Two global health experts say the time is ripe to re-think Gavi’s mission

In August, the former Nigerian Minister of Health Muhammad Paté will replace Seth Berkley as CEO of Gavi, the first African to hold the post since the vaccine alliance was established in 2000. As Gavi prepares for its first change in leadership in 12 years, two global health experts, both of them outspoken critics of Gavi’s role during the COVID19 pandemic, talked to Development Today about the future of the Geneva-based vaccine alliance.

For Ugandan epidemiologist Catherine Kyobutungi, Director of the African Public Health Research Centre in Nairobi, there are problems with the Gavi model that go far beyond the inequities in distribution of vaccines experienced by African countries during the pandemic. The fact that the Gavi vaccine alliance has existed for 23 years, she says, is reason enough to take stock.

On one hand, she says, there were certain conditions that necessitated Gavi’s establishment. “Do those conditions still exist today? If the problem has still not been solved after all this time, then you have to ask whether GAVI should continue to exist in its current form,” she says. “On the other hand, if conditions have changed – if child vaccination rates that were 40 per cent [in the 1990s] are now over 80 per cent now - should you continue with the same mandate that you had back then? Either way, there is a need to reconfigure the vision and mission of the institution.”

Gavi has received government donor commitments exceeding USD 37 billion, plus USD 6 billion more from the Bill & Melinda Gates Foundation, since 2000.

Kyobutungi says a change of mindset is needed. Instead of assuming that they will continue to exist forever, donor-funded global health initiatives like Gavi should be working consciously to makes themselves irrelevant, she says. They should have been building up regional manufacturing for vaccines and bed nets to push prices down and strengthening countries’ own procurement systems. Instead, she says, the momentum to continue year after year “seems to be intentional, built into the system. Things are done so that they can stay in business. Are the problems you are addressing so insurmountable that your existence will be justified in perpetuity?”

In an op-ed in Development Today, published in December 2021, Olusoji Adeyi,* President of Resilient Health Systems and Senior Associate at Johns Hopkins, critiqued the global health architecture. He placed equal blame on donors, “high on the opium of [narcissistic] charity,” and on African governments which, “drip-fed on deleterious forms of foreign aid,” wait for hand-outs, lacking the grit to self-finance their most basic health systems.

Adeyi says Gavi embodies this unhealthy relationship.

Malaria vaccine

A recent example of the problem, Adeyi says, is the RTS,S vaccine against malaria which was recommended for use in malaria endemic countries by the World Health Organisation in late 2021. “One would have expected African leaders to take the lead and say, this time around, we’re going to pay for this because it so ravages our societies. But that did not happen. Instead, it was Gavi that stood up and said they were going to commit USD 155 million. That brings into focus a terrible dysfunction in the current architecture of global health. Because once again, you had an international organisation arrogating to itself what should be led by the countries first. In the process, you perpetuate this dependency syndrome.”

Kyobutungi agrees, noting that donor-funded agencies like Gavi and the Global Fund tend to engender laziness among lower-income governments and an abrogation of responsibility. “We can’t treat our malaria; somebody will bring the treatments. We cannot afford bed nets; someone will step in and provide funds for that. But then you see the behaviour of governments in other ways with huge budgets on wars, money being stolen every day, huge cars and huge salaries, bloated cabinets, bloated Parliaments. While I agree that African countries are poor, our governments have their priorities upside down. Therefore, I agree that it is an unhealthy relationship between development partners and African governments.”

COVAX origin story

Gavi statistics show that one-third of all government donor commitments over the last 23 years (about USD 12 billion) went to finance COVAX, the platform that aimed to ensure that COVID19 vaccines would be available to developing countries.

In an interview with Amanda Glassman at the Center for Global Development in Washington earlier this month, marking the end of his tenure as Gavi CEO, Seth Berkley repeated the story, often told, of how he and Richard Hatchett, CEO of the Coalition for Epidemic Preparedness Innovations (CEPI), came up with the idea for COVAX.

