A conversation with the Measles Initiative on April 18, 2012

Participants:

Good Ventures/GiveWell: How is the Measles Initiative structured? Through whom does funding flow? Who is the implementer and what are they using funds for?

Measles Initiative: The Measles Initiative was formed in 2001 by 5 organizations: WHO, UNICEF, CDC, the United Nations Foundation, and the American Red Cross. We set up a structure to pool funds in one place, at the United Nations Foundation. The UN Foundation is in a unique position in that it can fund any UN agency.

We receive funding on an annual basis, and all the donors give at that time. We then give the money to WHO and UNICEF to give to countries to carry out activities. At the end of the year, WHO and UNICEF give a progress report, which is distributed to the partners.

We have very low transaction costs. We can move money between countries if one campaign isn't carried out. Another thing that makes us unique is that we spend all the money every year. We have a very clear strategy, and countries know what to do with the funds. A campaign needs about 9 months to be planned and implemented.

Good Ventures/GiveWell: How do the staff of the partner organizations split up the responsibilities?

Measles Initiative: Each of the orgs have different strengths, and because we have so much contact with each other, we can fill in when gaps arise. WHO and the CDC provide mainly technical assistance for campaigns and surveillance and help with training and logistics. The Red Cross societies, Lions Clubs, LDS and UNICEF work on social mobilization. UNICEF also purchases the vaccines. There is a core group of people who have been working on this since the beginning.

We have complementary roles that interface well together. It was a very deliberate decision to pool funds in this way. In the field of immunization, WHO and UNICEF have been preeminent at the country level for a long time. They have boots on the ground in every country

Good Ventures/GiveWell: So it is WHO and UNICEF that implement the programs?

Measles Initiative: The funds are funneled through them to national governments who are responsible for planning and implementing immunization activities, including campaigns.  Funds are sent from WHO and UNICEF HQ  to the country offices of each organization where they are used for technical assistance, training, microplanning, waste management, social mobilization/communications, logistics and per diems for health workers during the campaigns.

WHO and UNICEF may have partners in the countries in addition to national governments, and may contract with them to carry out some activities such as social mobilization. WHO country offices do the contracting with Ministry of Health and NGOs for campaign activities. Technical assistance to the Ministry of Health is provided by global, regional, and country staff of core partners agencies and when needed additional consultants are contracted for preparing and implementing the campaign. On the UNICEF side, the funding at the country level is mainly for social mobilization, so they may print flyers for health workers, and post banners and posters. They also purchase the measles vaccines.

Good Ventures/GiveWell: If we were interested in the breakdown of funding for the different components, could you share that?

Measles Initiative: Yes. There's an annual report we can share.

Good Ventures/GiveWell: Based on the funding update for 2012-13 that we found on your website, it appears that Measles Initiative has an approximately $30m funding gap for 2012. Will anything be different in 2012 if this gap is or is not filled? In what ways?

Measles Initiative: The main impact of not filling the gap is that many children scheduled to be vaccinated will not be vaccinated in time to prevent measles outbreaks.  Having the additional funding would enable us to tell the countries that we can support their scheduled campaigns in 2012 enabling them to begin planning for the campaign and ordering vaccine. We pay for vaccines and half of the operational support. We ask the countries to pay the other half of operational costs. We didn't have enough funding in 2009-2010 so countries delayed the campaigns. Then there were outbreaks and countries had to use their measles funding for outbreak control. As a result of outbreaks, countries are now requesting to vaccinate older children (above 5 years of age) because many of these children have been missed. The epidemiological data says we should do this, but we don't have enough funding.

Looking forward, we would like to have funding to respond to outbreaks and to move towards elimination and, eventually, eradication. 

In our new strategic plan, we lay out activities that would help us improve the quality of campaigns, such as greater disease surveillance. Most of the funds for surveillance now come from CDC, but we'd need more to reach our goals. We also see a need for more implementation and communications research because we are using strategies from the Americas where the social and political context is different.

We haven't had funds for outbreak response. Countries have become used  to seeing fewer measles cases and countries aren't prepared to respond to outbreaks. We need an additional $10 million per year to respond to outbreaks.

Our new strategic plan is being published next Tuesday and this will have more information.

Good Ventures/GiveWell: Why won't the funders that have covered 93% of the budget cover the remaining 7%?

