A medical doctor and epidemiologist, Dr Seth Berkley joined Gavi, the Vaccine Alliance, as its CEO in August 2011. Under his leadership, Gavi reached the milestone in 2015 of more than half a billion children vaccinated in the world’s 73 poorest countries. In the same year, Berkley led Gavi to its second successful replenishment, raising US$ 7.5 billion in donor commitments to support immunisation of 300 million more children by 2020. Berkley has been recognised by TIME magazine as one of the “100 Most Influential People in the World” and by Wired Magazine as among “The Wired 25 — a salute to dreamers, inventors, mavericks and leaders.” His TED talks have been seen by more than 1.5 million people.

Health Policy Watch: Please describe what Gavi does, why it is relevant, and what has been the impact.

Seth Berkley: Gavi’s ultimate aim is to create equal access to new and underused vaccines for children living in the world’s poorest countries.

Toward the end of the 20^th century, global immunisation coverage was beginning to plateau. Despite the huge progress the global health community had made, there were still 30 million children worldwide not receiving a full course of basic vaccines. At the same time, powerful new vaccines were becoming available, but not reaching children in the poorest countries because these governments could not afford them.

So, in 2000 Gavi, the Vaccine Alliance, was created to address this issue. Our unique public-private partnership model brings together UN agencies, governments and philanthropy organisations, along with the vaccine industry, the private sector and civil society, to improve vaccine coverage and accelerate access to vaccines for the world’s poorest and most vulnerable children.

By simultaneously bringing down the price of vaccines for low-income countries, improving availability of new and underused vaccines, and helping governments to improve on vaccine delivery, we have helped vaccinate more than 750 million children, saving over 10 million lives. This has not only ensured that new vaccines are rolled out rapidly in some of the world’s poorest countries, but it does so in a way that ultimately sees the governments of these countries fully financing their vaccine programs. We’ve seen 15 countries successfully transition out of Gavi support in the last four years.

Similarly, newly developed vaccines could take a decade or more to reach the world’s poorest countries. Through partnering with manufacturers, Gavi works to change that. An example of this is the pneumococcal conjugate vaccine. Back in 2008, Gavi launched an ‘Advance Market Commitment’ for pneumococcal vaccines. As part of this agreement, donors committed funds to provide an incentive for manufacturers to invest in developing vaccines appropriate for developing countries. In exchange, manufacturers committed to supplying the vaccine to low-income countries at a fraction of the price paid by industrialised countries. With the help of the AMC, low-income countries began to introduce the latest formulations of the pneumococcal vaccine, PCV10 and PCV13, within a year of them becoming available. And manufacturers even continue to lower the price: earlier this year, Pfizer reduced the price of the pneumococcal vaccine for low-income countries for the third year running.

Since our launch, immunisation coverage in Gavi-supported countries has increased by 21 percentage points, from 60 to 81 percent. But these figures can hide huge variation in coverage and pockets of low immunisation coverage. Gavi’s focus now is to use innovative approaches to reach the 1 in 10 zero dose children – the children who are still not receiving any vaccines – with particular focus on communities and demographics that have historically been missed.

HPW: How would you describe the Gavi model? How has it changed since you started and what changes do you anticipate in the future?

SB: There are many aspects of the Gavi model, but a key part of what we were set up to do is market shaping. Gavi pools demand from the world’s poorest countries and leverages this to negotiate more affordable prices for vaccines. It creates a large, stable market that can incentivise manufacturers to invest in affordable vaccines for low-income countries.

Since I joined in 2011, we have taken this approach further and created incentives for pharmaceutical companies to invest in developing new vaccines. In 2014, during the biggest Ebola outbreak in history, Gavi committed up to US$ 300 million to buy licensed Ebola vaccines, as well as US$ 45 million for operational costs. This provided an incentive for manufacturers to speed up the development of candidate vaccines. In 2016, we signed an agreement with Merck: we committed US$5 million to buy doses of their vaccine once fully licensed, and in exchange, Merck promised to create an emergency stockpile of the investigational vaccine.

Last year, this stockpile became an invaluable resource when Ebola broke out in the Democratic Republic of the Congo (DRC), helping to contain an outbreak in Equateur Province. The vaccine is now being rolled out again in response to a second outbreak in a different part of the country, North Kivu.

With the threat of pandemics on the rise, I anticipate further innovative mechanisms will be required to boost investment in vaccines against emerging disease threats.

