Bulletin of the World Health Organization

An interview with Julian Lob-Levyt: Vaccines for the poor

Dr Julian Lob-Levyt
Dr Julian Lob-Levyt

Dr Julian Lob-Levyt joined the Geneva-based GAVI Alliance in January 2005 as its executive secretary and chief executive officer and as president of the GAVI Fund. Previously, he worked with the Joint United Nations Programme on HIV/AIDS (UNAIDS) as senior policy adviser to the executive director. His career in global health has included work with bilateral and multilateral organizations. From 2000 to 2004, Lob-Levyt served as chief health adviser at the Department for International Development in the United Kingdom. He also served as Regional Health Adviser for the European Commission in Zimbabwe from 1998 to 1999 and health sector reform coordinator for WHO in Cambodia from 1994 to 1997. He earned his medical degree in 1980 at Bristol University and his MSC at the London School of Hygiene and Tropical Medicine in 1990.

Immunization is one of the world’s major public health successes, but many people are still not benefiting from it because they cannot afford the vaccines. Step forward the GAVI Alliance: a public–private partnership established in 2000 to raise money for vaccines to save the lives of millions of children who die every year from vaccine-preventable diseases. The GAVI Alliance was formerly known as the Global Alliance for Vaccines and Immunisation.

Q: Why fund vaccines?

A: Good health is a first step to building just and sustainable societies and economies, and vaccines are a highly cost-effective way to do that. Of the nearly 10 million children who die each year before reaching their fifth birthday, WHO (World Health Organization) estimates that 2.5 million die from diseases that could be prevented with currently available or new vaccines. Vaccination allows the global health community to make a real difference.

Q: How reliable are the figures on immunization successes, such as measles in Africa? Isn’t there pressure from advocacy groups to inflate these figures to make a stronger case for more donor funding?

A: As an alliance we rely on organizations such as WHO and UNICEF [United Nations Childrens’ Fund] to do two things: to help strengthen country information systems and to help validate the quality of the data they produce. In many countries, the reporting systems vary in quality, and some of the finance we provide has been to strengthen some of that. We are confident we can rely on WHO and UNICEF to give us the best estimates of where we are [with immunization]. Having said that, there are other useful mechanisms such as disease surveillance and other methods of testing the quality of data on vaccination levels. For example, for some of our results-based financing programmes we use external audit to validate the strength of the reporting systems and to recommend areas of improvements.

Q:In what way are you contributing to strengthening health systems? Simply focusing on a single-disease programme is not necessarily going to save lives if a range of essential health services is not available.

A: Absolutely, together with other global health partnerships and multilaterals we recognize that sustaining the success of more vertical initiatives is going to depend on the fundamental strengthening of health systems. In 2007, after consultation with developing-country ministers, we introduced a health systems support programme that enables countries to tackle critical bottlenecks to improve immunization coverage, but to do it in such a way that it strengthens the integrated delivery of child and maternal services.

Q: What’s the GAVI Alliance’s direct involvement in health system strengthening?

A: GAVI has committed US$ 800 million over a five-year period to help countries overcome health system weaknesses that impede sustainable increases in immunization coverage. This allows countries to design their own programmes that will help them tackle critical bottlenecks. GAVI financing is a small slice of what will be needed if we want to fundamentally strengthen health systems over the next years. The question is how that finance is coordinated with others. We believe at GAVI that the International Health Partnership (IHP) – a collaborative effort of multilaterals including the World Bank, WHO and UNICEF, bilateral and other agencies – is the best way forward. The IHP is a concerted effort towards better coordination to optimize the delivery of life-saving vaccines and health services.

Q: How is that partnership progressing?

A: It’s progressing slowly, but I think the leadership of WHO and the World Bank is looking good. Eight first wave developing countries are already on board, and we expect more to sign up shortly. These countries have agreed that they would benefit from closer donor and international partner coordination as they work to improve the health of their people. Immunization is a key element to providing a concrete measurement of health systems performance. GAVI and the IHP partners are firmly committed to overcoming the constraints and bottlenecks that hold back progress in many countries.

Q: Will the Advanced Market Commitment (AMC) mechanism to raise funds for vaccines get off the ground and when will we see the results?

A: AMCs are a new approach to public health funding designed to stimulate the development and manufacture of vaccines for developing countries. Usually it takes 15 or 20 years for a new vaccine to become available in the developing world. The AMC has been designed particularly around pneumococcal vaccine so that we will have a vaccine as early as 2010, bringing that time down to between three to five years. This vaccine is expected to save 5.8 million lives. The AMC is intellectually solid, well thought through and is on schedule to be launched in the second half of this year.

Q: Initially the AMC faced criticism.

A: One criticism was that the contractual arrangements were unreliable – we have made significant progress there and that’s not the case any longer. Second, that development assistance could be better spent on other interventions – we would argue very strongly that the selected pilot AMC vaccine tackles one of the world’s major killers of children: pneumonia. GAVI exists to find new ways to make a difference in development. Innovative mechanisms, such as the AMCs and the International Finance Facility for Immunisation, provide the opportunity to boost development aid and make a real difference where it is needed.

Q: GAVI offers great opportunities to poor countries but there are poor areas in middle-income countries that do not comply with your requirements? Why can’t you help those people too?

A: GAVI’s board made a decision to help the 73 poorest countries in the world, those with less than US$ 1000 gross domestic product per capita (according to the World Bank in 2003). Those countries are identified as the poorest in the world; this is the reason why GAVI concentrates its efforts towards them.

Q: How do you prioritize the vaccines you fund?

A: The choices are made by our board, which includes developing country representatives and research and technical health experts. This year we are going to consider the next package of vaccines to support. That will be determined by what we can afford, the likely impact on disease, and, of course, the ability of countries to take on new vaccines.

Q: Has this changed over the years that GAVI has existed

A: When we first started, the choice about which vaccines to fund was less informed by such thinking and data and more by which vaccine was available at the time. That has changed. Since then, GAVI has demonstrated that it is successful and here for the long-term, so there is a lot more interest from industry and we are seeing both demand for existing vaccines supported by GAVI as well as a pipeline of new vaccines. It’s been a long time in development but we now see new technology that will rapidly benefit developing countries.

Q: What have you achieved so far in GAVI’s five years of existence?

A: We have demonstrated our success as a partnership that builds on the strength of the public sector and private sector to work together to achieve more as an alliance than we would have done as separate institutions. Also, we demonstrated that we have been able to mobilize very significant finance. For example, the creation of the International Financing Facility for Immunisation is truly unique and has really broken the mould of how we raise development finance and will have lessons for others in the development community. In securing finance, in demonstrating that we are a long-term organization, we have also been successful in building the confidence of countries and of industry. GAVI is a results-based organization, aiming at providing proof of evidence of its success. For example, a study published in the April 2008 issue of the Bulletin outlines that with GAVI support, Haemophilus influenzae type b (Hib) meningitis has been virtually eliminated in young children in Uganda just five years after the country introduced the Hib vaccine nationwide. The fact that Hib meningitis has been eradicated in Uganda has been tremendous. Successes like these are proof of how, through an alliance, a group of committed partners can make a greater impact. ■