 Welcome everybody, I think we're going to try to get started. Very happy to have you all here today. Very happy to be able to welcome our webcast audience. I think we've got 70, 80 people joining us online. I'm glad to be able to welcome my co-moderator, Amanda Glassman, from CGD and our panelists. Before we get started with the program, I'm going to do a brief promotional announcement for two CSIS events tomorrow. At 10.30 tomorrow morning, we'll have Ambassador Eric Gooseby with us to talk about the future of the global AIDS response. That event is already closed in-person attendance, but we're also going to webcast it. So if you'd like to join us, please feel free to log in at 10.30. Tomorrow afternoon, we're going to be hosting a very interesting event. It's the culmination of a year-long effort here at CSIS to look at the contributions of the Department of Defense's medical research labs to the global health response. That's going to be over in Arlington starting again at 2.30. It'll feature a number of very high-level speakers from DOD, from the Gates Foundation, from the pharmaceutical industry, and from other partners of the Department of Defense. So there are some fliers, I think, upstairs and outside. Please feel free to grab one of them if you think you can join us for that as well. I'd like to also note that this is a collaborative event being sponsored by CGD and CSIS. Several months ago, maybe four or five months ago, we started working together to look at some of the key issues of facing GAVI and the run-up to its pledging conference. We issued a paper, looked at some of those issues. I think maybe you've seen it. And then of course now we're organizing this event today. I might just have to say it's really been a pleasure to work with CGD and Amanda on that effort and have really learned a great deal from her. So thank you, Amanda. I'd also like to just single out the contributions of one of my colleagues here, Margaret Reeves, who's a senior research fellow here at CSIS who's really played a critical role in both pulling together the paper in this event today. So we're very lucky to have with us our four panelists, all of whom were instrumental in pulling together different aspects of the pledging conference, a number of them participating in it. We have Joel Tangay, who's the Managing Director for External Relations at GAVI. We have Amy Baxen, Deputy Assistant Administrator for Global Health at USAID. Claire Moran, the Development Counselor at the British Embassy. And Nicole Bates, Senior Program Officer at the Bill and Melinda Gates Foundation. And I think it's probably fair to say that there are many organizations right now looking at GAVI with just a little bit of envy. It's really not common in today's economy to hold a pledging conference and then walk away with $600 million more than you asked for. So that's a great testament to GAVI's accomplishments. It's a great testament to the continuing generosity of the donor community, even in these tough times. And it's great news for the health of the world's children. I think the aspiration is that with those additional funds where the 250 million children will get immunized between now and 2015. But like all great opportunities, that also poses some challenges and some risks. So what we'd like to do today is explore them a little bit. We've asked each of our four panelists to tell us a little bit about the outcomes of the pledging conference from their point of view, but more importantly, to look forward. What does this mean for GAVI over the next several years and what are the key challenges and the new approaches going to be? So what we're gonna do is hear from each of our guests for a few minutes. Then we'll have a structured Q&A among the group up here on the podium. And then we're gonna turn to you and we'll try to leave about 25 minutes to have an hour for Q&A with all of you. So thanks again for joining us. Joelle, let me give you the floor. Thank you, Lisa. I would like to have my first words to be words of thanks. It's actually a testament to the work of many people in this room. And I wanted to particularly thank you, Lisa, Amanda, Steven, and Margaret for the work that you have done as well as the teams at CGD and CSIS. I think that everybody knows that about a year ago in October 2010, precisely, we called on the donor community, but also the Gavi country community and the pharmaceutical industry to help provide the means to actually a very ambitious plan to vaccinate 250 million children and save four million lives. It was not an easy step. As you can imagine, deciding that you actually need to call for multi-year funding and a substantial scale-up of such funding in a time of the financial crisis was a little bit challenging and one that really saw the ambition slightly tempered by that environment. But it was still, we're having very clear signals from the countries that the ambition was there, the wish was there, the demand was there, and therefore we decided to go ahead and to call on this collaborative approach to replenishing the Gavi means to roll out new vaccines. We had, however, to develop the political will. I think it was you and your colleagues who once wrote that Gavi was at the time a success, but a quiet success. And I think that it was very clear that we needed to convince donors that in the midst of that global recession, immunization and the Gavi business models were the right investments and that we were providing a best buy in health and development. And that took a village of advocates to actually deliver. And it took really a lot of help from civil society groups and donor advocates and who tirelessly built that political will over the months. And many of them are in this room and actually all my panelists here were part of the crew who really provided leadership to this exercise. So I want to thank them all. Some of the advocates were world famous like Bono and Bill Gates, but many of them were actually folks whose name is not known but have been tirelessly calling on the White House and others. And I think this was really is a testament to the power of coalitions and the power of that partnership. So we recognize that the long-term effort, the sustainability of this effort that civil society and donor advocates were allowing us to deliver was actually depending on a vision that brought all the factors, all the players into the game, not just a begging bowl to the donor community, but a real commitment to deliver really a change level of prices for vaccines, reduced prices of vaccines and supply security, as well as a solid commitment from developing countries themselves to actually co-finance the vaccine in a way that demonstrates that they believe in the cost-effectiveness of such intervention and the value of such investments. And that was actually what we called the three-legged stool, which we think was one of the key factors of success on June 13. The donors more than doubled their commitments in terms of budgetary contributions to GAVI from the previous three years' average. The G8 is now fully engaged with Japan, the G20 with quite a substantial participation and scale up from countries like Sweden and Australia, but also the emerging economies like Brazil joining the GAVI group really demonstrated that a broader-based support capacity could be engineered worldwide. And we intend to do that with emerging economies in particular in the future, not only as donors, but also as instruments to bring a broader, let's say larger number of market entrants into the vaccine market. So where that leaves us today is basically a real different kind of challenge. A different kind of challenge is first, we need to deliver, we need to demonstrate very soon the impact. One of the strengths that we brought, we think that the group here that echoed and worked on developing the political will really demonstrated was that GAVI had delivered results in the first 10 years, 280 million vaccinated, 5 million life-saves were really documented results. We need to keep on coming back to the community with documented results. So we'll be working on this. And that might take us also in paths that we haven't traveled. For example, working on expanded coverage of vaccination was something that we have worked through the pentavalent vaccine, supporting the basic EPI. But maybe now we'll be able to look within a country about how much equity there is built into the system and gear into the fifth child, the 20% of children who are not properly vaccinated, who are not having access to immunization at the moment will also and foremost, I think, will be challenged and are now planning to deliver a much more aggressive