Another area that Gavi is increasingly focusing on is health system strengthening, because we recognise that strong health systems are vital to ensure the delivery of vaccines to those who need them the most. We work with countries to strengthen their own immunisation programs, which are eventually sustainable without Gavi support. All countries pay a share of the cost of their Gavi-supported vaccines. As their economy grows, so too does their contribution until they eventually fully fund their own programs.

In recent years, we have seen the first countries start to transition out of Gavi support. In some cases, this has been hugely successful – take Sri Lanka, which has been fully-financing their immunisation programs since the start of 2016 and has maintained vaccine coverage at 99 percent ever since. However, some others have faced difficulties. The key here is that we remain flexible to respond to the needs of individual countries and tailor our approach to ensure their success.

HPW: The world is changing quickly – what are some key shifts you have identified that affect your work, and what are you doing to plan for them?

SB: The number of children missing out on vaccines is lower than it was in 2000, even though the total number of children continues to increase year-on-year. But despite such progress, a shift in demographics is proving challenging. Geography used to be the predominant barrier to immunisation, with the majority of under-immunised children living in remote or hard-to-reach areas. Today, many children missing out on vaccines are living in fragile or conflict settings; more are refugees; more are living in rapidly-growing urban areas.

This presents new challenges that require us to shift our approach. When it comes to reaching children in conflict settings or refugees, we have a new Fragility, Emergencies and Refugees’ Policy, which enables us to tailor our support to better help countries that are facing humanitarian emergencies or hosting refugees.

This year, our technology innovation platform, INFUSE, is looking at solutions to increase access to vaccines for kids in urban settings. INFUSE identifies and scales-up innovative but proven technologies that address immunisation bottlenecks. Previous years have focused on digital identity and data quality.

There is also a perhaps more surprising shift in the distribution of under-immunised children. When Gavi was set up in 2000, most children missing out on vaccines were living in the poorest countries in the world. But this is starting to change – in fact, a growing proportion are now in middle-income countries. As we shape Gavi’s strategy beyond 2020, discussions are underway as to whether we should be offering support to middle-income countries and if so, what form this might take.

HPW: Does the rise in anti-vaccination thinking affect your work and what can be done about it?

SB: In our experience, vaccine hesitancy is not as widespread in Gavi-supported countries as it seems to be in high-income countries. Service delivery, lack of knowledge and distance to the nearest health centre all tend to be larger barriers to vaccine coverage. But it is a worrying trend, and with the rise of social media we are seeing unsubstantiated anti-vaccine rumours spreading rapidly.

A study published recently in Lancet Infectious Diseases found that one-in-four people interviewed in two Ebola hotspots in eastern DRC didn’t even believe that the Ebola virus is real. Addressing such intangible barriers to increasing coverage can be complex but getting the community on board really is a crucial step to ensure the success of any vaccination campaign.

Gavi is working hard to tackle these issues. Take DRC as an example. In 2017, community health workers made 15.8 million home visits to lower coverage areas to discuss primary care issues and rumours around vaccination.

We work closely with civil society organisations (CSOs) on the ground to generate demand and spread the word about the benefits of vaccines. In Kenya, Malawi and Ethiopia, for example, we are partnering with Girl Effect, an organisation that leverages social and mass media to generate demand for the human papillomavirus (HPV) vaccine.

HPW: How do you partner with other organisations and at the government and local levels in the regions?

SB: Gavi is an Alliance. We rely on governments to implement immunisation programs and partners, such as WHO, UNICEF and CSOs to offer technical support on the ground. The Secretariat also works closely with the governments of Gavi-supported countries, because our business model is built on the principle of empowering countries to strengthen their own immunisation programs.

HPW: You have been in your role for some years now – what are some lessons you have learned? What has been the biggest challenge, and have there been any surprises?

SB: I’ve learnt how fragile progress in immunisation can be. As we are seeing with the measles outbreaks across the world, eliminating a disease is not the finish line – we must continue to work to maintain that progress.

New challenges – from fragility to economic decline, from a major disease outbreak to climate-related pressures – can put strain on a previously well-functioning health system. We must focus on building strong, sustainable and resilient health systems that are able to cope with the unexpected.

The biggest challenge has been continuing to move forward as these global challenges make it increasingly harder to reach kids with vaccines. The children currently missing out are not just the last to be reached, but the hardest-to-reach. Increasing coverage requires us to continually innovate. Luckily, this is something Gavi, as a learning organisation, does well – we are not afraid to adapt our approach if it will help us have a greater impact.

Image Credits: Gavi/Tony Noel, GAVI/2013/Adrian Brooks, Gavi/2017/Karel Prinsloo.