The Lions have taken to the streets of Tanzania. Moving from village to village, suburb to suburb, they employ trucks with speaker systems, banners and dancers, glue brightly coloured posters to pitted walls, and hand out a mass of leaflets to residents. They are an army of some 500 volunteers, and they are dedicated to one of the most critical health campaigns their country has seen yet.
Lions Club International (LCI) is one of the many aid organisations supported by the Gavi Alliance, a global health public-private partnership focused on increasing access to lifesaving immunisations in developing countries. This current drive is part of a nationwide campaign to protect 21 million children against the diseases measles and rubella, two potentially deadly illnesses that claimed more than 120,000 lives worldwide in 2012.
The campaign will enable the largest nation in East Africa to transition away from using a single-antigen measles vaccine in its routine programme, and replace it with a combined measles-rubella (MR) vaccine – and so stymie two diseases with one jab. Gavi aims to help countries reach more than 600 million children with the MR vaccine by 2020, vastly reducing the number of deaths from measles and the life-changing disabilities caused by the viral infection rubella.
“The most cost effective intervention in health is to immunise your children”As children aged between nine months and 14 years queue up for inoculation, LCI volunteers assist healthcare workers and pass on relevant information to parents. The success of the campaign rests in significant part on the Lions, who are able to leverage local connections to achieve their goals, engaging with influential community members including religious leaders who draw attention to campaigns and urge people to get their children vaccinated.
“Some parents might bring their children and get them vaccinated automatically, but some might not know about the campaign or say ‘I’m too busy’ and not allocate enough importance to it,” says Benjamin Futransky, assistant manager of international humanitarian programmes at US-based LCI Foundation. “These are all areas in which Lions, through social mobilisation, can add value to campaigns… [ensuring] a higher turnout, better coverage and more successful campaign – ultimately more children vaccinated, less children at risk.”
‘More children vaccinated, less children at risk’ could be a mantra at Gavi, which recently announced a partnership with Lions that will see $60m funnelled into measles and rubella programmes up to 2017. A total of $30m was mobilised by LCI, a sum then matched by Gavi, which brings together governments and institutions such as the World Health Organisation (WHO), UN children’s agency UNICEF, the World Bank, vaccine industry players, grant-makers such as the Bill & Melinda Gates Foundation, and the private sector.
“The most cost effective intervention in health – and health leads on to development – is to immunise your children,” says Gavi CEO Dr Seth Berkley. “It keeps families from tipping into poverty, it enables children to live to their full potential.”
Gavi generates 75 per cent of its funding from direct contributions. The remaining 25 per cent is raised through the creation of innovative financing tools to secure long-term funding and adequate supply of quality vaccines to countries that may not otherwise be able to afford them. Since 2000, this approach has enabled the Gavi Alliance to contribute to the immunisation of close to half a billion children and the prevention of approximately 6 million future deaths – the equivalent of the combined annual birth rates of Afghanistan, Bangladesh, Mali and Yemen.
“We are spending 50 per cent of our money in the OIC countries and getting almost nothing from them”On the sidelines of the G7 summit in Berlin in January, chancellor Angela Merkel will host the Global Immunisation Summit, a replenishment conference that will dictate the availability of funding for Gavi through its next phase of operations, from 2016 to 2020. The organisation is asking for more money than ever before – a budget of $9.5bn – a result of the ever-increasing geographical scope of its operations. While it has already secured $2bn of that funding, it will look to donors from around the world to provide the other $7.5bn.
“In the period between 2016 and 2020, we aim to subsidise 2.7 billion doses of vaccines worldwide,” says Berkley. “In the period afterwards, we estimate it will drop to a little over 2 billion doses, so the requirements for financing will go down.”
While he acknowledges this is a “big ask at a time of fiscal difficulty in the world”, Berkley says the funding will help vaccinate an additional 300 million children and prevent between 5 and 6 million deaths.
Traditionally, Gavi’s top donors have been the UK, the Gates Foundation, Norway and the US. However, the Alliance has been trying to ramp up support from other donors, including Germany, Italy, France, the Netherlands, Sweden and Australia, as well as governments and individuals in the Organisation of Islamic Cooperation (OIC), which currently receives a large percentage of Gavi’s funding but contributes very little to its income.
Between Gavi’s inception in 2000 and February 2014, it provided assistance to 33 OIC member states, with disbursements of more than $2.9bn representing 50 per cent of its overall $5.9bn spending across 73 countries. By contrast, support from OIC member states stood at a meagre 0.3 per cent of donated funds. Berkley calls this the “single biggest mismatch” Gavi has with any region. Given the economic woes plaguing many of its traditional supporters, it’s now crucial that OIC states step forward.
“Many of the countries that have traditionally supported us are in financial trouble so it’s unpredictable what effect that will have,” says Berkley. “This is why it is so important we engage in the OIC region. We are spending 50 per cent of our money in the OIC countries and getting almost nothing from them, and yet still expecting countries that are so stretched to be providing support.”
Berkley believes that Gavi’s ability to show concrete, quantifiable results will attract donors to the cause. Investing in Gavi’s 2016-2020 plan has the potential to save between $80bn and $100bn in costs related to treating diseases and avert more than 100 million cases of illness. This will also result in a 10-fold increase – from less than 5 per cent up to 50 per cent – in the number of children immunised with the 11 vaccines advised by the UN’s health organisation.
In 2013 alone, Gavi funded 41 new vaccine introductions, campaigns and demonstration projects to help immunise millions of children and adults in developing nations. In 2014 it managed to introduce the pentavalent five-in-one vaccine across all 73 countries in which it operates. The vaccine immunises against five deadly diseases: diphtheria-tetanus-pertussis (DTP), hepatitis B, and Haemophilus influenzae type b.