market shaping agenda, meaning that now having created a vaccine market, we are going to explore every avenue in order to deliver lower prices and a solid supply security for countries. And this will take more work. And last but not least, the opportunities here to introduce new vaccines such as HPV, typhoid, rubella, Japanese encephalitis and those new vaccines have a very significant potential impact considering the burden of disease that they correspond to. And we look forward to the opportunity to actually do so very promptly in the next five years. So it's been a watershed, I think, in the immunization community. We hope that it will have raised the interest and the visibility of how effective and how cost effective those interventions are. Thank you. Any? So the US government has been extremely engaged in GAVI since its inception. And in this year, when we're facing an extremely difficult budget climate, we continue to maintain that very strong support. And when we were making the case on the Hill and with others in the government, there were a couple of sort of very clear reasons why we felt that this was a good investment to make. This was a smart investment. One is, as Joelle has mentioned, is the issue of results. How many partnerships can you come together around the world to support where you will be able to ensure that 250 million children will be immunized and protected against diseases and have a track record and then the ability to go forward where you will be preventing four million deaths over the next five years period. There just are not that many interventions and opportunities to have an impact like that. This is an impact that's completely aligned with the President's Global Health Initiative where we have a very ambitious target around reducing child mortality. And our contribution to this larger alliance in immunization is going to directly contribute to helping us achieve that target. So it very much lines up with where we are setting the priorities and where we think we can have the impact. It's also by using a mechanism like GAVI, it's very much aligned with the principles that we have with the Global Health Initiative. The principle of partnership and recognizing that by bringing together partners with their different expertise, you can have a bigger impact than kind of going at it alone. And I think the biggest strength that GAVI has is in fact the partners, each of which is contributing their very significant kind of expertise, their voice and all of the other kind of aspects that they bring to the table on immunization. It's also transparency. Having a mechanism like immunization where you have a very strong kind of monitoring and evaluation component to it, it's been exemplary throughout public health that immunization is one of those things that everyone uses as a tracker for are we reaching, are we, do we have access to our health system? Are we reaching the right children? Where is the system falling down and using immunization, not only for immunization's sake, but for the broader public health interventions. It's about having sort of an opportunity for really smart, efficient efforts, like for us leveraging, so for every dollar that the US government is investing, it's getting more than an eight-fold leveraging because of the investments of other partners as well. And because we were part of, like many other donors, focusing on a multi-year pledge, which is very difficult to do in the US context, but a multi-year pledge, it enables Gavi and its partners to negotiate with industry a really dramatic price reduction because it's giving that longer-term horizon. It's allowing them to be really thinking forward to the future and in the case of rotavirus, it allowed a 67% reduction in price. So again, by simply by how we packaged our investment in kind of a multi-year, it allowed us to have huge impact on price and ensure that the resources that we're putting into this alliance are gonna go even further towards immunizing children. Third, it's also about innovation and it's making sure that these tremendous breakthroughs in technology, in the case of vaccines, with NUMO and ROTA and Meninge, that those are actually reaching the children that are gonna need them the most. But beyond those three, it's also looking to the next wave of vaccines. And by virtue of our being able to show industry that, A, there is a market, that we can make sure that these vaccines, once invested in, are purchased and do reach the target populations, that really helps pave the way for the next sets of vaccines where we want them to also be investing in the kind of development, the capacity and the scaling up to serve the world market, not just the US or the European market. And so as we look forward to vaccines like HPV, but even going beyond that to malaria and then in the future, TB and the holy grail of getting an HIV AIDS vaccine, our ability to kind of continue to show the pathway of vaccines and their ability to be introduced into the markets that need them the most becomes a critically important kind of real world test that this is working. Our USG investments though, aren't all altruistic, these won't surprise you, no. It's also about how are we making the most of for US health as well. And so we had an interesting meeting, it might have even been CSIS that hosted it, but where there was a state health commissioner there and she was talking about sort of the case of measles that gets off the plane. And for her that becomes her million dollar budget line item because that person comes to Dallas, they get off the plane, they take the metro or bus, they stop at a few shops along the way, two days, three days later when this case is identified, then they have to have this sort of running around, tracking every person that this individual came in contact with. And it becomes a tremendous kind of budget and time issue as well as a risk to the population as they're exposed to these diseases. And our ability to really help invest in protection prevention around the world has an enormous impact then in terms of our own populations and how we use our health budgets here. The last I'd say is that the US government, I mean, Gavi is extremely important and Gavi is helping to make that extra step to ensure investments in research, development, the drive of our biotech and pharmaceutical industries are actually reaching all children, not just those here. But it means that those investments that the US is making with the government through NIH, through CDC and USAID, as well as those of our pharmaceutical industries, our biotech, the entrepreneurs of the country, that those are actually having a much bigger impact and that they are achieving their true potential. And that's something that is a real motivator as well as we look at sort of the bigger picture of immunization and how do we drive it forward so that the whole world benefits from these investments. So with that I'll stop and I'm happy to talk sort of more about the US thinking behind this. We will take you up on that offer. But I think first we'll get through the rest of our guests. Please, Claire. Thanks. So I think people, everybody here knows that obviously the meeting was hosted in London and the UK attached a kind of huge commitment to try to make the most of that opportunity. So I think for us we've sort of heard already the kind of really impressive results in terms of financing and the opportunities that means for getting more kids vaccinated. But I think for the UK kind of on par was that was the fact that it actually really elevated Gavi internationally and it was a sort of well-deserved voter thanks in Gavi and the work that it does. So I was going to say a little bit about what the UK contributed and then also kind of why did the UK make such a contribution? So I think for the UK it was kind of two-fold. There was obviously the UK pledge which was very significant. We more than doubled our contribution and that's going to help vaccinate over 80 million children in the next five years. But I think more importantly was the political capital that the UK put into the event. And I think it's fair to say and I think Gavi and other people in the audience will accept that we really did ratchet up the pressure on this one. So the kind of commitment at the highest level the Prime Minister hosted. He rang around his contacts, his allies, his partners. Our Chancellor hosted a meeting with the private sector and in particular Andrew Mitchell, our Secretary of State for International Development was kind of really tireless on this and I don't think, I mean his staff has said to me he didn't have a single bilateral meeting in 2011 where he