 So good morning everybody, I know we're going to have a few people coming in But I wanted to get started on time. We're going to spend about an hour and a half today talking about the Gavi Alliance We have a great panel today that's going to help understand where Gavi is and in particular How it's going to make its pitch to the US as it seeks another three-year replenishment this fall five year five year So it's going to be a very exciting time for us to hear Where Gavi is how the US is going to respond? And some of the questions that we think Gavi is going to face in the US audience while we're hoping to hear from you and we're going to move to questions and answers with You shortly is your thoughts around where Gavi is with respect to support in the US What are the critical questions you see them needing to answer here? What guidance do you have for Seth and his colleagues around how to maximize their? Sellability to the United States Government as a major donor So we have of course our star is Dr. Seth Berkeley the CEO of Gavi Alliance He's been there now for about a year and three years. Geez. I'm getting old And before that 15 years as the CEO at IAVI the international AIDS vaccine initiative Where I met him and before that at the Rockefeller Foundation where he helped to set up IAVI We also have with us Dr. Robert clay who's the deputy assistant administrator at USAID for health Thank you very much for coming. He's the alternate board member on the Gavi board We have Nicole Bates who leads the Gates Foundation's work on child health including polio and immunization a couple low Priority targets for the Gates Foundation And of course Catherine Bliss from CSIS Who just authored a paper that's outside on Gavi and some of the challenges at my face as it seeks? It's replenishment efforts particularly here in the US so the format for today We're gonna give Seth about 10 minutes to offer some initial comments You'll have to be a little bit patient. He's just gotten off a boat So there's salt spray on his tie and I think this is the first time he's worn dress shoes and in several weeks And then we're gonna have a chance for Robert and Nicole And Catherine to come back with comments as well and Nicole just got off a plane So we're everyone here is freshly traveled And then that should take us Into about half an hour of presentations, and then we're gonna move right to you So we're hoping that you'll spend a little bit of time ahead Preparing some comments and questions and feedback to the panelists. So that's how we're gonna operate today should be fun and informal We also have folks online. We have about 50 people who joined us through the webcast. Good morning. Good afternoon So dr. Brickley over to you So thanks so much, and I am delighted to be here But I might be operating a little slower than I normally do so I hope you'll forgive me and I also wanted to Compliment Catherine on the excellent report that I got to read on the plane coming up last night And it's really exciting to be here as always Let me just say a few words about Gavi and I know many of you in the audience are very familiar But I think it's really been an extraordinary ride Immunization critically important priority to me It's the kind of base of the pyramid of the whole health care system in most of the countries We're talking about and you know, it's been quite successful We got to universal childhood immunization with Jim Grant and where Maybe not quite 80 percent maybe 75 percent, but with the basic six antigens And then it drifted off from there and Gavi was born at a time when a number of attempts had been done But in 2000 at the World Economic Forum Create a new public-private partnership that really would try to bring all of the critical groups around the table to focus on vaccines and to introduce new vaccines that needed to be moved forward and You know if I fast forward to today quite successful. We've immunized 440 million additional children. We've prevented more than six million Future deaths Which were averted so I think in that sense quite successful We've increased the number of vaccines dramatically now. There are vaccines against diarrhea pneumonia the two largest killers of children We have two cancer vaccines that are being used as part of this We have regional vaccines for example meningitis a which across the meningitis belt caused havoc for you know Eons and now you see the disease disappearing in those places with these vaccines. So I think in a sense a really extraordinary model Traditionally Gavi had started with one vaccine and grew slowly and organically and it had its first replenishment in 2011 in that replenishment It was not a good financial time There were some challenges Gavi had gone through in the period before that and the world came together and and really You know had an extraordinary performance the ask at that point was exceeded in that replenishment and Gavi was off to now deliver on its promises and when I joined Gavi It was to implement this new strategy that had been developed during that period Which was to immunize from 11 to 15 a quarter of a billion children and prevent an additional around four million deaths We had a mid-term review at the end of last year and we were happy to say that Overall, we were on target to meet those high-level goals However, there were a number of other goals that were challenging and I think this takes us to what the challenges are the next period and That related to some of the issues around equity some of the countries that still had low coverage and today 22 million children are under immunized in the world and most of those are living in Gavi countries So as we look forward to the next period what's going to happen and the board right now is putting together a strategy Robert might say something about that But we had a board retreat in Berlin now two weeks ago where we spent a full day going over Kind of where the strategy is and hopefully we'll have a new strategy approved in June And and the real part of that strategy is going to be multiple fold one is we really need to continue doing what we're doing We need to finish the job that was being done. We're in the process of rolling out vaccines We've been increasing the number of vaccine rollouts in 2011. There were 22 vaccine rollouts in 2015 It's estimated to be 71 before we add IPV So you can see the dramatic increases and in new vaccines that are being rolled out and IPV is Inactivated polio vaccine, which we can come back to that's in support of the end game strategy via polio eradication effort So there is this scale up going on, but then the question is is what about countries that are fragile? What about countries that have low coverage? What kind of special work can we do with those? So that's going to be one key component a second component is about equity today With the basic vaccines four out of five children