Measles Initiative: We don't have very many donors. We have a loyal core of donors, but there have been other donors that are in and out. We had GAVI money but we don’t now. We had money from Norway but don't now. Funding from the Gates Foundation is periodic. We recently started receiving funding from DFID. Polio eradication, by contrast has far more donors. There will be more information in the strategic plan on this question.

Good Ventures/GiveWell: I would think donors would be beating down the door to support this project, that has experienced so much success in the past. Why do you think GAVI is funded through 2015 and the Measles Initiative is facing a shortfall for this year?

Measles Initiative: There's so much happening in the global vaccine arena. More vaccines are becoming affordable. There is competition for funding and attention. Measles is an old disease with a relatively cheap vaccine that doesn’t get as much attention. In some ways, we are victims of our own success in that there is now some degree of complacency.

During the global recession there was a resurgence in measles and GAVI was extremely constrained. We're coming out of that now. We've have success with DFID and Norway. GAVI had a very successful pledging event. The funding climate has improved quite a bit.

Good Ventures/GiveWell: Were outbreaks in 2009-2010 due to lack of funding for the Measles Initiative?

Measles Initiative: That was one of the major underlying causes. The funding gap led to countries having to delay follow up mass campaigns or to cut corners on implementation or planning. They also often narrowed the target age group.

But it's also very important for sustained control to have strong routine immunization. Outbreaks are most likely in countries with low coverage of routine immunization. The resurgence has shown us how fragile the gains are in measles and it is critical that we sustain momentum.

Good Ventures/GiveWell: Does Measles Initiative focus on the second dose of measles?

Measles Initiative: No, we are doing a lot to strengthen of routine immunization, because this is one of our major strategies for reducing measles. We've worked hard to make the case for a routine second dose. That's the way most developed countries do it. For developing countries, they're not there yet. Mass campaigns have been a proven way to access children outside the reach of health system.

Good Ventures/GiveWell: So is Measles Initiative primarily focused on mass campaigns, plus making the advocacy case for a second dose of measles vaccine?

Measles Initiative: Yes, plus disease surveillance. There are other programs that primarily focus on routine immunization, and that's not our centerpiece.

Good Ventures/GiveWell: Why a campaign strategy for measles in particular? Why not use this strategy for other immunizations as well?

Measles Initiative: In a measles mass campaign, vaccinations are given to all children under 5 regardless of prior immunization status. It's similar to polio campaigns. Part of the reason for the campaign strategy has to do with the nature of the infection. Both measles and polio are viruses that are epidemic prone, and children can be given the vaccination multiple times without risk of increased side effects. Children who receive multiple doses of DPT in too short succession can experience side effects.

We also give vitamin A as part of the campaigns to reduce the severity of the disease.

Good Ventures/GiveWell: Where should we look for disease surveillance information?

Measles Initiative: Our annual reports provide this. Also, in the past year we put together 72 papers in a journal supplement that we can send to you.

Good Ventures/GiveWell: It seems like the cost effectiveness of the intervention would fall as cases fall. Do you think that's a reasonable way to think about things?

Measles Initiative: There are two ways to look at this. In terms of the marginal cost effectiveness, the effect of additional dollars, then that is a reasonable way of looking at it. But if you consider overall cost effectiveness, there is a potential for backsliding. Measles, because it is highly contagious, is very sensitive to ebb and flow of funding.

Good Ventures/GiveWell: Do you have any thoughts on the effectiveness of adding rubella to the initiative?

Measles Initiative: Rubella is the leading infectious cause of congenital malformation. We're combining measles campaigns with rubella efforts. Both are rash illnesses that can mimic one another so the same lab system can be used for both, and there is a combination vaccine. We are encouraging countries to use the combination vaccine.

Good Ventures/GiveWell: Will the announcement of the strategic plan include a fundraising push?

Measles Initiative: There will be a fundraising push later. The plan will be a useful tool for this. The GAVI Alliance has taken a new interest in us and has committed to supporting 50 countries in the introduction of rubella vaccination. This funding could amount to up to half a billion over 7 years.

We currently have a team of health economists and mathematical modelers putting together an analysis of the cost-effectiveness of adding rubella vaccine to the program. We should have something by the end of the summer.

Good Ventures/GiveWell: What do you think the prospects are for filling the funding gap for 2012?

Measles Initiative: I think we'd be surprised if we fully close the gap. We have prospects for filling part of the gap, but we face the prospect of doing less than the optimal and ending up in a position like 2009-2010, though we're in a better financial position than we were then. In addition to our founding partners, we have a number of other committed partners. It's a very communal partnership.