World Health Editors Network (WHEN) 66th World Health Assembly

World Health Editors Network (WHEN) 66th World Health Assembly
Basic facts about the GAVI Alliance Jon Pearman, Senior Adviser Vaccine Implementation World Health Editors Network (WHEN) 66th World Health Assembly

Overview About the GAVI Alliance Accelerated vaccine uptake
Rising demand Innovative finance Shaping the market Programmes of support for countries Moving forward

The GAVI Alliance: an innovative partnership
GAVI was established as an alliance in recognition of the fact that expanding and maintaining immunisation coverage in developing countries depend on strong partnerships, involving both the private and public sectors. The role and commitment of each partner is vital to the success of the partnership: Multilateral agencies and the Bill & Melinda Gates Foundation: - UNICEF has significant field presence and vaccine procurement capabilities. - WHO develops policies and strategies for vaccine use and provides normative guidance and quality control of vaccines. - The World Bank plays a key role in innovative financing and helps implementing governments develop sustainable financing for health systems, including immunisation services. - The Bill & Melinda Gates Foundation is one of the founding members of the Alliance and continues to support GAVI programmes. Developing country governments - The most important contribution to the Alliance is the commitment of developing countries themselves, which apply for GAVI funding and implement programmes to ensure the immunisation of hundreds of thousands of children every day. Donor country governments provide funding for GAVI programmes through official development assistance (ODA). Civil society organisations play a pivotal role in immunisation and health service delivery in many countries, as well as in advocacy and policy development, while research institutes bring their knowledge and experience to the Board and help build R&D capacity. The vaccine industry ensures the development of and access to vaccines and provide technical support Independent individuals bring independent scrutiny to the Board and provide expertise in a range of areas. The CEO of the GAVI Alliance serves on the Board in a non-voting seat.

Mission and strategic goals 2011–2015
To save children’s lives and protect people’s health by increasing access to immunisation in poor countries The vaccine goal Accelerate the uptake and use of underused and new vaccines The health systems goal Contribute to strengthening the capacity of integrated health systems to deliver immunisation The financing goal Increase the predictability of global financing and improve the sustainability of national financing for immunisation The market shaping goal Shape vaccine markets to ensure adequate supply of appropriate, quality vaccines at low and sustainable prices 1 2 3 4

What developing countries have achieved with GAVI support
Immunised 370 million children Prevented more than 5.5 million future deaths Accelerated vaccine introductions in over 70 countries Strengthened health systems to deliver immunisation Helped shape the market for vaccines Additional children immunised Sources: WHO-UNICEF coverage estimates for , as of July Coverage projections for 2012, as of September World Population Prospects, the 2010 revision. New York, United Nations, 2010; (surviving infants)

GAVI making a difference
Catalysing accelerated uptake of vaccines Contributed to preventing more than 5.5 million future deaths 370 million additional children immunised Supporting increasing country demand Rising demand for new vaccines US$ 7.5 billion committed to countries Introducing innovative finance mechanisms IFFIm raised US$ 3.7 billion on capital markets AMC accelerates access to pneumococcal vaccines GAVI Matching Fund – engaging the private sector Shaping markets for vaccines More manufacturers producing more appropriate vaccines Increased capacity secures supply, decreases prices GAVI is having an impact on immunisation and global health – introducing a new model for health and development: - country-driven demand, long-term support - innovative financing having impact on immunisation but also on how development funding is done - shaping markets and having an impact on supply and pricing

Countries have immunised an additional 370 million children with GAVI support
By the end of 2012, countries had immunised a projected 370 million children with support from GAVI. Sources: WHO-UNICEF coverage estimates for , as of July Coverage projections for 2012, as of September World Population Prospects, the 2010 revision. New York, United Nations, 2010; (surviving infants)

A strong platform 83% of children in the world are now reached through routine immunisation programmes Immunisation closer to universal coverage than most other health interventions Enables rapid introduction of life-saving vaccines Important opportunity to deliver other child and maternal health services DTP3 coverage in low-income countries was 79% in 2011 – just four percentage points below the global average. This is the highest level ever seen in the developing world. Source: WHO/UNICEF vaccine coverage estimates (July 2012) Country income categories (World Bank) as of July 2012 (2011 GNI per capita)

Immunisation coverage in 73 GAVI-supported countries
Immunisation coverage with DTP3 in 73 countries supported by GAVI 2011–2015 increased from 61% in 2000 to 74% in 2011 Source: WHO/UNICEF vaccine coverage estimates (July 2012) Note: This estimate includes the 73 countries supported by GAVI 2011–2015

