Sharmila Shetty 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”?

There are going to be a lot of challenges for Gavi in this next strategic period. One of the biggest challenges is with coverage of basic childhood vaccines. While Gavi admittedly has come a very long way in its 20-plus years to bring vaccination to children in some of the world’s poorest countries, there is still lots of progress that needs to be made in basic childhood immunization, equitable immunization, and health system resilience.

At Médecins Sans Frontières, we see the consequences of the large numbers of zero-dose and underimmunized children on a daily basis. We see increasing numbers of outbreaks of vaccine preventable diseases where we work, including diseases that we thought were under control, like diphtheria.

Also, newer and often more expensive vaccines are being added to the menu—many of which involve new touch points beyond childhood. Maintaining immunization coverage while dealing with outbreaks and also expanding the vaccine portfolio is going to become increasingly complex.

Another important challenge for Gavi is that its current eligibility, transition, and co-financing model is not fit for purpose and is failing some countries. Although 10 countries were expected to transition from Gavi eligibility during the current strategic period (2021–2025), only three have done so to date. Coverage rates in former Gavi-eligible countries were hit hardest during the pandemic. Challenges with the current model will only amplify as newer vaccines are introduced, particularly given the increasingly difficult fiscal climate.

Additionally, more than a quarter of Gavi-eligible countries are considered fragile or conflict-affected—with the number expected to increase in the next period. Gavi’s transition model needs to take this reality into account.

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?

First and foremost, it will be important for Dr. Nishtar to get Gavi back to focusing on its core business. Gavi has been underperforming on some key indicators like numbers of zero-dose children, diphtheria, tetanus, and pertussis (DTP) coverage, and equity. To address these shortcomings, Dr. Nishtar will need to concentrate on improving performance on some of these basic indicators before venturing out too far into new areas and spreading Gavi too thin.

Dr. Nishtar will also need to steer Gavi towards innovative strategies and new partnerships to reach the significant number of zero-dose children that live in conflict-affected or fragile settings. Gavi is set up more as a development organization, rather than a humanitarian organization, so I’d like to see Gavi ensure that its policies and practices better support the humanitarian actors that have solid track records in vaccinating children in fragile and humanitarian settings.

In parallel, humanitarian actors must be given the flexibility to operate in these contexts. One place to start would be aligning Gavi’s policies with the World Health Organization’s (WHO) Framework for Vaccination in Acute Humanitarian Emergencies, which allows for some additional flexibilities in humanitarian contexts. I’d also recommend that Gavi develop framework agreements with governments to guarantee that non-governmental organizations (NGOs) can quickly and efficiently engage in vaccination activities in hard-to-reach areas. Another recommendation would be to enable the creation of in-country stocks of vaccine doses to which NGOs would have swift and unhindered access when undertaking vaccination activities, including for reactive outbreak campaigns.

Additionally, in humanitarian settings, it is critical to align with WHO recommendations for interrupted or delayed routine immunization and extend the age limit to vaccinate children to up to at least five-years of age in order to adequately reach zero-dose and underimmunized children. Currently, Gavi’s routine immunization support does not extend to that age, with the exception of the timebound “Big Catch-Up” campaign.

Another priority action is to ensure that Gavi has a new transition model that better supports countries, including humanitarian settings, where they’re at and puts them on a sustainable path to self-sufficiency. Over the past 20-plus years, it has become apparent that gross national income (GNI) and public health indicators do not always correlate. Further, Gavi is still off-track in tackling subnational inequities in immunization. Gavi’s transition model has to reflect these realities and should potentially include public health indicators and equity indicators. Gavi should also consider improving vaccine access and affordability for countries that have already transitioned from Gavi support, which would entail improving pricing commitments and promoting new vaccine suppliers, including a focus on local and regional suppliers.

Last but certainly not least, I’d like to see some reform in Gavi’s governance model to be more inclusive and ensure that the perspectives of Gavi-eligible countries are prioritized.

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

Success in the long-term will depend on vaccinating more children and fully protecting them from vaccine-preventable diseases, resulting in fewer outbreaks. Countries should also be able to improve coverage rates while at the same time balancing the introduction of new vaccines that are the most impactful for them. Also, there should be more equitable access to vaccines, even at the sub-national level and among children in fragile and humanitarian settings.

Success also means more countries achieve sustainable self-sufficiency without requiring donor support. More countries should be able to successfully transition from Gavi support without sliding back. Transitioned countries should also be able to better sustain coverage and have access to affordable vaccines. Middle-income countries have been hit hardest by the pandemic and are not able to introduce some of the newer vaccines that Gavi-eligible countries have introduced.

Finally, success means having an operating model that puts Gavi-eligible countries more in the driver’s seat, where they are empowered and supported to choose the support that they need. This support should fit in with their priorities and their national immunization strategies. The voices and perspectives of implementing countries should be front and center in discussions, with their needs being the driving force.