get them That's better than any other intervention out there on the other hand that means that one out of five isn't and these are Chris Elias once made this statement, which I love which is that the problem is that fifth child is not standing together with the other four children And so how do we reach those children? How do we change the systems to do that and to do that? We really need to modernize the systems. We've got the the immunization system has not really been modernized, you know since the 1960s when it was basically a paper-and-pen system and obviously High-quality data is critical and being able to understand where these Children that are being missed are what the issues are what the systems are where the vaccines are where the cold chain is all of Those issues need to be worked on so that's going to be a critical component The other major thing about the goppy strategy is there's two other parts now I've talked a little bit about replenishment, but there's two other key components one is the cost of vaccines And as we know vaccines when they're new and innovative and today we have some of the most complex vaccines ever made for example One of the pneumococcal vaccines is 13 strains in it. That's really 13 vaccines put together in one Expensive complicated. How do we get the cost down while keeping the quality up while keeping? You know business able to continue to innovate as a critical priority for us But if we can drive the cost down then that allows sustainability and and sustainability is critical to what we're doing so working with industry in doing activities to improve the marketplace not only in in in reducing prices and keeping quality but also in increasing healthy competition in making sure there's adequate suppliers and goppy has been quite successful since 2011 we've seen on the major three vaccines a 35% reduction in price. We've seen more manufacturers come particularly from Developing country manufacturers coming in creating a healthy marketplace and this is going to be critical to sustaining it But the third part of our virtual Triangle is the fact that countries need to contribute and this is a very important part of Gavi's program There is no free lunch here every country that wants a Gavi vaccine Has to contribute something if you're very very poor they contribute a little as the countries get wealthier They contribute more until eventually they graduate graduation today is at $1,570 it's an odd number because it's adjusted for inflation and when those those countries graduate What's important is that they have the fiscal space to be able to pay for those vaccines So when you're a poor country initially You want to bring these vaccines out it would cost six eight ten percent of your health expenditure clearly You know although I think it's a good buy too much for countries to handle by the time they graduate We're talking about on average about point five to point six percent of their health budgets Which is the fiscal space that country should be able to spend but during this next period We have 20 countries graduating and so what's going to be critical is making sure that those countries have the Maximum chance of success to be able to sustain these programs and that's going to require working with companies to make sure that for a while they have continued access to Gavi pricing that as Prices increase over time which they will that they go up at a at a level that countries can sustain and can be able to afford and that Countries that have particular challenges and there are a number of them that are in the graduating cohort particularly countries who are So-called commodity middle-income countries countries who have gotten wealthy because of commodities haven't necessarily invested in their systems There is a risk that those countries particularly are going to have problems And so how do we work with those countries to make sure that their graduation is as successful as possible So these are some of the challenges that are going on in the next period Let me say that the next period will be the largest period of funding for Gavi And the reason is is that we will be purchasing the most number of vaccine doses in the next period It's estimated we'll be purchasing 2.7 billion doses of vaccine and And during this period obviously will also continue to invest in health systems invest in Graduating countries, but after this these numbers of countries graduate. We're going to see the costs coming down So in essence during this period We're going to have to go out to Governments and and make the case to say that this is a good investment. It's a cost-effective investment It's effective investment But that during this period and during a tough financial time that we actually need more money to be able to Cover this period of getting these vaccines, you know up to high levels of coverage Getting them out to as many children's as possible and working with countries towards their graduation So with that maybe I'll stop and obviously I'm happy to answer questions great Thank you very much Robert the US has been a supporter of Gavi from the early days the AID administrator when he was at the Gates Foundation and helped to get Gavi off the ground It'd be great to hear from you where the US is whether it's a report What's the what's the lead up to the replenishment discussion and and what does Seth need to tell you and the US? Congress in order to attract even greater resources good. Well, thanks Todd and it's great to be back I was at an event earlier this week at CSIS and you all do a great service of bringing people together and the reports that you Produce are actually quite helpful to to the community I think most of you know that USAID has two major Goals and in global health one is an eighth free generation the other is ending preventable child of maternal deaths and if you look at the Ending preventable child maternal deaths I mean vaccines has a really critical role to play in terms of achieving that the bold vision that we're we're looking at and so That's why the US government is really Supporting Gavi. We were one of the first bilateral donors. I think with Norway We've been a continued supporter over the time I think now we're over a billion dollars in our support and When you know when you sort of in these to budget discussions, there are always trade-offs We have to determine where do we put a limited amount of resources? And I think why Gavi has continued to to get support from the US is is what Seth was talking about the results that it achieves the number of children immunized 440 million children Estimated, you know, six million children's lives saved those are real tangible results That are very very important and it's really helps us Realize that bold vision that we have in the future, but it doesn't end there and I think that's very important to state my my impression or my