Taking stock: the immunisation gap
130 million surviving newborns in 2011: Here is how we are doing in terms of getting vaccines to the world’s children. Of 130 million surviving newborns in 2011: 83% of children were reached with DTP vaccines. The biggest gaps in coverage are for the vaccines that GAVI supports. Good progress has already been made with Hepatitis B, shown in red. Here we have seen an increase in recent years to 74% coverage Hib vaccine coverage is also catching up (following recent widespread introduction in GAVI-eligible countries) But the critical gaps are in the bottom 2 bars, pneumococcal and rotavirus vaccines Rolling out these vaccines is GAVI’s focus for the coming years Note: Coverage refers to the final dose of each vaccine. Sources: WHO/UNICEF coverage from July 2012; United Nations, Department of Economic and Social Affairs, Population Division (2011). World Population Prospects: The 2010 Revision, CD-ROM Edition.

Driving equity in vaccine access
Here we see the result of the unprecedented catch-up by low-income countries. The red bar shows the percentage of high-income countries using hepatitis B vaccines in the year This climbed to 78% in 2011. Next to it we see the proportion of low-income countries using hepatitis vaccine in And this is how that changed in just 11 years. A huge jump. The same has been achieved for Hib vaccines. GAVI was launched to address an inequity – life-saving vaccines available in rich countries are denied to children in the developing world. These charts show that GAVI has made a difference. Working together we have brought a dramatic change in access to two key vaccines that were hardly in use in the low-income countries in 2000. Hepatitis B Hib Source: WHO, Vaccine introduction database. Country income categories (World Bank) as of July 2012 (2011 GNI per capita)

Driving equity in vaccine access
Pneumococcal *Planned 2012 introductions as of July 2012 Source: WHO, Vaccine introduction database. Country income categories (World Bank) as of July 2012 (2011 GNI per capita).

Total projected number of children immunised by the end of 2012 (increase relative to the end of 2011) Sources: WHO-UNICEF coverage estimates for , as of July World Population Prospects, the 2010 revision. New York, United Nations, 2010; (surviving infants). GAVI Alliance, 2013

Vaccine introductions in 2011–2012: pentavalent, pneumococcal, rotavirus
Number of newborns (millions) Sources: UN DESA, Population Division, 2011: World population prospects, 2010; GAVI Alliance, 2012 15

Impact on the ground Eliminating Hib meningitis in Kenya (Kilifi district) Looking behind the headline figures, and translating them to a country level, here’s an example among many of the powerful impact of vaccines. Hib disease causes meningitis and severe pneumonia. It leads to high mortality rates and often leaves children with permanent disability. This graph shows the impact of Hib vaccine in Kenya; one of the first countries to introduce the vaccine with GAVI support. The introduction in 2001 resulted in a massive drop in cases of this disease. Source: Cowgill KD et al. 2006

Early impact of pneumococcal vaccine in Kenya
Admissions of children under five for invasive pneumococcal disease, Kilifi District Hospital, 2003–2012 The line shows the annual number of admissions for Invasive Pneumococcal Disease of serotypes 1, 4, 5, 6B, 7F, 9V, 14, 18C, 19F, 23F among children aged <5 years admitted to Kilifi District Hospital (KDH) who were residents of the Kilifi Health and Demographic Surveillance System. Routine immunisation of children <12 months began on January 11, 2011 and the first round of catch-up vaccination took place between Jan 31-Feb 6, Since the introduction of the catch-up campaign there has been a marked attenuation in the frequency of cases. However, there has been considerable variation in the number of cases year-on-year and it will take several years to be confident that changes in disease frequency are attributable to vaccine. Source: Anthony Scott, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya, 2012

Rising country demand Countries approved for GAVI support
Country demand is rising. Alliance partners have been successful in stimulating demand. Source: GAVI Alliance data, as of 31 March 2013

Country demand: number of approved vaccine applications
Note: In 2011 the majority of countries were approved for pentavalent vaccine, rather than for Hib and hepatitis B vaccine separately. Therefore, from 2011 onwards GAVI changed its reporting method to include the combination pentavalent vaccine only. Source: GAVI Alliance data, as of 31 March 2013

US$ 7.5 billion committed to countries
As of 31 December 2012 GAVI has committed US$ 7.5 billion in funding to countries until 2016. By far the majority of GAVI funds are committed to the provision of vaccines: over 80%. Source: GAVI Alliance data as of 31 December 2012. Note: These commitments are from inception until 31 December 2012.