didn't mention Gavi. And I think it was definitely a collective effort but I think we hope that the piece that we played really paid off. So in terms of kind of why the UK made such a large contribution, I think for me it kind of really illustrates the coalition government's approach to international development in that there's a sort of set of guiding principles and Gavi kind of quite nicely touches on all of them. And I think it's no coincidence that the Prime Minister used the Gavi conference to give his first address on international development. So I think kind of firstly there's a very clear moral case and everybody here knows that case is pretty straightforward that it's a scandal and it shouldn't happen that every 20 seconds a child dies from a disease that could be prevented. I think it was also clear as Amy has said that it was very much in the UK's national interest and part of the coalition government positioning on international development is making this kind of dual case between the moral and the national interest. In terms of actually why Gavi, the new government has a very big thrust on value for money, transparency and results. And Gavi kind of quite nicely, as Amy said, kind of picks up on all of these. I think some of you know we did a kind of root and branch review of all of the UK's development assistance. So we looked at all our bilateral programs, all our multilateral investments and our humanitarian aid. And in the multilateral review, Gavi was sort of one of the top performers. And one of the commitments that Andrew Mitchell made was that basically those who perform well according to our assessments will get the funding ramped up and those who do less well will get less money. So I think Gavi is a really nice test case of we finished the multilateral review, we've done our budget allocations and this is how it's going to start impacting. And then also like I said, so I guess, you know, it's also, there was a very clear case about why it was a cost effective intervention. And the fact that Gavi could provide these sort of clear, measurable and transparent results. And I think the sort of final piece was around the innovative partnership. And again, for the coalition government, there's a huge interest which is closely held here in the US around how can you bring together coalitions of interest to really make a difference. So one of the things that we've been very active in is a new matching scheme with the Gates Foundation linked to the private sector where we will match new contributions. And certainly for us, I think looking ahead we'll be very keen to kind of keep the political momentum, keep the spotlight, keep the energy, keep reaching out to new partners, looking at how we can engage the private sector. Thanks, Lisa. So first I'd like to just thanks CSIS and CGD for hosting this event today and for having the foundation on the panel. A couple of remarks. The first thing is that the work of the Gavi Alliance really sits at the heart of what the Gates Foundation believes in and what we do. So the foundation was founded on a set of core principles, one of which was that all lives have equal value. We also have a core approach, which is that we really look to invest in technology-based health solutions. So when you put those two pieces together, vaccines rise very immediately and very clearly to the top of the investment list for the Gates Foundation. And that's why Gavi has been kind of at the core of our strategy, our global health strategy for a very long time. Gavi is one of our oldest investments starting in 2000 with 750 million, an additional investment in 2005, 2006 of an additional 750 million, and then on June 13th with an additional $1 billion through 2015. So this is an institution and a partnership where we feel that we can have incredible impact on health around the world. At the foundation we like to talk about the value of vaccines. They're proven, you guys have heard all of the talking points. They're cost effective, they save lives and investment now means a lot in terms of health and economies and nations for the future. But I think that Prime Minister Cameron also had an incredibly powerful argument that goes beyond health in his remarks. And if you haven't seen them or read the transcript, I really encourage you to. He talked a lot about value for money and why vaccines aren't just about health, but they're about international interest, national interest and so on. And that's really a way that we should start thinking about our investments in vaccines specifically and in health more generally. So when we think about June 13th, if the indicator for success was money in, obviously it was a blow out. As some folks have said, it's not often that you meet your target when you're talking in the range of billions for health, particularly in this economy, and it's rarely that you exceeded and exceeded by so much. What I would flag is that actually if you take the initial target, you take the money that actually came in in terms of new direct contributions, but you add on to that the value of vaccine price cost savings, as well as you factor in the donors who may not have pledged additional money but would keep their current contributions constant, it's actually even more. So it was success on top of success and so that's incredible. If you use a couple of other indicators though, more donors, great. We have Japan, we've rounded out the G8, you have Brazil with their innovative finance contribution, so you're starting to see the G20. You saw Korea come in last year, you have signals from China, so you're starting to see former recipients consider being new donors. This is actually really exciting and this is what you want to see in terms of the model. I think it's important to keep in mind though that the money that currently exists for Gavi is still concentrated within a few donors and so just to say that while it has been a success, there is still work to do to expand that donor base and get new donors up at a level so that combined they're still not a minority of the funding. So just to say the agenda is not over, it was a great day but it's really kind of a milestone as opposed to the finish line. We think about June 13th outside of money as an indicator. I think someone has mentioned about Gavi's brand recognition and also the CSIS report spoke about Gavi's brand and messaging. I think that it is not an exaggeration to say that a year ago Gavi's public and political brand recognition in major markets was relatively low and that has been a significant turnaround in the past year and that has taken a lot of effort from the secretariat, from partners, from donors, kind of bilateral peer to peer pressure and kind of awareness raising and that's actually, I would consider that to be a win. Two other wins that I would suggest and maybe we can come back to this middle one which is the role of the civil society community. This is a community that did not exist a year ago. Certainly some were mentioning vaccines, those who were working on child health. This was not the profile there but now you have, I believe it was 170 civil society organizations that signed on to a call to action and statement of support for the pledging meeting. I know in debriefs after the pledging meeting there were 90 groups on just to hear what happened, how it happened. There are other communities within global health now they're saying, how did you guys do that? So Gavi is definitely on the radar and there are a number of people that are engaged not just from a vaccine perspective but from child health, global health, international development. The last win or kind of success indicator that I would use is actually not money, it's not people that were engaged. It's why many of us do our work every day and it's the fact that for the first time in history because of these resources, children in poor countries are able to have access to vaccines at essentially the same time as children in rich countries and that was the challenge that Gavi was set up to address before the time lag was 15 to 20 years. Even if the vaccine existed, there was not money, there wasn't the partnership, there weren't the mechanisms to get the vaccine out and that's no longer a barrier. So there may be other rate limiting factors but now money is not the excuse and that's what's really exciting for the Gavi Alliance. Maybe just two last points. One is kind of how this effort in this win for Gavi fits into the foundation's broader interest. As I mentioned, vaccines are the top interest and top priority of the Gates Foundation. In January of 2010, we made our co-chairs, Bill and Melinda Gates, made a call for the next 