experience with Gavi is that it's really grappling with some of the fundamental issues of development and When you when you look at country ownership you're looking at reaching the fifth child getting that access out to the farthest reach Bringing in other partners growing the pie. I think Gavi is on the cutting edge And and I've learned quite a bit and I think others in the field have learned from Gavi's experience of really pushing our understanding of how we do Health and development in general, and I think we we've appreciated that and that's why we support the program the the new strategy I think continues that tradition of really looking at how we how we do things differently or how we Get down into the real nitty-gritty of how we make a long-term investment sustainable and stick The the co-financing where we have governments that are committing themselves in the last strategy that's estimated about 5% The funds came from governments. We're looking at now around 15% for governments to contribute Donors resources would be going down because of that increase from from local resources and also what's been very innovative for Gavi has been the market-shaping work and You know an increase in that projected over the next strategic period so that we all have lower Prices as we move forward. So I think those are very important the innovative financing the the bringing in You know long guarantees and working with other partners. I think has been Cutting edge has been very important for for our support And I think you know again sort of going back to this theme of really tackling the hard Issues, I've been part of the health system strengthening advisory group for for Seth this past year and You know Gavi has tried Early on to focus more on how do you build health systems? I think it was a very broad approach and it didn't have the results that people Were expecting but now we've actually gone back looked at the drawing board looked at ways in which we can test and make an impact both on Building the systems but also having an impact in immunization and I think some of that discussion and dialogue has been very very important And it's it's one of the reasons again why why we continue to support Gavi and it's moving forward. I Would also add and that Gavi is not the only thing we support We do feel that It's a it's an innovator and it's an important component But we also have a broader MCH program. We have other work that goes on in terms of immunization We would like to see more work go into routine immunization programs through our bilateral assistance We do the best we can but we are hoping that as Gavi moves forward particularly on the polio front with the global polio Ratication initiative GPI that we get much more Engaged in building the routine system because that's the way we're going to sustain this over the long run So we're looking forward to that And then finally it's maybe repeating a little bit, but the but the ownership by countries in the graduation I think is is a really important phase that we're going through and getting that graduation the criteria The support that's needed making sure we don't backslide as countries move into their own Financing and also how do we support countries that are middle income so that they can use their resources and their abilities to address Poor people in their countries people that aren't immunized because they're going to continue to be large cohorts in these countries But the question is how do we interact with this growing amount of resources that are available and in developing countries? Particularly middle-income countries and utilize those funds in a better way to achieve the results Thanks Robert from Nicole Gates Foundation has obviously been a prime supporter of Gavi helped to get it started Provided large amounts of resources one of the top donors I probably guess that Seth Berkeley is on Bill Gates's speed dial Where is the foundation in terms of helping make the case for Gavi and what are the challenges you see in the audience and And how do you think Gavi can use the the results that Seth talked about to? Make the case here in a way that will impel the US to provide even more Thanks Todd. Good morning everybody. It's great to be here Let me add my congratulations to Catherine for a very smart report very much agree that CIS puts out products that Captures the history and the strategic investment opportunity in a way that's just incredibly helpful for public and political dialogue So thank you for that. It actually seems just like yesterday that we were in London it was June 2011 and a set of global stakeholders came together and a really impressive and energetic event to Say two things or message two things to the world One is that collectively we all value the value of vaccines and the contributions that they make to health and broader economic development And two we actually have a vote of confidence in the Gavi alliance That's the mechanism that can help us to reach that shared goal of saving children's lives So it's really as you've heard from Seth as you've heard from Robert already Since that time Gavi has basically done what they said they would do and that's why donors and other stakeholders Continued to be highly supportive and positive on Gavi and the potential that we have over this next period 2016 to 2020 so you've heard about the number of children who have been reached you've heard about the number of future deaths prevented or averted and you've also heard about the number of vaccine introductions But also impressively the pace of those introductions It was not long ago that it could take upwards of 20 years when a vaccine was first available To when it actually got introduced in the poorest countries and actually reached the kids who needed it most Gavi is actually proven through their model that they can change that curve that they can accelerate introduction And then it and because of that we're actually saving more kids sooner and that's for greater long-term result So it's really based off of this foundation again that we're looking to 2016 and 2020 to continue that momentum So let me make three main points. The first is why does the foundation invest in immunization and specifically in Gavi? so immunizations Gavi specifically polio as well. They are the top the top priority of the Gates Foundation We believe that children deserve a healthy start to life We believe that vaccines are a way to do that so that instead of focusing on getting over sickness or instead of Experiencing an unfortunate death kids can just get on to the business of growing and being healthy And we like that and we believe and we have seen that vaccines are a proven safe intervention to help us achieve that So in top of that we also have observed that Gavi is an innovative model. It is a public-private partnership We say Gavi in shorthand, but it is an alliance that involves