International Finance Facility for Immunisation (IFFIm)
Supports GAVI by accelerating availability and predictability of funds for immunisation Uses US$ 6.3 billion in long-term donor pledges to back the issuance of bonds (AAA/Aaa/AA+) on the capital markets Raised US$ 3.7 billion since 2006 Provides long-term predictable funding for immunisation This helps multi-year planning, market shaping and rapid roll-out of new vaccines

Advance Market Commitment (AMC)
Accelerates the manufacture and delivery of vaccines: Donors commit funds for new vaccines at pre- agreed price Manufacturers get incentive to invest in R&D for new vaccines Vaccines must meet stringent criteria and be requested by developing countries Manufacturers legally commit to supplying vaccines at lower price long term Long-term price is paid by beneficiary countries and GAVI

The GAVI Matching Fund Public-private partnership initiative
The UK Department for International Development (DFID) and the Bill & Melinda Gates Foundation pledged US$ 130 million to match private sector contributions to GAVI Also match funds from customers, employees and business partners Brings private sector funding, visibility and innovation to GAVI programmes - DFID pledged £50 million to match donations from UK-based and prominent private sector partners, and BMGF pledged US$ 50 million to all other private sector groups GAVI has eight private sector partners for the Matching Fund: Absolute Return for Kids (ARK), Anglo American, the Children’s Investment Fund Foundation, Comic Relief, J.P. Morgan, the “la Caixa” Foundation, LDS Charities and Vodafone. - The minimum donation is US$ 1.5 million (equivalent). A US$ 1.5 million donation could buy enough vaccine to immunise 142,000 children against pneumococcal disease in 2012 (unloaded price, i.e. not including freight, safety boxes, syringes, health care workers and delivery costs. Why corporations give: RESULTS: Immunisation is proven to save millions of children’s lives. The initiative also makes a significant contribution to UN Millennium Development Goal 4: to reduce by two thirds the mortality rate for children under five by 2015. REPUTATION: Corporations can enhance their reputations among customers and employees by championing this global initiative, providing further opportunities for engagement. GAVI, DFID and the Gates Foundation are partners with strong records of delivering effective solutions. LEVERAGE: The value of giving is maximised for corporations, their customers and employees through the Matching Fund mechanism.

Contributions from corporate partners and matches bring total to more than US$ 84 million
Absolute Return for Kids (ARK) Anglo American Children’s Investment Fund Foundation (CIFF) Comic Relief Dutch Postcode Lottery J.P. Morgan “la Caixa” Foundation LDS Charities Vodafone

Market shaping objectives

Increased competition reduces vaccine price
Price decline of pentavalent vaccine and number of manufacturers The weighted average price for pentavalent vaccine for 2012 fell to US$ 2.17, a drop of more than US$ 0.30 per dose compared to the year before. This is important as the pentavalent vaccine is a major cost driver for GAVI. The price drop will allow the GAVI Alliance to immunise many more children against five diseases through the pentavalent vaccine: diphtheria, tetanus, pertussis, Hib and hepatitis B. Source: UNICEF Supply Division, 2013

Tiered pricing GAVI-eligible countries are now firmly established as the accepted low-income pricing tier. This means manufacturers use GAVI countries as a benchmark in their pricing strategies. Vaccines are available to the world’s poorest countries at significantly lower prices than to industrialised countries. Blue is GAVI market. Purple is US public market. For example, the price of pneumococcal vaccines for GAVI countries is less than 5% of what is paid for the same product in the US. Source: UNICEF Supply Division; CDC

Vaccine supply 2001 – Vaccine supply: 5 suppliers from 5 countries
By aggregating demand from developing countries and pooling donor support for immunisation, GAVI has been able to create a viable market where one did not exist before. New market entrants, including from emerging markets, help to secure supply and increase price competition. Here you can see what our supplier base looked like when we started buying vaccines in 2001. Source: UNICEF Supply Division, 2013

Vaccine supply 2012 – Vaccine supply: 10 suppliers from 8 countries
Supplier Name Supplier Country of Production Supplier Country of Ownership 1 Biological E. Limited India -1 India 2 Bio-Manguinhos Brazil Brazil 3 Crucell Switzerland AG Korea USA 4 FSUE of Chumakov IPVE, RAMS Russia Russia 5 GlaxoSmithKline Biologicals S.A. Belgium UK 6 Merck & Co., Inc. USA USA 7 P.T. Bio Farma (Persero) Indonesia Indonesia 8 Pfizer Inc. USA USA 9 Sanofi Pasteur France -8 France 10 Serum Institute of India Ltd. India -1 India Source: UNICEF Supply Division, 2013