10 years to be the decade of vaccines and they did that with the very solid belief that if we as a community work to accelerate our efforts in the areas of vaccine discovery, development and delivery, we could save more lives, improve economies and make gains at the rate that we've never seen before. So what it take in 50 years might happen in 10 and it's with that concentrated effort that this would be possible. So Gavi, in particularly this pledging meeting, Gavi number one in general is gonna play an incredibly central role to delivering vaccines and meeting a number of the goals for the decade of vaccines but this pledging event was really a very early milestone, a very early win to build momentum and get the community and other stakeholders really excited and engaged about what's possible. One last thing that I would just say in terms of looking ahead, Joe all talked about the three, like it's stool of the pledging conference, right? So donors, country investments and then also the investments of private sector. In terms of maintenance, to make this money work as effectively as we need it to, it's a formula of money out and efficiencies with the money that you have. So when you saw the vaccine pricing announcements, now that there's this money here, it's also about how we spend it. So we're looking forward to working with Gavi in the future to make sure that the great potential is realized. Okay, well, thank you so much to all of our panelists. These are really great comments. I think we've heard a lot about the importance of the coalition and the partnerships, the large number of civil society organizations that joined together to support Gavi. That's actually quite remarkable. And that that had an impact on leveraging funds from new sources and for fundraising in general and explains a lot of the success that we saw last, was it last week? It seems like a long time ago. The other importance that we're talking about is new vaccines. We're talking about HPV, typhoid, rubella on the list of things to do. And when we move to our next round of questions, I'd like to ask, how would you, how will Gavi prioritize those new vaccines? How will they work with countries to roll them out? We've also heard about the importance of equity that now that Gavi is fully financed, the question is how to reach that 20% that is hardest to reach in some of the countries that have been eligible. And finally, the centrality of market shaping as a strategy, how important multi-year pledges are in this context and the visibility of those multi-year pledges in terms of bringing the price down. And just that great announcement by GSK that they would reduce the price of Rota that was such a trigger as well. And I'll ask our panelists for another round before we turn to the audience. And one is that Claire had mentioned the importance of the Prime Minister himself getting involved in the costs. And I think that's really interesting because it seems to suggest that if you move these global health issues up to the very highest level of leadership, something that presidents and prime ministers will be asked to discuss, that you can get just this enormous momentum. And I'm just wondering, is that a possibility for France, for Germany, and then also for the recipient countries themselves that we're not just talking to ministers of health, but we're talking to heads of state. And a second question is we've heard about the magic formula that Gavi has, the moral imperatives, the national interests, the value for money, the results, the transparency. What other causes in global health have that combination? How generalizable is the Gavi strategy to others? Or how could, let's say the global fund and others take some of the lessons learned from this period to their efforts going forward? I'll turn to, since Amy gave me that look, I'll start with Amy. Just kidding. We can start with Joelle. Joelle. Sorry. I think you mentioned for a moment the leadership and I think that I want to stress this again. What really the village that I mentioned it took to actually deliver the political will globally took a wide number of advocates, but it actually was led with a real personal commitment of a few individuals. And the leadership of the Bill Melinda Gates Foundation, the personal leadership of the Secretary of State in the UK and the Prime Minister and that of Raj Shah himself as USAID administrator, made all the different in this exercise. But to come back to kind of what are the lessons learned for other institution, I think, and think part of that was an essential component of winning formula. We heard also about the political context in which this intervened, but maybe foremost the importance of having a clear strategy going forward and clear sense of where the funding will go. And I'm well aware for example that the global fund is driving a very clear process now to clarify policies going forward and particularly strategies and sustainability. The notion of sustainability cannot be underestimated in the future of GAVI and other organizations success at raising support. Part of the promise of GAVI and that has been partially realized but not fully realized is the fact that it is a convergence of prices of vaccines coming down and rising GDPs from countries with rising commitments of co-financing that makes this investment equation an investment in the short term and not necessarily a long term commitment and that we're able to go from what was a pentavalent vaccine investment soon to a rotavirus and a pneumococcal vaccine and then down the road in 2015 to a malaria vaccine. And that is something that is very much of a preoccupation and priority for GAVI. So you raise the question of market shaping that has become for us since 2010 a strategic priority for the organization. We've undertaken an exercise of revisiting our supply strategy to actually be much more proactive in this area. You've seen some results before the pledging conference where we actually helped engineer some announcement from pharmaceutical companies both on rotavirus on HPV but also on pentavalent and announcements by companies not to be underestimated that the GAVI price would be also made available to graduating GAVI countries which is also a factor of sustainability down the road for the countries that are raising from low income to middle income but are still able to continue and sustain their investment. What we see this as doing is ultimately fueling the interest of countries to accelerate further to do more and faster. What's already happening now is that with the environment in which we are now we have seen the number of applications for GAVI funding number of countries applying double since the last round. We are most likely going to see as we see further prices going down more countries applying for resources. So when we say we were greatly successful we were successful in meeting the demand that was estimated in 2009 but the true demand the true capacity to drive down the number of children dying of vaccine preventable disease is really not yet within our reach and is our efforts over the next five years will be to maximize everything that we can do in that arena. Amy. So just picking on a couple of your questions one is how important is a multi-year pledge? And I think that given the economics of vaccine production where you have a lot of fixed investment required it's actually very important. I mean industry is you know it's not easy to change your capacity in vaccines so they have to make a really long-term decision in terms of how big to size a facility a production facility. And if it's looking kind of uncertain of when donors may step in and a little here a little there they're gonna size it at the smaller like less risky level which is gonna mean higher prices in the end and sort of not adequate supply. So by virtue of being able to really give a greater certainty to the industry that the resources to purchase these vaccines will be there that the demand behind them will be there that gives them the ability to kind of take out a little of the risk and go for that higher sized production which in the end comes out in lower prices and sort of the rapid availability for countries. It's also a function for governments themselves. I mean when a country makes a decision you know our one year kind of pledging to countries is really problematic and we've had lots of reports about how donor funding can be sort of the volatility of it, the uncertainty of it really is negative impact on country's own decision making. And so the ability to give countries a longer horizon also helps them as they think about it. As we start to get those lower prices as Joel was