Daddy Healthbucks: How Will the Gates Foundation Leverage the New $10 Billion for Vaccines and Immunization?

February 8, 2010

In announcing a $10 billion, decade-long commitment for vaccine development and immunization in poor countries, Bill Gates made no claims that the vaccine financing challenges are solved. Quite the contrary. He and many others have highlighted the need for other donors, industry and developing country governments to up their own ante to immunization. As Orin Levine, head of the International Vaccine Access Center at Johns Hopkins, said in the Seattle Times, “The Gates Foundation cannot achieve the full promise of vaccines on its own. Manufacturers must increase their investments in vaccine research and development, donor countries must mobilize to help fund new vaccines, and developing countries must make the investments and take the steps necessary for delivering life-saving vaccines to their children.”

Success does depend on “crowding in” other funders’ investments, but under some scenarios the $10 billion could actually “crowd out.” Bilateral donor agencies, who themselves are fighting a tough budget climate, might breathe a sigh of relief thinking that they can hold at historical spending levels or even pull back from GAVI, and Daddy Healthbucks will save the day. Governments in GAVI-eligible countries, which under current rules now provide a co-pay for every dose of vaccine, might drag their heels a bit on moving toward greater levels of financial self-sufficiency. “Why are we chipping in 10 cents for every jab,” a Minister might ask, “when Bill Gates can afford $10 billion?” Even industry might think that they can cut a more favorable deal on both prices and support for R&D through product development partnerships.

But I expect that the Gates Foundation will use the resources in ways specifically designed to leverage others’ investments, and to lower the costs of getting vaccines to market and then to kids and teens. Accomplishing this will require a combination of incentives and institutional improvements to make all the dollars for vaccines and immunization work as hard as possible. What follows is pure speculation, but maybe they will:

• Put up all new contributions to GAVI in the form of a match: For every dollar GAVI raises from other sources, Gates could match it 1:1. (Interesting research shows that matching strategies are effective, but there’s no benefit from higher matching levels.) If particular types of contributions – say, support from private individuals – merit greater emphasis by GAVI’s resource mobilization team, the match could be higher as a special motivator to the organization.
• Invest in strengthening and streamlining the regulatory infrastructure, both globally and – very importantly – within the countries that are home to emerging manufacturers (Indonesia, India, Brazil). Ditto for clinical trials capacity and platforms that can be used for the development of multiple vaccines as time goes by. Bringing down the costs of developing these products, which is not as significant an issue in the price-insensitive markets, is high priority.
• Create the Maurice Hilleman Global Vaccine Prize, named after the remarkable microbiologist who developed more than three dozen vaccines. The prize could recognize achievements of scientists who have made major contributions to the development of vaccines that specifically benefit low-income countries.
• Explore whether and how strategic investments or incentives can hasten the development of joint ventures and other collaborations between multinational research-based firms and capable emerging manufacturers. Over the long term, moving to a high-scale/low-cost model of production is the route to vaccine affordability, regardless of whether the payers are national governments or donors.
• Recognizing that the health of the vaccine market globally is essential to the continued and diversified supply of vaccines for the poorest, make a one-time contribution to the Pan American Health Organization’s Revolving Fund to manage the introduction of higher-priced vaccines to the middle-income countries of the region.
• Create a 10-year Global Health Policy Fellows program, modeled on the Robert Wood Johnson Foundation Health Policy Fellows, to place mid-career global health professionals within Congressional and Executive branch offices. No amount of advocacy from the outside for health aid can replace dedicated, value-adding expertise on the inside. And the eventual network of Policy Fellows would be the next generation of policy movers and shakers.
• Endow immunization advocacy organizations in key countries, like Nigeria, where voices outside of the government are essential to keep the pressure on for immunization performance, and to counter the proliferation of negative messages about vaccines. An endowment rather than a grant is particularly important, so that the organizations can credibly say they are independent of a particular outside agenda.
• Work with the leadership at the World Health Organization and UNICEF to reinforce capacity for processes like developing evidence-based recommendations about vaccination schedules, prequalifying vaccines, issuing tenders, forecasting demand and more. Look at all the bottlenecks and focus resources on eliminating them.
• Create an innovation prize not for a vaccine but for a technology that will make many vaccines more usable in developing country contexts, such as for needle-free administration.

Oops, I think I just spent $10 billion!

These are just a few of the possible ways that the generosity of a lead donor can be extended and amplified. I suspect that cleverer ideas are being cooked up out there on the shores of Lake Union – and by some of our blog readers. Please use our comments feature to offer up your own thoughts.

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1. James Says:
   February 9th, 2010 at 10:54 am

   Thank you Ruth for a great article. This week I’m here in Mozambique where Villagereach has been working to make vaccine delivery mechanisms more effective and efficient for the past 7 years. Globally, the logistic systems, including the cold chain, that support the throughput of vaccine delivery, are poorly conceived and executed. The opportunity for Gates is to recognize and incentivize innovative approaches to the delivery mechanisms.

   The problem is that its difficult to imagine how the NEW vaccines would reach their intended recipients when the CURRENT vaccines already have many deliverty issues in many countries. While Government should have this role, the difficulty in delivering anything to remote locations is a fairly daunting prospect for global supply chains nevermind under-resourced health ministries.

   In a nutshell: Product benefits (and these vaccine products have great benefits) are quite useless without the channel to market.

2. Ruth Levine Says:
   February 9th, 2010 at 4:11 pm

   James – I completely agree that the delivery challenges are both large and important to address, and have done work myself on some of those issues (although not as much as you have!). And certainly GAVI has been playing role in reinforcing those delivery channels along with providing money to procure currently available products. But investments are needed throughout the spectrum — from basic science through product development and the delivery system — and for the most part the Gates Foundation has shown a preference for product development (aside from the big grants for GAVI). If they are going to focus there, great — I’d just encourage them to do it in the way that leads to the broadest benefits, and takes into consideration from the outset the need to keep the eventual product prices as low as possible.