“Gavi has been able to take this vaccine, which was a novel vaccine when it started, and bring it to every country,” says Berkley. “Some of those countries such as Yemen, Pakistan and Somalia are difficult countries so it’s extraordinary to see it rolled out.”
Still, one in every five children is dying of vaccine-preventable diseases, with the fifth child denied access to the most basic vaccines. This is the reality Gavi seeks to alter in the coming years.
“The challenge now is to reach the unreached,” says Berkley. “That is going to be the focus of the next period, and that is a much more difficult challenge because the unreached may be so as a consequence of societal stigma or geography, or maybe because they are unregistered.”
In addition, he notes, the migration of human beings to urban centres means that people move more readily from place to place in search of work – making them harder to track.
Nevertheless, reaching the marginalised souls will be crucial to the alliance’s efforts to chase down polio. Cases of the highly infectious disease have dropped more than 99 per cent since 1998, from an estimated 350,000 cases in more than 125 endemic countries then, to 416 reported cases in 2013. Today only parts of three countries – Nigeria, Pakistan and Afghanistan – remain endemic for polio, and Gavi’s rollout of the inactivated polio vaccine (IPV) should reduce cases still further.
Distribution of IPV began in 2013 as part of the Polio Eradication and Endgame Strategic Plan 2013-2018. The plan urges countries to phase out the use of oral polio vaccines containing a weakened but live form of the virus. Gavi has been able to negotiate a record low price of €0.75 ($0.93) per dose of the vaccine and has received applications from 66 of the 73 countries in which it operates.
The adoption of IPV may be the biggest switch in vaccine history, according to Sona Bari, spokesperson for the WHO-led Global Polio Eradication Initiative. IPV will end the use of type 2 polio in vaccinations, which is the leading cause of vaccine-derived polio and occurs when a weakened vaccine reverts back to a paralytic form in areas where routine immunisation is very low.
“This is a major logistical challenge because it requires over 120 countries simultaneously stopping the use of what we call trivalent or pro-vaccines,” she says. “It means stopping the use of one vaccine and introducing another bivalent that contains only [polio types] 1 and 3 into their routine immunisation programmes. We seem to be on track to do that.”
According to Bari, Gavi’s work helps protect children “from diseases that are entirely preventable and that we take for granted in many countries”. She recalls the afternoon she spent in her hometown of Kolkata in India, in the house of the last victim of polio in the world’s second most-populated nation. Sitting with the child’s remorseful mother, Bari heard how she had vaccinated her older children but delayed inoculating the youngest as the girl was ill at the time. Consequently, the mother blamed herself for not protecting her child from the disease.
“This was not through any lack of loving her child, but it really drove home to me that parents make the choice they think is best for their children,” says Bari. “I was fortunate to have opportunities for a healthy life that we need to make sure kids like this have.”
In purely financial terms, eradicating polio entirely could save the global economy between $40bn and $50bn in reduced treatment costs and improved productivity. The alternative, a return to the days when 200,000 children every year were paralysed by the disease, would be “morally unacceptable”, she says. Thanks to the work of organisations such as Gavi and the Lions, those days should be firmly in the past.
Since 2006, Gavi has raised $4.55bn through its International Finance Facility For Immunisation (IFFIm), which used $6.3bn in long-term donor pledges to back the issuance of vaccine bonds. In November, IFFIm expanded its offerings and issued its inaugural sukuk, also known as Islamic or Sharia-compliant bonds, in Abu Dhabi, UAE. The three-year notes were oversubscribed and raised $500m towards immunisation in the world’s poorest nations – and the majority of it from new or Muslim investors.
The Abu Dhabi sukuk marked the first issuance of socially responsible Islamic bonds dedicated to such a cause. It was a milestone that Gavi CEO Dr Seth Berkley describes as “a very big success” for the organisation, which is seeking to tap a larger pool of donors from Organisation of Islamic Cooperation members as it eyes funding for its next phase of operations.
Another effective funding mechanism is the Gavi Matching Fund, a private sector programme created to raise $260m for immunisation by the end of 2015. As part of this initiative, the UK Department for International Development and the Gates Foundation have together pledged around $130m to match contributions from foundations, businesses, customers, members, employees and business partners. Contributors include the likes of JP Morgan, Vodafone and Spanish bank la Caixa.
By driving up demand across the 73 countries in which it operates, Gavi is able to convince vaccine manufacturers and pharmaceutical companies to provide vaccines under long-term agreements at significantly reduced prices. For example, it is able to supply Gavi-eligible countries with pneumococcal vaccines at $3.50 per dose or less, more than 90 per cent cheaper than the public price in the US.
“One of the reasons we can do that is because we can make long-term contracts with companies and bring new companies into supplying vaccines, knowing that they will be financed,” explains Berkley.
The organisation has expanded its supplier base from five companies in 2000 to 13 today, reshaping the marketplace and ensuring far-reaching benefits both for those children being immunised and the philanthropists or governments donating or allocating funds for vaccines. Without Gavi’s intervention, those entities would likely be forced to pay exorbitant prices for the same vaccines.
Countries are eligible for Gavi support based on their per capita incomes. Once they cross a certain threshold, they enter the graduation process and eventually lose Gavi support, at which point the prices of the vaccines rise. “We are also working to make those prices stick with countries even after they graduate for a period of time,” notes Berkley.
Photo credit: GAVI Alliance