarrheal vaccine,
whether it's HPV in the future is going to be dependent
on the success in mobilizing finance and that challenge
since the economic crisis is a tough one
but the kind of momentum created by the Bill and Melinda Gates Foundation
leverages others and we need to work very hard to do that.
Now we have amongst the most cost-effective of interventions,
the most affordable of interventions, we have a very strong message
to be able to say this is where our focus should be in child health
in these areas and we have a great track record
so we have a lot to build on but it is challenging.
We look to organizations and others to work with us to mobilize
that finance and particularly civil society.
I think if we're honest in the *** world,
there's a strong civil society which is fabulous,
which has helped mobilize finance, keep the pressure up
and we'd like to build the same thing for child health
and for maternal health I would like to say as well
and we need to build that same constituency
because it's just as vital, just as important.
Every year more children die from pneumonia than die from ***,
TB, and malaria. Now I'm not saying don't do ***, TB, and malaria.
I'm saying absolutely do that. That needs to be financed
but let's me rebalance with financing to other very important MDG areas.
And I hope that this session and seeing the successes after 10 years,
part of what we do from here is to go out and continue
to put the pressure on to keep the momentum going
because 10 years of success is not enough.
This has to be a rally and cry in many ways.
It's great to talk about 10 years of success
because we sustained this success and these 10 years really
make a difference and I think that advocacy part and I look to Melinda
for the living proof and what you're doing
through telling the kinds of stories that you're telling to give people
the hope in fact if you can make a difference
I think that's what gets people mobilized to do more.
And we have to be serious, this has to be large government funding
that comes in and advocacy groups. I mean what one has done
for the global fund to keep pressure on governments,
to keep governments honest about what their commitments are,
but also to create new financing which they've done through Product Red
to get businesses signed up so that a certain amount
of their profit from Armani products, GAP products, Hallmark products
goes towards the global fund. They've raised over $100 million
for global fund, that's something nobody dreamed of 8/10 years ago
so we're going to need more help with advocacy and creative ideas
of how do you keep even private money from flowing towards mechanisms
like GAVI and global fund.
I think we have time for one more question and then
I'm going to ask the panel to just kind of maybe give
one last comment on what do you want this audience to leave here
knowing about GAVI and the successes and how we can take forward
the successes of GAVI to more broadly have an impact on health
so Francis Collins.
Yeah, I'm Francis Collins the Director of the National Institutes of Health
in the United States and I want to express again our congratulations
to GAVI on this 10th birthday and to the Gates Foundation
for this amazing announcement today. Global health is one of the priorities
I'd like to set for NIH in the coming years
and one of the challenges is to figure out where are the gaps.
We had a meeting about three weeks ago that I think helped identify
some of those. As we hear about the progress that's being made
with vaccines and it's really quite exciting, it seems like we should
be planning for success in every possible way. NIH's investment
in vaccines is largely in the discovery and development phase and we spend
about a billion dollars a year on that when you add up everything
that's going in to ***, tuberculosis, malaria, influenza, etc.
But we don't in general have as part of our mandate
because we're a research organization the delivery part. So my question
is do we have a good assessment of whether the impedance matching
is optimized. If we imagine new vaccines getting developed
in the coming years and it seems quite likely they will be,
are there predictable rate limiting steps that will block
for a longer period than you would like,
the ability to get those in a country where they are most needed?
And if so, what are we doing to try to anticipate what those obstacles
might be and knock them down?
Part of the design for GAVI was to shorten that timeframe
and using innovative mechanisms such as the advanced market commitment
to get a pneumococcal vaccine 3 to 5 years faster
and we would have done otherwise. I completely agree with you
and I think a better analysis of those rate limiting steps
as new vaccines and new products are coming through needs to be done.
There's a lot of lessons really still to be done in GAVI
but I think it's a critical point you're making.
And maybe from the country perspective we've talked a lot
about these mechanisms but you'll clearly
at the country level there are real obstacles.
There's the health work force, there are systems.
Maybe if you want to say a little bit about where you see
some of the obstacles from the country level.
You mentioned some of them so eloquently. For instance
I have one worker to 30,000 people but for every level of work force
we have very few of them and the majority of the people
like to live in towns, 80% of my population is out there
in the rural areas. In those we train wouldn't like to work
in the rural areas so we are incentivizing them,
we are improving conditions because rural means poor, no road,
no running water, no electricity so it's not just a health issue,
it's a whole government. has to build roads,
we have good transport and so on and so forth.
Great. Well we are about at the end of our time but I really would like
to give each of the panelists just a moment to just say
what's your big message you'd like to leave the audience with
and I'll start with *** Clark and I'll just say we mentioned
several times HPV and just to recognize the role that Merck has played
in already trying to jump start some of the work
and getting that vaccine available in developing countries.
But everybody, what's your last thought that you'd like to leave
the audience with?
Well certainly from a Merck standpoint and an industry standpoint
our commitment and our excitement now about the ability and basic research
and clinical development to not only think about vaccines
for the developed world but at the same time think about them
as for the developing world. So when these vaccines were approved
in the developed world, they developed it,
they approved at the same time for the developing world
in the past. We can't have that happen anymore so our mission and our values
is to make that happen in the future and I think the second important thing
is access. We've got to make sure that the pricing is right
from an access standpoint. It does no good to create a wonderful
vaccine and then patients and governments cannot afford it
and that's our commitment as well.
If I could leave one thought with the group it's this,
this type of aid, this health aid is incredibly effective
and it works and we now have evidence. I mean we don't have to sit around
and debate anymore. We know we're saving lives
and so getting stories out there about how it's working, what we see
so that we can keep donor commitment up both from private companies,
individuals and governments. If we can get the stories out there
and keep the message in front of people "this is important
and we need to keep at it."
but the audience in general, how do we get the messaging right
because the wrong message is we need loads more money.
Yes we need more money but it's in a context of a design
of GAVI that also looks to a long term financing scenario,
one where governments gradually increase their coffers
and we need to understand the ability to pay better so that we can
differentiate that response. There's also how we shape markets
and get the right products so we can drive down prices as well
in different ways so as prices come down as government's budgets go up
and as co-finance increases, that is the out for GAVI
but there's a timeframe for that which.
Get that messaging right and that's a very powerful message
to convey to donors who invest in GAVI and to put more money at this time
and I think we still need to work it, really learning the lessons
and the timeframes and different scenarios to convey that message.
I personally would like to applaud the spirit on which GAVI was founded.
Here we have a set of conditions, health conditions, and I think
what has been manifested is that health is a global issue
because starting a fund like we have in GAVI, the majority of the people
here and even those who put in the kit have never suffered from this diseases.
Just because a health situation in our part of the globe
is a health situation in your part of the globe. I think I would thank
on behalf of we, as beneficiaries, I would like to keep up the spirit
and we mentioned that as conditions GAVI is there for us
to emulate, try to fight health conditions together
as one family in the world. Thanks.
Thank you and as your moderator I just want to thank all of you
the wonderful panelists for you presentations,
the audience for your great questions. As a health professional who now works
in a development organization I must say that I continue to believe
that our investing in the lives of children around the world
is one of the most important things we can do so it's been my real honor
and pleasure to be part of this and be part of this
incredible 10 year anniversary of this success story so thank you all.