How GAVI works

GAVI vaccine support Currently supported vaccines:
Routine: pentavalent, pneumococcal, rotavirus, human papillomavirus (HPV), yellow fever, measles second dose Campaign: yellow fever, meningococcal A conjugate, measles, rubella Stockpile: meningitis and yellow fever vaccines for outbreak response Prioritised for future support: Japanese encephalitis and typhoid conjugate vaccines Monitoring development: malaria, dengue Pentavalent = diphtheria, tetanus, pertussis, Hib and hepatitis B vaccine

GAVI supports the world’s poorest countries
Type and value of support, 2000–2012 Note: Pentavalent, pneumococcal and rotavirus vaccines represent GAVI’s main areas of support. In 2012, GAVI also provided support for measles (second dose), meningitis A and yellow fever vaccines, as well as for health system strengthening and civil society involvement in immunisation. Source: GAVI Alliance , 2013

Health system strengthening (HSS) support
Strong health systems essential to expand and sustain immunisation coverage Objective of GAVI HSS: address systems bottlenecks to achieve better immunisation outcomes Examples: Health workforce Supply, distribution, maintenance Organisation, management More than 50 countries approved for support by end 2012 Courtesy of Aga Khan Health Services, Pakistan

Six building blocks of a health system
Good health services Well-performing health workforce Well-functioning health information system Equitable access to medical products, vaccines and technologies Good health financing system Leadership and governance In assessing their HSS needs countries are advised to look at the six building blocks of a health system. This can help countries identify bottlenecks that prevent them from reaching all children and women with immunisation services and how GAVI HSS support can complement their HSS efforts. Good health services deliver effective, safe, high-quality health interventions to those who need them, when and where they are needed, with a minimum waste of resources. A well-performing health workforce works in a way that is responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances. For example, there need to be sufficient numbers and mix of staff fairly distributed, and staff must be competent, responsive and productive. A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health systems performance and health status. There needs to be equitable access to essential medical products, vaccines and technology that are of assured quality, safe, efficient and cost-effective. A good health financing system raises adequate funds for health, in ways that ensure people can use the services needed and are protected from impoverishment associated with having to pay for them. Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-building, the provision of appropriate regulations and incentives, attention to system-design, and accountability.

Support to civil society organisations (CSOs)
CSOs deliver up to 60% of immunisation services in some countries GAVI provides support: to involve local CSOs in planning and delivery of immunisation and other child health services to encourage cooperation and coordination between the public sector and civil society © UNICEF/NYHQ Anita Khemka In many countries, CSOs are the backbone of the health system and deliver much of the immunisation services, especially to remote and vulnerable populations.

Women’s health and immunisation
Child and maternal mortality inextricably linked Immunisation a platform for other child and maternal health services GAVI supported immunisation of 40 million women against maternal and neonatal tetanus Supports HPV and rubella vaccines Supports strengthening of health systems to better meet needs of women and children GAVI/09/Olivier Asselin Countries with the highest child mortality rates also have a high burden of maternal deaths, as well as high rates of birth and population growth. Integrated programmes which combine maternal, newborn, child and reproductive health services can accelerate progress towards achieving the health MDGs. Almost 80% of children in low-income countries are reached with immunisation. This provides an important opportunity for women to access an integrated package of maternal, newborn and child health services. Together with UNICEF, GAVI has supported the immunisation of 40 million women with vaccines protecting against maternal and neonatal tetanus. GAVI supports two vaccines that specifically benefit women’s health: HPV vaccine, which protects against cervical cancer, and rubella vaccines, preventing congenital rubella syndrome and reducing the risk of miscarriage and stillbirth. GAVI support to HSS helps countries to provide better health services to women and children.

Equal immunisation coverage of girls and boys
2010 study by WHO’s Strategic Advisory Group of Experts (SAGE) on gender and immunisation found no significant difference in immunisation coverage for girls and boys at the global level. low status of women may prevent them from accessing immunisation services for their children. GAVI instigated the SAGE study (in collaboration with WHO and PATH) to ensure that all girls and boys have equal access to vaccines. A WHO study on gender and immunisation, conducted in 2010, showed no significant differences in immunisation rates between boys and girls at the global level, although exceptions exist in settings with high gender inequity. In some countries, the low status of women prevents them from accessing immunisation services for their children, both boys and girls. GAVI works with its partners to increase immunisation coverage and to overcome barriers to immunisation and related health services. GAVI implements a gender policy that aims to ensure that all girls, boys, women and men, have equal access to immunisation and health services. Activities implemented include this review of the evidence base on gender and immunisation in collaboration with WHO and PATH, as well as desk reviews of the impact of antigens on the health of women and mothers, and the influence of immunisation services on maternal and child health services. In 2011, a gender help desk was established at GAVI.