3. Marja Esveld Says:
   February 12th, 2010 at 6:49 am

   Dear Ruth, thanks for this very interesting comment. It is good that you focus not only on financial mechanisms to increase financial supplies, but also on ‘community’ and ‘technical’ mechanisms to increase and better organize the demand. Many donors, like the Dutch, are indeed looking for additional ways to increase access to medicines and commodities, besides the obvious ‘grant’ approach. Your comment is very inspiring.

   Marja Esveld
   Ministry of Foreign Affairs, Netherlands

4. Shawn Says:
   February 12th, 2010 at 8:16 pm

   Ruth, thank you for insightful ideas and this discussion platform. In the interest of full disclosure I’ll mention that I’m a director of the US non-profit VaxTrac. While everyone acknowledges that there are myriad things that need to be improved to approach universal immunization, we see the problem through the lens of our work in vaccine wastage and supply inefficiency.

   That being said, I whole heartedly agree with James that the deficient vaccine delivery system will assure that more innovative and expensive products released in the next decade will suffer even greater challenges to reach the people who need them. Every unnecessarily redundant dose and vial lost to poor refrigeration is a missed opportunity. I don’t think that we should take focus away from the development of new vaccines, but we need to do more to quantify our problems so we can intelligently work on solutions. If we don’t in five years we may have a host of wonderful new medicines that only a handful of countries can afford to deploy.

   To Ruth’s response about the need to be considerate of product prices, that is clearly important. What isn’t mentioned is that systemic wastage acts as a multiplier for all costs including the price of vaccines. We’re paying for, shipping, and refrigerating far too many doses that never end up treating the people that need them.

   We know that these problems are pervasive, but the only way to understand and treat them is to focus on monitoring. Instead of asking a national ministry of health to increase their stake by paying a relatively small amount more of the product cost, consider giving them the tools to accurately monitor their own programs. With accurate monitoring in place, goals and incentives for efficiency can be set. If we can tease out and solve logistic issues, we’ll have more money to improve infrastructural issues. Ultimately, the discussion moves away from “which initiatives do we fund” towards “in which order are they funded.”

5. Robert Steinglass Says:
   February 19th, 2010 at 11:13 am

   Dear Ruth,
   Thanks for sharing your innovative ideas about how the $10 billion infusion of support for immunization from the Bill & Melinda Gates Foundation could be used to maximum effect. It’s interesting to note that the comments from James, Marja Esveld, and Shawn all focus on the critical issue of ensuring that once vaccines arrive in country, they do indeed reach their intended beneficiaries. While many obstacles to efficient, effective immunization exist, promising interventions and innovations for immunization service delivery are also taking place under difficult circumstances. However, these experiences have not been systematically captured or shared—at least, not in the Africa region. Towards that end, the Gates Foundation gave a grant to JSI Research & Training Institute for a two-year learning initiative called ARISE (Africa Regional Immunization System Essentials) whose mandate is to identify, review, and document promising interventions leading to improved and sustained routine immunization system performance in sub-Saharan Africa. ARISE will explore how promising interventions are being implemented and adapted, as well as how they are diffused, sustained, and scaled up. The initiative aims to translate these evidence-based solutions into clear and focused options for investments by global, national, and local communities. The findings of this initiative should help inform approaches about how to get the maximum benefit out of those resources that are devoted to getting vaccines out to those who need them. ARISE will be posting information about its findings on various websites. We’d also welcome information about promising experiences to include in our analyses and encourage people to reach us at arise@jsi.com.

   Robert Steinglass
   ARISE Project Director

6. Rosamund Lewis Says:
   February 20th, 2010 at 11:13 am

   The approaches mentioned to strengthening vaccine development and delivery are critical to the long-term success of the health systems that will deliver immunization programmes into the future. There are situations, however, where one-time investments also provide excellent value for money and pay handsome dividends in achieving a measurable public health impact. This has been clearly demonstrated in the case of measles control strategies which involve ‘catch-up campaigns’ to rapidly achieve high rates of population immunity. Similar catch-up strategies in appropriate age groups and populations would prove beneficial to public health outcomes across a wide range of vaccine-preventable diseases, including pneumococcal and rotaviral infections, meningococcal meningitis, yellow fever, hepatitis B, HPV, rubella and others. Hib vaccine introduction would have benefitted from this approach. These strategies ensure that once a new vaccine is introduced in routine immunization, infants (and immunization programmes) gain the maximum possible health benefit right from the first jab.

7. Nancy Birdsall Says:
   February 22nd, 2010 at 6:35 pm

   For more ideas from Ruth Levine on how to spend $10 billion on vaccines and immunization go here.

8. Orin Levine Says:
   February 23rd, 2010 at 11:52 am

   Ruth, interesting blog piece. So often thoughtful blog pieces enter the cyberspace and its unclear if anyone uses them or reads them. So I thought that I’d let you know one way that your post is being used in practice. I teach a course at JHSPH, Vaccine Policy Issues – the only course at any School of Public Health dedicated solely to vaccine policy – and on Thursday night our speaker is Steve Landry from the Gates Foundation. In preparation for his talk, we’ve made your blog post on Daddy Healthbucks required reading. We hope to use it to stimulate a discussion about policy objectives and policy alternatives for the use of Gates funding with lots of input from the students.

   Keep on bloggin’. It’s even helping graduate students in vaccine policy.

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