WHO UNICEF countries the private sector CSO is importantly in that work And so that's super and critical because it's not just one entity But it's a collective effort and that's what you need for to achieve goals as ambitious as we're trying to achieve with child health And it's for that reason that to date the foundation has committed $2.5 billion to the work of the Gavi alliance and looks forward to partnering with other donors and other stakeholders to continue the momentum in this next period of replenishment So as I mentioned on the model Gavi again has changed the trajectory of how and when new vaccines are introduced into poor countries We've shaved decades off of the time that it takes to help improve health Robert spoke about and I believe you spoke as well about what previously was called the three-legged stool Right donors have been incredibly generous either through direct contributions through innovative financing mechanisms Very diverse ways of getting money into the system to help finance vaccine introduction Industry has come on board in a way. They demonstrate great innovation There are many more suppliers today than there were at the beginning of Actually, even just a few years ago and what that's doing is it's making sure that vaccine supply is there It's making sure that quality is there and it's making sure that vaccines are affordable because you have competition in the market And that's hugely important and finally Robert gave the specific Statistics on the fact that countries are co-financing and will continue to pay more over time Particularly as countries begin to graduate so that means a few things when you take the market and countries into into account One is that the donor dollar goes further right because the vaccine is less expensive You reach more kids with that same amount of money and then countries are also pitching in so there's just collective buy-in into what we're trying to do So I'll just close out by a quick look ahead So to date donor confidence is fairly high again in the model Gavi has enjoyed Very high ratings and multilateral aid reviews by the UK by Australia also by Sweden The midterm results have been very clear that we are on track And so now I'm going to get to the cliche cliche part of these these panel discussions, which is in the environment is changing Right. It is a tough fiscal environment. They're competing priorities We could say this insert your issue or your agenda, but we all have that same experience But it's very true for immunization and child health So there are a couple of things that need to happen one is that Gavi is going to have to do an incredibly strong Articulating its updated value proposition, right? They've done a good job to date What does this next phase look like and as you've heard the board is having those conversations around relevant policy and program decisions That will help them get there. The second piece is that along with the success. There are new realities Countries are not demanding these vaccines So we have to make sure that they're available and that they're affordable and that they are reaching that fifth child Who is not standing with the other four? in this period as Seth said this is kind of a Peak and so hopefully we can get over this hump of heaviest spending and then start to see this development model really kick in But during this time, you're gonna have a record number of countries graduating. That's a new experience Can they actually pick up financially is the political will there? Do we have advocacy capacity in these countries to actually help take some of the pressure off of donors and make sure that This is actually a sustainable model. So those are the kinds of things that we're thinking about So all to say that the Gates Foundation feels that Gavi is an incredibly capable organization It has incredibly strong leadership that has been very effective over the past Since 2011. I'm just off of a plane. I can't add that quickly There's great huge political support CSOs are playing a huge role in implementation in Advocacy but also in accountability and holding Gavi accountable for doing what they said that they do so collectively I think that we're teed up for huge success. That's why we're in and that's why we're looking forward to partnering with all stakeholders over This next period great. We'll come back to some of the questions around middle-income countries and how number of donors are graduating countries all at the same time and what are the implications for that and I'm I'm curious as to whether or not you're seeing the implications of the vaxophobia that seems to have Taken over in the US and whether or not that's a political challenge last night on the news I don't know if you saw a lot of reports around spikes and measles And that crazy stuff that seems to happen only in this country. So it's not only in this country. I'm mostly in this country Catherine fantastic paper You've laid out three questions that you think Gavi needs to answer So did you get the answers? Where are we at in terms of getting from Gavi the information that the world needs to make the case that Nicole Requires to help with the advocacy Well, thank you I've wanted to just say a little bit about the origins of this report and the questions that are posed and some of the recommendations around us engagement and how the United States can think about its approach as it looks forward to the replenishment leader this year Basically this this took place over kind of three phases I was able to attend the Gavi midterm review in Stockholm in October of 2013 And was able to learn about both progress during the current phase and interview some of the partners and Stakeholders about their impressions and and their thoughts about the upcoming replenishment I traveled to Geneva in December to meet with Secretariat staff and with other locally based partners And then I carried out phone and personal interviews over the last few months And one thing I can tell you is that I don't think anyone turned down my request for an interview people were Incredibly supportive and enthusiastic about Gavi I had people actually asking if they could review drafts of the of the report And it just it was really very interesting to see the enthusiasm of the support that that was generated The analysis focused on two sets of questions The first was what are the questions that decision-makers? Particularly those in the United States are going to be thinking about or looking for in the run-up to the replenishment And the second group was what are the concrete? Practical recommendations for the United States to consider as it develops its own approach to the replenishment in supporting Gavi's work So the first three questions, you know the kind of the three key questions that I focused on were how well is the Gavi model of promoting? Vaccine uptake through advocacy