Vaccines have a long-term positive impact beyond health outcomes
Protecting children from infectious diseases raises IQ, improving cognitive function Vaccination keeps children healthy, thereby reducing the burden of care on parents; improving their productivity and freeing them from crippling medical costs Decrease in child mortality leads to a decline in birth cohort: families have fewer children to achieve ideal family size 30-50% of Asia’s economic growth from 1965 to attributed to reductions in infant and child mortality and fertility rates Spending on child health has the greatest impact on improving lifetime earnings Source: David Bloom, “The Value of Vaccination,” January 2011

The economic value of vaccines
Child vaccinated More politically & economically stable countries Child lives longer Improved community stability and productivity Fewer illnesses Immunisation is one of the most cost-effective ways of improving living standards, health and the global economy Strengthened economic condition within family Birth rates drop – mother’s health improves More reliable workforce Lower ongoing healthcare costs Greater educational opportunities

More than 22 million children still unimmunised
Global number of under-five children unimmunised with 3 doses of DTP, 2011 More than 22 million children in the world do not get immunised with basic childhood vaccines. Over 75% of these children live in the 57 countries that are GAVI-eligible. DTP = diphtheria-tetanus-pertussis vaccine Note: Revised figures for 2011 ( July 2012) Source: WHO/UNICEF vaccine coverage estimates (July 2012)

Impact 2011–2015 With GAVI support, countries can prevent 3.9 million future deaths between 2011 and 2015 Source: GAVI Alliance Strategic Demand Forecast version 2.0 and Long Range Cost and Impact Model

Global Vaccine Action Plan Shaping Immunization Programmes in the Current Decade

Global vaccine action plan
The vision for the Decade of Vaccine is a world in which all individuals and communities enjoy lives free from vaccine-preventable diseases. Its mission is to extend, by 2020 and beyond, the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live GVAP endorsed at the 65th WHA

Why a Decade of Vaccines?
Significant progress in the past decade Progress with disease eradication or elimination Millions of deaths averted Ability for deliver immunization with high coverage Already reaching over 80% children globally Higher than any other intervention across continuum of care Increasing number of diseases now vaccine preventable Robust vaccine pipeline Progress with adding vaccines in national programmes Despite many challenges, opportunities to do much better

Goals for the Decade of Vaccines

From GIVS to GVAP Focus on mortality
Focus on mortality, morbidity and economic impact Top-down decision-making Country ownership Supply-side emphasis Supply and demand-side interventions Reaching Every District Reaching Every Community Immunization coverage Comprehensive disease prevention and control / focus on surveillance Access focus on low-income countries Access focus on low and middle-income countries A strategy (GIVS) Predefined accountability framework that includes all stakeholder and not just countries

Key actions for the Decade of Vaccines
Generate political commitment Better governance Requisite investments Promote greater community awareness and participation Address "vaccine hesitancy" Strengthen systems Supply chains Data quality and use Greater integration with broader health systems Targeted approaches to reach the "unreached" Affordable pricing and procurement for middle-income countries Regular monitoring and corrective actions

Translating the GVAP into National Priorities and Actions
Using the cMYPs and annual implementation plans as the basis for implementing GVAP at the country level cMYP guidelines reviewed and updates to: Accommodate the transition from GIVS to GVAP Place immunization more firmly within the context of PHC and National health Plans Better use of programme reviews in situational analysis Promote greater engagement of sub national managers in the development of the cMYP Opportunities for countries to pilot the new guidelines

GVAP Goals Indicators

GVAP Strategic Objectives Indicators

GVAP Progress Reporting and Review
In line with the guiding principles and request of member states to build on existing systems: Country Level: Immunization Coordinating Committees , … Regional Level: Regional Immunization Technical Advisory Groups , Regional Committees. Global Level: WHO SAGE, Executive Board and WHA. The GVAP Monitoring and Accountability frameworks will be presented to the 2013 WHA. 2014 WHA to be presented with the first progress report of member states towards achieving the GVAP goals and objectives.

Thank you GAVI/2011/Ed Harris

World Health Editors Network (WHEN) 66th World Health Assembly

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