Note: This conversation between GiveWell and GAVI is a follow up to previous conversations in which Good Ventures also participated.
- Mercy Ahun — Special Representative to GAVI Eligible Countries, GAVI Alliance
- Alex Palacios — Special Representative, GAVI Alliance
GiveWell: Vaccination rates are below 100%. We as donors are interested in what our options are increasing vaccination coverage.
GAVI: You could either target a group of countries that need support, or target the particular countries with the lowest vaccination rates. You could look at what the key bottlenecks are. There are bottlenecks in logistics: adequate cold chain and human resources to manage cold chain. There are also bottlenecks in the quality of country administrative data. GAVI has been working to address this data challenge, instituting data quality audits, and improving data quality especially at the district level. When donors give, they want to know not just that vaccines coverage rose but that disease has been reduced.
You could also improve the health system more generally. Many countries have high proportions of their populations living in rural areas. Many people live far from health facilities.
GiveWell: More specifically, we are hoping to donate money to increase vaccination rates. Do you see opportunities to do this with a few million dollars, up to perhaps $10 million?
GAVI: Are you willing to put your money into a basket fund?
GiveWell: We have no preconceptions about the mechanism. The issue that matters to us is that the money leads to children being vaccinated who would not have been vaccinated without the funding.
GAVI: Yes there are opportunities. GAVI has a basket fund for performance-based financing for countries. The challenge is if you say 'we want to see an increase in vaccination rate in two years.' $10 million is significant and could make a difference.
Although we have pledges from governments, we also have challenge grants from the UK and the Gates Foundation to match funds from the private sector. These funds won't be released without more private donations.
GiveWell: Can you be more specific about what a particular program would look like — how $10 million would lead to additional vaccinations?
GAVI: Countries are going to apply for support. They are given rewards for increasing coverage. You could put your money in this basket. Are you going to be looking at increasing vaccination rates in specific countries or at the global level?
GAVI is a pooled fund mechanism. We have been at the center of a drive to increase immunization coverage rates, but the main mandate of the organization is to introduce new and underused vaccines. Work is at the national level.
GiveWell: We are comfortable with whatever will accomplish the most good.
GAVI: We can certainly say the X dollars buys a certain number of vaccines, immunizes Y kids, and prevents Z deaths.
GiveWell: We want to cause children to be vaccinated who would not otherwise have been vaccinated.
GAVI: I understand that, but I feel that every dollar we receive accomplishes that.
GiveWell: Our understanding is that when GAVI looks out to 2015, pledges cover expected demand. So the question on our mind is are there ways to increase coverage above expected demand.
GAVI: Part of the answer to whether GAVI can fund demand is that we have to get the challenge grants to meet that demand. That's how your money can help us get to meet the expected demand.
GiveWell: Let's assume that the challenge grants are met. We still would not be at 100% immunization coverage. What can we do to improve vaccination coverage, specifically? What are the main obstacles?
GAVI: That's why GAVI got into health systems. We first looked just at immunization programs, but in order to increase vaccination coverage, you have to look wider. For example, Ethiopia has nurses but 40% of people were living in rural areas far from health facilities. They trained 30,000 lower level health workers to reach these people.
GiveWell: The current demand forecast, that's the level GAVI could provide without additional health infrastructure. Is that correct?
GAVI: GAVI does not provide entirely what is needed. Countries and other health organizations are expected to meet the rest of the needs. GAVI only fills part of the gap.
GiveWell: Are there countries that have sufficient infrastructure but not enough vaccines?
GAVI: GAVI has policies that don't allow it to fill the whole gap. We're mandated to provide support for the introduction of specific vaccines. There could be unmet need in traditional vaccines. In the UNICEF model, which is a more incremental model, an additional $5 to $10 million definitely lets them do more. The have a core program and then a supplemental program.
GiveWell: Would you be able to provide us a contact at UNICEF?
GAVI: Yes, I can send a contact for the U.S. Fund for UNICEF.
GiveWell: It sounds like one reason that GAVI would not fully fill a gap is that GAVI wants the country to do its part. Are there other reasons GAVI would not fill the gap?
GAVI: We are an alliance. It's our philosophy that everyone should chip in. The pie is very big. Most countries have gaps. They let donors come in and say how they can fill gaps. I don't know of a single country in Africa that has been able to fully fill its gaps. Funds are always needed. GAVI does not fund basic vaccines. Others provide support for cold chain, surveillance, etc.
Tanzania wants to increase coverage to 95%. That would take a lot of resources. It's more expensive to reach the last child. It's about weighing options.
GiveWell: When you look at the landscape of country programs, do you see opportunities for donors to run/support programs to increase coverage?
GAVI: I know of countries that are bringing services closer to the communities. Health workers are paid to go live in rural areas. Even after decades of the programs, they haven't been able to cover the whole country. There are specific strategies that countries could use to reach additional children.
GiveWell: We are interested in learning about the specific opportunities that are available today, as well as past examples.
GAVI: I will try to send examples from Ethiopia and Ghana.
GiveWell: Are these past or potential?
GAVI: They are ongoing projects, involving the training of heath workers. The workers want more training. Retention is a key challenge in rural programs. How do we keep staff motivated?
Many countries are looking at bringing health workers closer to the communities.