market-shaping activities and the health system strengthening work How well is that working and what steps is the alliance taking to address problem areas? Are Gavi-supported countries successfully moving toward greater co-financing and sustainable ownership of domestic vaccine programs and what are the Secretariat and partners doing to ensure smooth graduation processes and Then finally how robust is donor appetite for increasing contributions and how realistic is it for Gavi to expand its resource base? Over the you know over this next period So I think the other panelists have really addressed the first two issues So I'll focus on the third and on the recommendations for us engagement on The resource mobilization side, you know It seems like kind of the biggest unknowns are will the kind of traditional core base of donors increase their contributions in this round as They did add the historic replenishment in 2011 that Nicole mentioned When Gavi actually got more than than it's asked than it asked for during that during that replenishment And then the second is to what extent will new or emerging donors whether government or the private sector step up? Either in this particular replenishment, you know actually at the the conference or over the next phase of operations and You know some of the factors that then emerged from discussions and interviews and that really kind of filtered out were You know one that the Global Fund replenishment in 2013 could kind of provide a preview for how some donors are thinking about things where we saw some Conditionality attached to to some of the pledges so it's possible We could see some of that for Gavi, which which might have pluses and minuses You know the second is that it may be possible to see increases from some of the the long time You know supporters like Germany and and the EU But it may be less likely to see increases during this phase from France and Australia and the Netherlands Which have seen some tightening of aid budgets over the the last period You know one question is what about new donors? We saw that South Africa and Brazil have both pledged to the international financial facility for immunizations Around a million dollars a year over a 20-year period Certainly, you know the IFM funds are an essential component of Gavi's funding model And it's important to get those countries involved But that spreads the it spreads that out over a long-term period and kind of front loads the The pledge with the the money extended over a couple of decades India has recently made a commitment for a direct contribution of four million dollars over four years So a similarly important Important pledge yet not necessarily the the kind of money that are really going to push that that next budget amount forward Haven't seen a lot from many of the other emerging Economies yet, but it may be that that there's there's more in the pipeline So I think in the looking ahead it's going to be essential to engage the traditional donors to be sure But are the long-term Gavi is going to need to develop a greater Whether it's a diplomatic capacity or just outreach capacity to reach those emerging economies and make the case over the next period Just a few of the recommendations in the short term What I argued in the paper is that the US should increase its funding with a three-year pledge Recognizing that US commitments to Gavi and bilateral child health assistance as Robert pointed out are complementary and mutually reinforcing US policy makers might want to condition future increases on better data or Thinking about some of the sustainability of the graduation scheme But that might be you know over the next replenishment period kind of looking ahead to the next one Reaching out diplomatically to the US constituent block which includes Australia Japan and South Korea to encourage them to increase their own Contributions during this upcoming replenishment is certainly a practical a practical step that could be taken and the same I think could be true for US ambassadors to some of the middle-income countries That have become more engaged on global health to encourage them to make direct contributions or to increase their support during this period In the longer term I think the US can ensure that its own bilateral assistance and technical assistance around immunizations is complementary to what happens in the field and you know to make sure that staff at the US mission level in the fields are aware of the work that Gavi is undertaking in those countries and find opportunities to to complement that work and then finally I think you know because the United States through the Agency for international development has its own experience around some of the graduation issues and has lessons to share from that I think that Sharing some of that history and some of that experience can also be useful as Gavi thinks about its own graduation processes And so I guess if I may take the liberty of kind of throwing a question out here as well You know certainly the I think the question of graduation and how that graduation process is going to unfold you know, it's one that You know where there are likely to be you know some challenges over the next period So I'd be interested Seth to hear you just you know speak a little bit about how the the alliance is is kind of trying to Anticipate what some of those might be and and at the same time You know we'd just like to follow up on this question about some of the middle-income countries and what some of the thinking around how to You know ensure that it might be possible to reach those Vulnerable populations in countries that are really at this point not Gavi eligible So thanks, I think that's a it's a great start-off question I mean most of my experience is with a global fund and many of the issues that are that are hitting Gavi as you said Robert are also hitting the global fund maybe a little bit later in terms of response So you guys are ahead of the curve in some ways, but this question around how to address middle-income countries where? Over 70% of the poorest people in the world now live Is a real outstanding one? You know we have a Similar approach with the global fund where financing is connected to GNI per capita So as country GNI levels rise Their co-financing expectations change and in some cases their eligibility is impacted and that means that for places where you Actually see rising disease rates and rising income rates. There's a disconnect And certainly at the board you have some donors who look at this very much as the fifth child is their primary priority And in the past that was all about low-income countries Struggling to figure out what a donor responsibility is and therefore what a Gavi in a global fund should be doing in these middle-income countries Is more of a challenge market shaping is maybe one It'd be great to hear how you're thinking about that