saying that also helps us with your issue of equity. How do you start to reach that last, well in 20% sort of globally but in many countries we're still reaching not to the fifth child we're still going for the third child or the fourth child. And it's gonna be a question of letting our money go further which these lower prices will help us do. It's also though about new innovative approaches to reaching the communities to reaching the populations. And I think that we're learning a lot about community based delivery really getting beyond just sort of fixed facilities. How can we use health extension workers in the Ethiopia model or other community health workers to really reach out to where the children are in their communities. And other innovative approaches like performance based financing. How can we use these new mechanisms that are focusing on results rather than inputs to really drive forward that focus on going the last mile or two miles or 10 miles as the case may be to hitting those children and reaching them with the vaccines that they haven't been reached. I think one of the last key equations on this equity though is holding governments, holding stakeholders, holding civil society even in NGOs accountable for what is happening in the country and where you see a state in India or Nigeria with 10% coverage, it is unacceptable. And to have other leaders point that out and really raise the question of how are you Prime Minister Singh going to make sure that your population has access to vaccines. It has real weight. So I think this issue of leaders and making sure that our leaders are focusing on results and really using the money that we've now committed to best effect will have an impact. This is one of the reasons why at the end of the pledging conference, US government has offered to host a high level meeting in a year's time. We wanna make sure we're pivoting from the focus on dollars to the focus on how are we using those dollars to deliver real results and how is everybody making the kind of commitments in their work programming and activities to turn that money into children's lives. Great. Maybe just a couple of reflections on leadership. So I think in this sort of case it's clearly shown that leadership has delivered results. I think what's interesting is that sometimes it's a little bit of a double-edged sword. So the challenge is if you do elevate issues to a higher level, the expectation is then set that that level will continue. So for every one anecdote is we were told a particular country would only put more money and if the prime minister rang. And it's like, well, the prime minister's happy to ring but should he have to? And it'll be interesting as you move ahead is every extra bit of money gonna need that kind of engagement. And also I think for us, certainly for the UK it really shone a spotlight on this issue which was fantastic for Gavi's profile but it was a huge amount of work for us in relation to the UK public and all these questions of, well, why is the UK doing so much more than everybody else? Why should we have to? So I mean, partly that's healthy and it means we have to explain what we're doing but it's also quite tough. Just I guess one comment on how, how much this experience can be generalized and I think it would be easy to sort of look at Gavi and say, well, it's this unique set of circumstances when you heard Amy and me and the Gates Foundation, it was clear it kind of tick lots of boxes when you looked at all the things that we all care about but certainly I know if you asked my secretary of state he would basically say the onus is on every organisation to track and document and demonstrate their results and we live in an era where if you don't do this or you can't do this, basically you won't get backing and certainly we all know there are certain aspects of global health that are easier to measure and certainly global health is probably easier to measure than lots of other development interventions but he would basically say that's not good enough and that's certainly what he said to the entirety of DFID, you know, do not give me anything unless you can tell me what does this mean for ordinary people's lives and he wants the story and he wants the detail and basically it's kind of interesting when you push people to do that, they can do it it's just that they won't naturally. So maybe just three thoughts. The first is we heard, you know, it took a village but this really was an all hands on deck effort and it was intensive not just for one or two organisations but for an entire community for a few months and so when we think about this model moving forward is how often can you repeat that? For how many issues can you repeat that and can you actually sustain that? And so that's something that we need to reflect upon as institutions and as a community and figure out what the most effective model is moving forward. Secondly, in regards to, you listed kind of the different cases, moral, national interest and the value for money argument keeps coming up and came up a lot on June 13th and leading up to it. You know, part of the role of the Gavi Alliance moving forward with their market shaping work with some of the work of Alliance partners is to make sure that vaccines continue to stay a best buy in public health, that they continue to stay one of the if not the most cost effective interventions. There are new generation of vaccines that are coming out that are complex, they're expensive and so Gavi's gonna have a very key role in terms of continuing to shape the market, continuing to help negotiate prices coming down so that vaccines are in fact the affordable interventions that countries decide to invest in. And then the last comment that I would make is, you know, as much as we are celebrating and deserve to celebrate the $4.3 billion that we're mobilized, we wanna be careful that we don't get stuck on that dollar amount and become complacent because of it saying, okay, we're fine for a while. Joel just said that this was for vaccines that were approved against forecasting conducted in 2009. So as there's this very robust pipeline of vaccines that could become available, again, expensive ones, part of what happened a year ago, part of what happened just a year ago is that there were countries that could not apply for vaccines because there wasn't enough money to finance them and that was an honest part because of complacency for fundraising in years previous and we wanna make sure that we don't get too comfortable that we always say kind of what's next and keep that in mind to make sure that we're never in that place again. Thank you. Lisa? I'll just share an anecdote that I think, Nicole, you'll find interesting. We were doing some background research on press coverage related to Gavi in the run-up to the Pledging Conference and one of our summer interns, so I think it's here with us, actually found an article published in the Sanaa Times in Yemen about Gavi, which I actually thought was quite remarkable considering everything else is going on in Yemen right now, so I think the reach is really quite far and extensive. I think maybe I just put out one or two other questions and then we'll turn to the audience and I guess my question is Gavi's at a great place right now but it's got there through its own learning agenda and it's been an iterative process and some things have worked better than others over time. There's been issues operationally in countries, there's been issues around how to maximize the value of the core partners, there's been issues around how to interact with industry and I suspect there'll still be issues there because there's some people that think there is a strong conflict of interest so if there are any panelists that would like to comment on, when you look at the most important lessons that have been learned, things that you've been fine-tuning, trying to improve, which of them are gonna be most important to stay focused on going forward as you really look at these issues of scale up at country level and shaping that market access agenda and then the second question is and we've been talking about Gavi because this event is about Gavi but the immunization landscape is much broader so what does the role of Gavi, the success of the pledging conference, mean really for the rest of the vaccine agenda and what does it mean for coordination across the basic EPI program and the Gavi specific vaccines and how should that happen over time and so again that's to anyone who'd like to take on either one of those questions and then we'll turn to the audience. Maybe take a stab at the second question from the perspective of the growth of