Mahima Datla 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”?

The first priority, in my view, is expanding immunization coverage. This area would not have been my top priority before COVID, but it is important to conduct catch-up campaigns and overcome the setbacks in routine vaccination caused by the pandemic to protect the gains from the past few decades. For example, measles catch-up campaigns were disrupted because of COVID. It is critical to get these campaigns back on track because the world does not need a deadly measles outbreak.

Second, Gavi must make sure it is equipping countries to meet co-financing needs. Gavi has done a great job of getting countries to support themselves with respect to co-financing requirements. However, COVID has stressed countries. And countries already have different challenges with strengthening and improving their own health systems. As a community, we need to be pragmatic and accept a situation in which certain countries may find it more challenging to meet their co-financing requirements.

On a third and related point, Gavi needs to help countries create the fiscal space to continue investing in immunization and make their systems and investments more sustainable. This objective will be particularly important as several large countries are expected to transition from Gavi support soon.

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?

Three priority actions for Dr. Nishtar are to (1) get vaccine coverage rates up, (2) get vaccines into countries that need them most, and (3) facilitate greater regulatory harmonization.

First, and building on one of the challenges I mentioned above, a priority for Dr. Nishtar will be to help countries improve and maintain coverage levels. Gavi has had so much momentum in this area, especially in supporting new product introductions. Dr. Nishtar will need to help ensure that countries that have already signed up to introduce new vaccines have the ability to rollout the products. Importantly, several countries that had previously been approved to introduce a new vaccine did not have the bandwidth to execute the rollout during COVID.

Second, Dr. Nishtar will need to reinforce Gavi’s role in vaccine introductions. In particular, action is needed to balance market shaping efforts with sustainability and inclusivity. In some cases, Gavi has anticipated a certain level of demand, which materialized before manufacturers had the chance to scale-up production. Dr. Nishtar must help Gavi close the gaps between projections for demand, actual demand, and manufacturers’ capacities and timelines to ramp up supply.

As a case study, shortages of the inactivated poliovirus vaccine (IPV) are causing unintended consequences. Everyone believes introducing this vaccine is the right thing to do. Gavi recommended countries introduce IPV, and UNICEF put together projections. However, manufacturers were not really prepared to scale-up capacity and production. As a result, some countries, including India, decided to change the route of administration. Intradermal administration—which involves a reduced dose, and therefore requires less doses overall—is being used in many cases to accommodate the lack of available product. However, this approach is not optimal or productive in the long run. A lot of countries struggle with adequate training for intradermal use. Moreover, it is not how the products were licensed for use, making it off-label use.

Dr. Nishtar has the opportunity, with all the right stakeholders around the table, to make these decisions more inclusive and appropriate. She should focus on evaluating the market, including identifying when decisions are driving affordability, pushing past the point of sustainability, leading manufacturers to exit the market, and/or causing stockouts.

Finally, regulatory harmonization will be lower hanging fruit and an important tactical consideration for Dr. Nishtar. For example, the time lag between World Health Organization (WHO) pre-qualification and the actual introduction of a product to a country is an obstacle for Gavi in delivering on its mission. Gavi can work to address this challenge by facilitating greater dialogue between WHO and country regulators.

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

Success will certainly be about sticking to the plan and delivering. Dr. Nishtar does not need to worry about Gavi’s replenishment right away. But efficient execution of Gavi’s mission will require getting all the stakeholders to align and focus on the end goal.