and then how does a country that's looking at graduation from Gavi and graduation from Ida and graduation from global fund and graduation from concessionary pricing from companies Respond to the poorest people that they continue to have to serve So lots of great questions and lots of discussions will kick off here. Let me start I'm actually going this afternoon. There's going to be a seminar at the Saban Foundation Which is their 20th year anniversary and one of the slides that I prepared for that is about the perfect storm of Nigeria and Nigeria is going to go towards graduation and if you look at the donors which I have listed on one side of the slide and they Will progressively disappear as you just described and it turns out that about 51 percent of their health budget is going to disappear with that now You know not going to be all exactly at the same time But the bigger challenge in Nigeria is what is the commitment of the government to spend on vaccines? Because year after year at the last minute money has been taken out of the pot for routine vaccines and Has been used for other sources and they've ended up with some of the lowest coverage of any Gavi country Despite that there is substantial wealth in Nigeria and so I think this is really the challenge that we have to work on So what am I worried about in graduation countries that have had a slow economic development and have invested Appropriately in their social systems. I think we'll do fine. Is it a challenge? Absolutely, but With time with working with the Ministry of Finance with having people understand the importance of this they'll do fine What I worry about are countries such as Papua New Guinea Which has a lot of wealth now because of the minerals that are there and the mining that's going on etc But that hasn't been funneled back into the social system And so you know will they really make it a priority to continue it now You can make an argument in a country like that that in fact since so little of the system's work Immunization is one that can work better than others and of course in that case the government certainly should but will they and I think That is really the challenge that we're gonna have to deal with and so to Nicole's point We we need is in this next phase a whole new different phase of engaging now Somebody described Gavi as the as the best Known secret in global health and the reason is is up until now Gavi has not been about promoting Gavi We don't have a product red. We don't have a you know friends of the fund Gavi's been about Countries investing in their immunization and delivering it. It's been about partners helping them And you know Gavi has been known in in small elite circles obviously to funders and others But hasn't had that kind of general visibility and one of the questions is do we need to do more visibility? And in countries do we need to do more engagement on political advocacy to make sure that Countries are being held accountable for this And and this is going to be absolutely critical if we're going to succeed in the next period Some of the issues that were brought up in the report the issue of conditionality. I think that's a you know It's a it's one that has to be dealt with carefully done Well, it's helpful in terms of leveraging other donors But you can also end up in a situation you can imagine where you end up with multiple conditionalities And you end up not being able to maximize the resources available which would be tragic because they will lead to Ultimately death. So I think we have to be careful in how one thinks about that in terms of increasing Donors you didn't mention one very important one, which is the Middle East now It turns out that 48 percent of the children that Gavi serves are actually in OIC countries and that's the organization of Islamic Cooperation and And and and yet the only support that Gavi receives from countries in that band are from a very generous gift from the Crown Prince of Abu Dhabi who gave 30 million dollars in the last period but There's obviously You know Discussions going on to try to see if we can increase engagement there Four of the five bricks have supported Gavi now the one that hasn't is China again China has a very interesting history with Gavi where We worked with them on hepatitis B where they had a terrible problem 350,000 cases of liver cancer a year high Hepatitis B in infants and today it's gone from 10% to less than 1% of infants having Hepatitis B carriage and therefore those cancer rates are going to drop and it's seen as a great success But also China has now entered with its first pre-qualified vaccine and therefore they're engaging in this as a as a Supplier as well. And how do we work with them? We're trying to help China enter but also obviously assuring quality of Vaccines is going to be critical because quality today anywhere in the world is the same as In any one country because if there is a problem of quality it affects You know the trust that we talked about that leads to some of these problems, which aren't just us problems They may be magnified here, but in terms of the anti-vaccine movement that exists We've been working very hard to try to engage Some of the the donors that are punching below their weight in this In terms of engagement and having discussions with Germany and Japan and the EC as potential supporters The US has been increasing its share It's now about 8% of of global support just below Norway in terms of the donor for for Gavi and and you know I think the challenge for us in this next period is can we make the case? Can we get people to step up to the plate to a level that will allow us to be able to? get over this hump that Nicole so carefully described Robert any comments on the Recommendations the questions that came out of Catherine's paper and this question around what to do with some of these graduating countries Yeah, so a couple of comments one, you know, we talked about The importance of the new strategy and we've had some really I think productive Dialogue with both the donors in a workshop as well as the board retreat and one of the points that keeps coming up in terms of graduation Is that we we need to be more sophisticated in our? Analysis we tend to look at national figures and particularly for large states that have federal systems where a state is a Is more where the health is? We need to be looking at at Disaggregated data and looking at what's how states are performing and I know that personally having lived five years in India that You know the the overall numbers may look great, but then you'll have you know the northern belt Bihar UP that really are more like African states And so we need to be thinking much more sophisticated about pockets within countries and how we move forward So that was a point I wanted to make I just make one point on that the Uttar Pradesh Which one of the states you mentioned has