the advocacy community over the past year. As I mentioned, a lot of groups weren't necessarily working on vaccines, certainly weren't working specifically on Gavi a year ago so that's been a big change and usually it takes a lot longer to build a community and really get bought in and kind of mobilize support and there are a lot of people in the room results and one and save the children and others who are played an incredibly important role. There's been this debate of well, did CSOs, did advocacy really do this or was it an inside game and I think you could make arguments on both sides but the point is I think that I like to take away as a fact that now there's this capacity and this was an early win for this community to say hey look what we can do and what it also did is it put Gavi, it put immunization and vaccines on the map as a potential investment and it also put donors on notice to say that okay, we have your attention and there are gonna be groups coming back to you in terms of accountability, did you deliver on your pledge and it's also keeping the Gavi Alliance accountable quite frankly, did you deliver with the money that we advocated to donors on so I think that's actually incredibly important. For the foundation again, our interest is the vaccine portfolio writ large and it is true, Gavi works in the poorest countries, it's vaccine delivery, there's still discovery and research, there's still development and taking things to scale, there's EPI, there are vaccines and polio that's not even within Gavi's remit and so I think it's really important for sustainability purpose for Gavi to position itself as a contribution to those broader immunization and health and development goals and that's gonna be and I think it has started to happen a pivot point for the institution but that's a part of to me the potential sustainability model and making sure that immunization and as a default Gavi stays on the map for a long time. Thanks. Anyone else? I would, the first question a little bit about kind of going forward, I mean like any organization with a lot of partners in particular, Gavi's had some important learning and I think the most important issue is in fact that openness to learn, the recognition that you don't get it right always the first time around, that you have to constantly be kind of monitoring, evaluating what you're doing, listening to what different partners have to say about it and improving upon it and it's that kind of openness to learning that kind of I think in the end makes or breaks an institution because institutions that close themselves off and say we refuse to listen to criticism, we refuse to recognize that anything may be valid, they don't grow and they don't learn and they don't maintain their partnerships. So I think that that's the most kind of pivotal component of success and we've seen the value of it. I mean this replenishment was very much a function of what the partners did and how they engaged and they own Gavi, they feel very strongly about it to the point where the prime minister is willing to make personal phone calls to get investments in it to the point where Bill Gates was making personal phone calls to get there. So it's that kind of engagement of the core partners and the learning from those partners as they sort of see new and different and alternative ways of going forward that I think is going to be the most important, strongest issue going forward. I would say for Gavi, I would totally echo Amy's view that the partnership is essential. The partnership also with not only with donors but the partnership with WHO and UNICEF has been absolutely outstanding with both Margaret Chan and Tony Lake calling for support to this effort but also the partnership with countries and the fact that we're country driven and carefully calibrated to actually accompany countries and rather than impose on or market to two countries I think is a very important component that we need to keep in mind as we seek to accelerate, go further and faster to still remain very much in tune with the country preoccupation and in countries finding ways to actually speak to the minister of finance and not only to the minister of health to make it a national dialogue about why those investments must be made is probably the next frontier that we'll need to go to. At least that's the learning we've done recently about rolling out a more aggressive co-financing strategy. And last but not least, I would say this was a wake up call when minister Rudd from Australia who was a wonderful partners to these great donor advocates and walked into London and said I am, you know, multiplying by four my investments into a gathering. He, before he was able to say that publicly he met a journalist and the journalist said you're coming to, here you're coming to London for a meeting on immunization. Some people would say, isn't that a snore? And his response was, well they should wake up. And I think that's exactly what happened is that there was a wake up call and a wake up call, I'd like to echo that wake up call today and make us realize that we shouldn't feel too much self-satisfied at what we have achieved although frankly a lot of kudos go to a lot of advocates including some of the most powerful ones who have helped engineer the success but the real impulse has to be in meeting the MDGs and we're delivered a milestone with 250 million children and four million lives potentially saved but it's important that we keep on continuing and I think that sense of commitment to delivery and commitment to accountability. So in 2013 we'll be sitting down with our donors and our partners and looking at what are the results that we have achieved. How did the exercise that we will do next year in the United States to rally the forces to deliver actually is starting to deliver and how much are we on course with what we promised last year. So that will be a very important part for us. Let's open to questions please. We have two mics so if you have a question if you mind coming up to the mic so our webcast audience can also hear and please just introduce yourselves before you ask your question. Hi, thank you. First off, congratulations. For those of us that work in immunization this is a very encouraging result that we're seeing. Thanks also to CSIS for hosting this. My name is Laura Shemp. I work as an immunization advisor for John Snow Incorporated but have worked for about 15 years now on USAID, WHO, GAVI, Gates Foundation funded projects including helping about 10 countries the last month with their introduction plans and their applications that went in in June. My question, obviously given the high level profile of the meeting and the funding commitments for the cost of the vaccines themselves and the long-term pricing. I was curious if some of the discussion also focused on the long-term recurrent costs of the delivery platform, the operational aspects of the program that will make it function. In the past, the standard vaccines cost about $2 for the full complement for a child under 12 months. Now it's up to $15, $20 depending on whether you include HPV and some of the more expensive vaccines. But there's also that recurrent cost that GAVI has tried to address through some of the HSS funding and the ISS funding and the CSO platforms which is the delivery of those vaccines year to year at levels as Amy was saying, we're a bit perfectionist. 