“It actually started at Davos” in January 2020, Berkley told Glassman. “Richard Hatchett and I sat down and said: ‘if this is the big one … what do we need to do?’ That is where COVAX had its origins.”

This origin story does not sit well with Catherine Kyobutungi. “From where I sit, as a decolonize global health advocate, the process of conceptualization was the main problem with COVAX,” she says.

Though COVAX eventually delivered some 1.9 billion to nearly 150 countries, the objective of equitable access was scuttled early on by high-income country hoarding, a lack of upfront funds, and export bans. Two years into the pandemic, 80 per cent of doses had gone to G20 countries, while low-income countries, most of them in Africa, had still only received 0.6 per cent of vaccines, according to the World Health Organisation.

“Good intentions are not enough,” Kyobutungi says. “Come on! Two men cannot sit in Davos and think that they are going to create a solution that is going to save more than 1 billion people in the world. And then think that is okay. Not being aware of how wrong that is, is problematic. It takes away everybody else’s agency. It takes away everybody else’s power and dignity. It puts so much power in the heads and hands of two men.”

Adeyi has a similar reaction. There is “something fundamentally wrong” with having a small group of people from high-income countries dictating to the rest of the world, he says. “This is not the 19th century … Never again shall we have a situation where a couple of people meet in a cafeteria and decide how the rest of the world should be run. I think that was an egregious example of all that is bad in global health.”

Reviving an old debate: Gavi and health system strengthening

A key dilemma, debated since Gavi was established, is the tension between Gavi’s narrow focus on vaccines and general support for all aspects of the health system.

A seminar organised by Norad this week shines a light on this issue. Norad notes that the current global health architecture is dominated by global health initiatives, like Gavi, that are oriented towards specific interventions with less focus on systems building. During the pandemic, essential health services like routine immunisation were disrupted, while resilient health systems turned out to be a key factor for an effective response. “This has led to renewed attention towards health system strengthening … in global health,” Norad states.

Kyobutungi says the re-think of Gavi’s model must take into account the consistent failure to address the fundamental problem of weak health systems. “Gavi’s mandate has been to increase equitable access to vaccines, especially in poor countries. So, they move mountains to get high vaccination rates without asking why they were low in the first place: They were low because there were problems with the health system, whether it was healthcare financing, human resources, or supply chain.”

She describes how results have been achieved despite weak health systems. “Gavi brings a strong well-funded programme on vaccination and superimposes it on a weak system. By virtue of the fact that they have a lot of resources, they will literally ram through outputs, and they will get results. But the fundamentals of the system that necessitated their existence in the first place are not addressed … You write a proposal, you get money, you power it into a narrow tube, within a big hole, and then everything in the tube is fine but the big hole stays.”

Future of Gavi

Adeyi has put forward a grand plan to phase out Gavi by 2030 and to use the remaining years of the decade for countries to plan for the take-over of responsibility for financing basic health commodities and services. In the wake of COVID, he says, there seems to be a willingness to explore new options that are not beholden to the ossified traditions. “I think we are now at a moment in which many more people are willing to have that conversation,” he says.

Kyobutungi says she would not put a precise timeframe to it. But she agrees that Gavi should be working to achieve its objectives in a way that it eventually either ceases to exist or evolves into something different.

She welcomes the appointment of the first African to head Gavi, Muhammad Paté, a former Health Minister, who has held posts at the World Bank and was shortlisted to head the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2017. Reportedly, Paté’s critical public comments about President Donald Trump contributed to him not being selected. Kyobutungi sees that as a positive sign. “Maybe it says something about him,” she says.

Adeyi describes Paté as a serious person with a sense of duty who is “superbly qualified to lead Gavi.”

If Adeyi’s proposal gains traction, Paté might end up being Gavi’s last CEO.

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*Adeyi’s argument is laid out in his book, Global Health in Practice: Investing Amidst Pandemics, Denial of Evidence, and Neo-dependency, published by World Scientific Series in Health Investment and Financing in January 2022