a the second largest number of under immunized kids in the world after? Nigeria if it was a freestanding country and its per capita income is around $400 if it was a state so if it was a separate country you'd say my god This is one of the poorest one of the largest, you know problems of under immunized kids But it sits within a country that people say well, you know They're sending rockets to space and they have a nuclear program and therefore, you know It's just about internal reallocation, but we know how difficult that is and I and I think you know India the national government does have a lot more responsibility for Addressing those lagging areas, but but states are really the drivers of the health initiative And I think we have to look at how to support those states I fully agree that you know as donors have come in particularly on some of the real high priority areas of HIV AIDS And malaria and so forth we have crowded out government resources And it's it's a logical decision that a finance minister makes he's got lots of money over here So he moves his own money so we we need to be thinking how we bring them back in and And there's a lot of discussion now about in these countries. How do we move them from grant aid? to to mix loans You know subsidized loans to more commercial loans and so that they have ownership In this area as we move forward in the future So there's there's a lot of discussion about and also how do we generate domestic resources through taxation and other things to improve the financing in terms of the recommendations on the outreach. I just wanted to share that We're working very closely with the Global Diplomacy Office of the State Department and We've set up now a system where all ambassadors US ambassadors going out and get briefed on global health And so I've been involved personally in quite a few Briefings where we have talked about Gavi The ambassador to Canada for example we talked to him about the prospects of Gavi and how the importance of Gavi in terms of Achieving our results but also ambassadors going to the Middle East and so there's quite a active Outreach going on through our own ambassadors, but also we pledged in the That we would use our diplomatic clout outreach To to talk to countries as we move forward in the replenishment Next week. We're having a delegation from Japan. I'll be meeting with them on Monday Again, we brought this up in previous meetings, but we'll be talking to them Also about the best buy of Gavi and how they can be helping on that and then finally I would say the recommendation about More participation at the country level. We really appreciate that recommendation Because in some ways our field staff they see Gavi as either a central contribution or you know Multilateral, but it's somehow something other than what they're responsible, which is largely the bilateral but in fact with with our Assistance we have a big role to play particularly where we need the eyes and ears in some countries in addition to WHO and UNICEF so we're talking to our field staff making sure that they're as the health officers They are quite engaged and provide us with the feedback that we need On programs as we move forward certainly been a part of the ship with between the US Bilateral programs and the global fund on HIV TB malaria where you've started to see rather less antagonism Yeah, we're working together in partnership. Yeah, that's really one of the keys of the alliance that Nicole talked about it's an alliance of groups and that partnership has been one of the strengths Nicole so not too much more to add here on graduation, but I think that Nigeria is a really interesting case study of Many countries because again just because you make it to a certain level of eligibility or something on paper Does not not not not mean that that's what it is in practice And it's certainly not uniformed across the country and so the true test of success not just for Gavi But for development in general is once you make an investment Are you actually setting the countries up to carry themselves forward? And so that really is a part of the work and I think that I'm coming from an advocacy perspective and a political will Background and we spend a lot of time in donor markets talking about that value to get donors to invest We're just in some ways and displaced I guess we use the language the plant rather than support some of the domestic spending But we really need to think about how do you generate public demand not just for the product But for the political commitment that will carry it forward So in addition to that the only other piece that I would add is thinking about a glide path So it's not you know Here's the deadline date and it's on and off, but it's really kind of a trickle down or a scale up However, you'd like to see it, but that's really how we're going to get to sustainable sustainability Great, so I want to turn to the audience so one last quick question Which is as you said Seth in the beginning part of the reason that Gavi was established was not only to make sure that routine immunizations were widely available But also to help with the expedited access to new Vaccines and you've done that with rotavirus who've done that with HPV and the the specifically defined designed meningitis vaccine What else is coming at you and and and how much additional money do you have to raise in order to deal with that? You've got obviously IPV which you mentioned if you could tell us a little bit about what that's going to look like There's discussions around a military vaccine There's increased call for more routine immunization with cholera vaccines You know what else is coming at you from the from the innovation stuff that Bill Gates is investing in that you're going to end up having to pay For how does that factor into your estimates of what you need others for punishment? So thanks, we we try to look strategically and in the old days Gavi would you know a new vaccine would appear and then we discuss that vaccine and then another vaccine would appear and you discuss That and so the way it's structured now is we have a vaccine investment strategy That's done every five years We just finished that and what we do is we start out and ask the question in the next five years What is existing now that could be rolled out? What's new in the pipeline that is likely or even has a chance of being licensed in the next period and Turns out that this last vaccine investment strategy. We started out looking at close to 60 different vaccines that were possible Existing or new that was whittled down to a smaller list and then an incredibly complex process of consultation with the public with technical experts Building up the cases for the vaccines understanding cost effectiveness delivery systems efficiencies What do we know about and then ended up with a a few vaccines being recommended The one vaccine