80% is not sufficient to us. We want 90%, we want 100% so that we can reach those unvaccinated children or under vaccinated. So I was curious if that came into the discussion also because for many of the countries when they're doing their financial sustainability plans it's an issue of just being able to meet the basic costs of the platform itself and then reaching those populations. So I was curious if that came up in the discussion because really it's beyond just the additional $15 for the vaccine, it's the $15 delivery above that to make sure that health workers are getting their money and that outreach is happening. Thanks. Volunteer. I think that it's still, people often still focus on the vaccine because it's sort of tangible and it's sort of the novel piece of it. That being said, I think there was sort of more of a sense that we need to be, when we're looking at the commitments, I mean, as has been said today, yes, this is a lot of money that donors are putting forth but what the countries are financing themselves is multiples of that amount. And yet we don't always put as much attention on it. We don't capture it. And that there's a need for us to kind of think about new ways of looking at what are the countries investing in the delivery of their own, largely the delivery of these programs and how are they being held accountable for it and how are they being recognized for it? I think there was also, I mean, just last week I was at the Health Pacific Summit and there was a lot of talk about, there's actually that whole coal chain and all the costs associated with it and how could we really be driving down the costs of maintaining, distributing, keeping the coal chain complete and really needing to think about that so that it's not just the cost of the vaccine, it's that whole and full cost of getting that vaccine into a child and that that becomes our metric as opposed to just the vaccine vial. Questions? Hi, John Foszer with Results. So first of all, an additional sort of heap on the congratulations and also the thanks to donors for the commitments that were made on June 13th and there's been a couple of references to multi-year pledges being difficult in this kind of current fiscal environment but I think it also works the other way around that you need to make those commitments in order to actually build and sustain the political case for continued investment in global health so to be able to articulate what this money's gonna be used for vaccinating a quarter of a billion kids in XYZ countries is actually, yes it's difficult to actually win that money but better to sort of try than fail by not trying at all so congratulations to all of you for that. A question I think probably to Joel and then would welcome the perspective of other panelists. There's been some criticism of Gavi leading up to the pledging conference around not being sort of aggressive enough in driving down prices of vaccinations and I think both the actual concessions that were made by the pharmaceutical industry and Gavi's responses I think has sort of attenuated that criticism a bit. I have heard several representatives from the secretariat say now we're going to be more aggressive in the sort of market shaving agenda and would just welcome a little more specificity or thoughts about what does that actually mean? What are the next steps in defining that agenda and then maybe for others what's the role of board members and donors in sort of helping that market shaving strategy, thanks. Thank you John, may I really remind everybody of the work that you have done here and thank you very much for the mobilization of results. The question of market shaving is foremost for Gavi and quite different from the way we used to formulate it in the past. We used to think that it's suffice to actually aggregate demand and resources to actually have a working market and that would in itself bring new entrance to the market and lower the prices. The major difference and I welcome Amy also speaking to this point since she's been an architect of this exercise. The major difference of what we want to do now since we decided last year to actually prioritize market shaping is to understand that there are inefficiencies in this market and to actually we need to carefully facilitate the jumping over the hurdles and addressing the inefficiencies in that market. We need to accelerate the market entry from wherever and address the hurdles to new market entrance coming in. The long-term commitments as Amy explained are part of the solution but they are not sufficient. We need to think vaccine by vaccine, market dynamic by market dynamic, how and where the hurdles are and addresses one by one. We also have an amazing opportunity which is to lean on the breadth of the partners to actually invest where it matters. So while Gavi might not be investing in late stage clinical trials for a market entrance from India, it just so happens that that's the kind of work that the Foundation, Bill and Melinda Gates Foundation is doing. So there's an opportunity to actually bring a whole lot of targeted and concerted efforts from all the partners in the way we invest. We can also kind of reach out to new partners and why not looking at regional development banks in helping invest and scale up the investments in critical countries that have the ability to produce in large volumes and bring down the price. So what we're looking at here is a much more targeted thought-through and daily involved process that still leans on UNICEF as a partner for procurement but actually bring the whole breadth of the partnership and into action for the market shaping agenda. Let's go to Alchepin. So I think we sort of support all the work that Gavi's doing in the area of market shaping and for us, I think the critical role is our role on the board. So in terms of both supporting Gavi, holding them to account on that kind of piece of it, I think a sort of second piece is also then kind of looking at the overall governance and making sure that if there are either conflicts of interest or perceived conflicts of interest that the governance structures allow that to be well managed. And it certainly our view that that's happened so far but it will be something that we'll be keeping an eye on in the future. I think sort of back to the original question when we sort of talked about a moral case to invest in vaccines, there's also a moral case to make the money work as hard as it can and if we're not, we're failing children around the world. So yeah, certainly for us it will be probably the top issue for us moving ahead. I just note that when we're talking about market shaping and we focus a lot on price because that's a critical component but that's not the only component of market shaping. So I mean, if you do encapsulate it, what we really want are affordable, reliable, adequate supplies of quality vaccine today and tomorrow. And when you sort of look at that bigger picture, it's not just use a big stick and get down to sort of the lowest price you can today and risk the future supply in the process. It's rather, how do we really make sure we're using our money to best effect now and in the future? What are the ways that we can find inefficiencies and take them out? What are the ways that we can mitigate risk at no cost to us but that has real value to industry and then we capture that value by pushing down price. So it's really a much more sophisticated dialogue that is vaccine by vaccine specific and the importance of ensuring we're really getting each vaccine sort of the strategic plan of where are we today? Where is it going? What are we gonna do to get it there? What is our long-term picture of where that price should be, where the supply should be, where the demand should be and all the steps that are gonna drive over time. Becomes an extremely important kind of component of what GAVI will really be helping drive forward. And Amy, as a follow-up, maybe you could just say a few words about what do you think the most important milestones are going to be to ensure that this three-year commitment from the US government can be realized? Are there specific things that you're gonna be looking for that you think that Congress is gonna be looking for that you'll need to have documented and ready to present to people? I think what is gonna be very important is seeing the plan of action of how these vaccines are starting to roll out. So which countries are coming on board? When are the vaccines being introduced? What is the kind of scale-up that we're seeing as it goes from early introduction on up to the sort of coverage levels in the countries so that we know that we're really hitting the promise, which is we have these three vaccines. For once, we're not having to wait 15 years to get them out, but we have them now. In terms of the supply, in terms of the money, now it comes down to the actions we're taking in country to be realizing that and how we're really reaching every child as rapidly as possible. So as was already said, we've taken out several of the barriers that we've always sort of said, oh, well, can't get these vaccines out there because we can't get a low price. And when we got a low price, well, we can't get them out there because we don't have enough money in hand. Now all of that's there. And the only thing standing between us and having a world that's immunized against these diseases is sort of the countries and our ability to partner and support them in really the scale up and the delivery of these products. So that's what we're gonna really focus on. Steve Morsom, CSIS, congratulations to Gavi. This is a remarkable story. And one thing that jumps out from your presentations is that a very powerful government, a very powerful foundation, and two or three other very powerful state partners, a very small nucleus coalition can really go against the tide of our expectations in this period of austerity and really drive things forward