David Miliband on Shaping the Agenda of Gavi’s New CEO

What are the most pressing challenges facing Gavi as it embarks on its next strategic period, known as “Gavi 6.0”?

I view Gavi 6.0 through the lens of IRC’s mission: to help people whose lives and livelihoods are shattered by conflict and crisis, including the climate crisis, to survive, recover and gain control over their futures.

Over the last five years, humanitarian needs have concentrated and intensified in settings where poverty, conflict, and climate impacts overlap. In these areas and elsewhere, we see outbreaks on the rise.

The twin challenges of driving vaccine equity and improving health security should shape Gavi’s work in the next strategic period. To improve equity, Gavi will need to expand the reach of immunization programs. To improve health security, it will need to enhance agility and speed.

Global institutions designed to tackle extreme poverty have made significant gains in stable settings. Success has been achieved by working through governments and mitigating risk for donors. Yet more needs to be done in fragile settings where outcomes have remained stagnant or declined. A leaner, faster, more risk-tolerant approach is required.

The immunization sector is no exception to this trend. Fragile and conflict-affected settings are disproportionately home to under-immunized populations, missed communities, and zero dose children—children under five who have never received a single vaccine. These children may be under the control of armed groups and non-state actors. They are often on the move, crossing borders to find safety and sustenance. They may live up to 100 kilometers from the nearest health facility, over treacherous terrain.

In such contexts, a partnership model that relies not only on the governments but on the full complement of actors works better. IRC leads the REACH consortium, one of two multi-sectoral partnerships that Gavi has funded to reach those children. This partnership is already making encouraging progress. In the first year of programming, REACH administered over one million doses of childhood vaccines, in part by improving access to missed communities from 16 percent to 77 percent.

But improving reach alone will not be enough, speed and agility are also key. In addition to unpredictable humanitarian crises, the number of countries battling measles outbreaks increased nearly 70 percent from 2021 to 2022, driven in part by inadequate immunization coverage in crisis contexts. A rapid response is required to prevent these kinds of epidemics and pandemics.

What priority actions should be at the top of the new CEO’s agenda to ensure Gavi can deliver on its mission in Gavi 6.0 and beyond?

Priority actions for the new CEO should be funding, scaling, and institutionalizing models to deliver in fragile settings and to increase the speed and agility of outbreak and emergency response.  

Gavi has already piloted a model that directly engages a broad spectrum of actors, including humanitarians, local civil society, academic partners, and the private sector.

For example, the REACH consortium’s strategies include establishing a centralizing project management unit to drive progress to targets across all consortium partners and countries, engaging grassroots organization to negotiate access, partnering with academic and private partners on supply chain innovations, precision data analysis and human centered design, and using timely data for robust adaptive learning that iteratively improves impact and scale.

The initial progress is promising, but to meet the full scale of need—20.5 million zero dose and under-immunized children worldwide—the REACH model must become the rule rather than the exception.

We estimate that this will require mobilizing up to $200 million annually (roughly 10 percent of Gavi’s current annual budget based on back-of-the-envelope calculations) to expand the REACH model to the 25 countries that are home to over 90 percent of the zero dose children in fragile settings. This should be a priority. The CEO should work with the board and Alliance partners to ringfence the majority of the $200 million and simultaneously explore innovative financing mechanisms such as public-private matching schemes, debt swaps, and social bonds.

In addition, increasing the speed and agility of outbreak and emergency response will require systematically shifting decision-making much closer to the frontlines.

Dr. Nishtar should explore at least two structural shifts. First, consider adopting a results-based financing model for actors operating in fragile settings and outbreak response. This approach would devolve significant discretion to project management teams as long as pre-agreed outcomes are achieved within a total budget envelope. Second, as CGD has described elsewhere, Dr. Nishtar should consider setting up a subsidiary within Gavi to better serve fragile settings and emergency functions with a higher risk tolerance. The goal of these efforts would be to enable more responsive and less heavily regulated programming. 

The new CEO should also consider setting a clear goal for response times. At IRC, we’ve done something similar—making a public commitment to respond to emergencies within 72 hours—and found it a useful benchmark for planning and performance.

What does success look like for Gavi’s new CEO?

Quite simply, success looks like measurable progress on vaccine equity and health security. For example, in five years, Gavi should: (1) halve the number of zero dose children and increase the coverage of routine childhood immunizations in the highest burden fragile settings; and (2) halve the time required to respond to vaccine preventable outbreaks and reduce the number of vaccine preventable outbreaks worldwide.

The measure of success for Dr. Nishtar and for Gavi 6.0 has to be progress towards the Immunization Agenda 2030 goal of universal coverage and, ultimately, towards a safer, more equitable world.