to this point and turn around expectations. And that's a very promising development and one that I think took a lot of people by surprise and congratulations on that. My question is, what do you all fear most looking forward? Because we know that there are vulnerabilities, there's dollars, there's the secretariat, there's market forces, there's private sector actors, it's a very complicated portfolio of people who have to deliver. What are you afraid of looking forward in the next two years? That's the question everybody really likes to answer. That's the question everybody really likes to answer. Anyway. I can start. I'll spin it just to not use a fear frame but to say what I think really is essential for this to work. Again, we have all of the pieces in place. First is that the reason why this worked is, as you said, Steven, because there was this coalition, a core nucleus, but that needs to be the full alliance working in this way, moving forward. So as you all mentioned, UNICEF and WHO have been great champions for Gavi, needs to go in both directions. And so whether the World Bank, the donors on the board, everyone needs to keep this at the top of their priority list and that's gonna take some work from advocates, from the secretariat, some peer pressure to make sure that this stays on the map. So that's number one, Gavi is an alliance and making sure that it operates as such, moving forward. The second piece, and I mentioned this a little bit before in relation to the money that's come in, is that we not get lulled into a false sense of security or complacency that we're okay for a while, we can ride for a while. We always talk about the morning after. So the 13th was fantastic. It really was and we, again, should all be very, very proud. Thanks, congratulations. Everything belongs to, it goes to everyone on this stage and the audience and people who aren't here. That was a moment in time and what we're looking for is momentum. So how do we stretch that out and keep it moving forward would be what I'd look to. I'll second that. What I've read on my page was momentum as well. I think that we do have an extraordinary opportunity and now we have to realize it. And ensuring that this is not a secretary it's gonna go off and do this, it's not a one government or two governments are there. This is something that every, it's every partner in the immunization community and new partners that we need to bring into that community really need to own this and kind of bringing to bear the creative, better approaches to doing business, the kind of excitement and hard work that this is gonna take on top of what's already fairly loaded agendas that we all face, it's going to be the really critical issue going forward. So we just need to maintain this excitement and maintain the focus on results and how we're gonna really deliver on those in the future. I think maybe for me, probably my biggest fear is probably in relation to the donors. I think I have sort of full confidence in Gaby that with the resources that it gets is gonna use them really, really well. But I think it's so often donors come together and you pledge at these events and then actually the pledge is what you say you're gonna do but actually the resources gonna flow there are kind of countless occasions that you can add up with these really amazing numbers and we're still kind of trying to collect them a decade later. So for me, I think it's really holding people's fire to making sure they meet what they've said they can meet. I can see we're on the same wavelength here. It's very critical for us in Gaby that the capacity and the real power of influence that was created and engineered for June 13 not be missed in the critical next step of the appropriation of the money that has been pledged. And we think that there is as much work needed in creating bipartisan support in all countries in delivering the pledges as there might have been in securing them. And that should be really our part of our priority as much as ensuring effective delivery and results. So when the accountability moment comes we're both demonstrating that we have vaccinated the children and saved lives but we also have received all the funding and distributed promptly to the countries. I think another area of important preoccupation is to actually always make sure that the demand does not outpace the resources and vice versa. And somehow we're all fixed on this idea that we went ahead of what was the demand in 2009. We just should not be too complacent and find ourselves suddenly with the demand having outpaced what is really the promised resources on the table. So keeping an eye on how countries are evolving on how the uptake of new vaccines will be very important. And last but not least, this kind of exercise is a long-term exercise. It takes years to actually think through how much support can be engineered. And I think it's time to think post-2015. It's time to think what we'll be able to do for the Millennium Development Goals but also what can we do for child mortality and on the immunization and health agenda post-2015 and get ready for it very soon. So that's I think a long-term efforts that may not be in everybody's mind as we are on the end of a process where we all got energized, but needs to be there. Our commitment to drive down the number of children that are dying of vaccine preventable disease needs should not be limited to a couple of years time for it. Any other questions from the audience? My name is Paul Emer and I'm presently with Medical Care Development International. But this question kind of goes back in my own history to the time that I spent at AID. I had the good fortune of being involved in some of the early talks about GAVI and also some of the early talks on the Global Fund. And I think you guys have touched on this again but I'll just ask the question to allow you to maybe expand a bit. And the question is in both the Global Fund and GAVI there has always been a tension between being able to support the delivery systems, the health systems that are going to deliver the vaccines in the case of GAVI and deliver the interventions in the case of the Global Fund against buying those interventions because it's very easy to go to donors and say we bought this many vaccines, we deliver them to the country or we treated this many people. But the issue is to actually produce those results and save those lives. You do have to have important changes in health systems. And so I'm just wondering how GAVI particularly is dealing with this tension between investments in health systems and the necessity to actually make those investments against. It isn't easy but sometimes the easier the market issues, the issues of producing the vaccines, the issues of getting the producers out there to do the work. The hard work is in the countries actually delivering and how have you dealt with that tension? Well, actually that tension was at the heart of GAVI, very intense in recent years. How much should we do vaccine only or new vaccines? And how much should we actually do health system strengthening? And the dialogue with partners and alliance members has really evolved through extensive consultations last year and we decided to calibrate somewhere between 15 and 25% of our resources would be allocated to health system strengthening activities that really allow and cash-based grants in general that allow country and empower country to build the infrastructure necessary to distribute the vaccines. So that is an effort that still remains part of what we do and is evolving also in a dual way. We're looking at new ways of doing cash-based support to countries and we're also looking at advancing a partnership with the Global Fund and WHO and the World Bank on health system strengthening platform ensuring that we do not individually go to country and create silos, investments in health system strengthening knowing it's the same system we're all strengthening and that somehow there is coherence and in the ways that our agencies are working forward. Closing thoughts. Well, there's a lot to look forward to. So I think I've gotten the very clear message that it's all about momentum and stop with the complacency in case you were feeling self-satisfied because we're moving on. I'm just so impressed with all the work that all of you have done and I congratulate you and we're also really pleased to have collaborated on this paper looking forward to the challenges that Gabby faces over the next five years. I guess we'll just stay tuned and keep following your work with great interest. Thank you very much and thank you to the audience for coming. Thank you. Please thank our panelists.