that you mentioned that you know sat on the cusp was the malaria vaccine and the problem was it was a little early in in in timing in that the critical data on duration of protection and boosting of vaccine wasn't available and so the board Did something unusual it didn't say no, but it also didn't say yes It said we will look at that data when it comes in and then make a decision on it But I think in terms of going forward that vaccine if it was To to be rolled out that decision wouldn't occur until that data is there until the sage does a recommendation that's the strategic advisory group of experts of WHO that we rely on for these Expertise on when and how you'd use a vaccine and then until that vaccine was pre-qualified So we're still talking about some timeline and in the next period that would be a relatively small Cost although in the years after it could be quite high depending upon what the recommendations We're going to be other vaccines that are around and that are being discussed Dengue a very important vaccine doesn't cause a lot of mortality, but causes a lot of morbidity Rabies is a vaccine that's been around for years We're going to do some studies during this period One of the problems with rabies is that if you have it available it gets used and it gets used a lot And one of the challenges is it does save lives, but you can't keep up with the demand given how common bites are So what are the ways to use it that would make sense and you can't get it out to every place You'd have to have some central location. So we're going to try to look at that Yellow fever has changed its epidemiology. So the board has approved going out and and doing some more campaigns for places that have New yellow fever epidemics We also discussed a cholera stockpile with an understanding that cholera We don't really know how to use it in in endemic settings So a cholera stockpile has been set up for epidemics and the idea is that With vaccine doses that will be expiring using some of those to try to understand how to use it at routine settings And one of the places this is going to be most acute is in Haiti that continues to have and Kind of a halfway between an epidemic and endemic setting And the argument that's gone on between water and sanitation and vaccines should it be one or should it be other and the answer Of course is in that circumstance it should be both How do we use it? What can we learn from that? So it's important that as we think about that we learn about it the last vaccine that was Discussed as part of the vaccine investment strategy was influenza in in pregnant women and and it just wasn't enough data to make the case for Whether that made sense as an intervention globally, but that's something again We'll we'll look at carefully because that might be a vaccine that's important Particularly in the neonatal period and today with all the success we've had in child survival. I mean it's been wonderful Yes, we haven't you know We're not on target to meet the Millennium Development goal of a two-third Reduction and under five mortality, but we're you know around 50% which is extraordinary Given the fact that populations sizes are going up Deaths have been reduced to you know six and a half million from you know more than 12 and a half when we started But because we've had such good success with vaccines and other interventions 44% of those deaths are now in the neonatal period So one of the challenges going forward will be how do we strengthen neonatal health? Are there vaccines we can give to mothers that will protect their unborn children against infectious diseases and other complications? Etc. Yeah, and you're also dealing with HPV You're sort of getting into an area where you're starting to talk about a very different cohort of People to reach into vex vaccinations, right? Yes, absolutely. And can I just say one other thing about middle-income countries? I think that's important The you you rightfully made the point in when Gavi started Basically, it was simple 90% of poor people lived in poor countries with poor infrastructure and poor immunization coverage and today we have you know about 70% of Poor children living in middle-income countries and so one of the challenges is as countries graduate We're going to have as Robert has talked about large pockets So what do we do about that? How can we help and there hasn't been a lot of interest in our development partners and saying let's extend Gavi's subsidization of vaccines to either more middle-income countries or to dealing with these large pockets But are there other things we can do and we're investigating right now Whether we could use some of the work we're doing on market shaping to try to make some of the pricing available to these Countries over a longer period of time and have the growth in pricing as countries get wealthier Not go from you know a Gavi price to a big stepwise increase which would make it unaffordable But perhaps some slope with that and the and our policy committee is going to be looking at some Potential policy interventions that might be done not just for the Gavi graduating countries But perhaps even for other lower middle-income countries that haven't been Gavi eligible and they might get you around the sort of a messy conversation you've been having with paho right around Whether or not they're going to be able to get the lowest prices which traditionally have gone to Gavi So it's a it certainly seems an issue that's hitting you and dr. Dible and others leading these international institutions. We're going to turn to you For questions or guidance or advice on how to make this case in the u.s I think as Seth said the u.s. Has been a consistent supporter, but it's eight percent or nine percent at the global fund It's right up at a third and bumping up against that a few months ago We had the global fund replenishment and it was like the the haul of u.s. Government stars. We had president Obama. We had secretary Sibelius we had secretary Kerry. We had Susan Rice It was really quite a cavalcade of stars So you've got Natasha on board and so it's certainly going to help but but how do we? How do we build the same kind of energy around Gavi? It's in some ways It's still surprising to me at least that was such an easy case to make was such an efficient delivery mechanism with the The idea of just saving babies that we're still struggling to kind of generate the broad level of support you want So we double for you see east is so low right so if we double some of these countries triple them We're still at rates that are way lower than they are giving to a lot of other institutions So maybe you can help us figure out what it is that they need to be doing a little bit differently to make this case So we have microphones Elisha there dr. Kramer soon to be in the back when we take a couple questions and then we'll let our panels respond Thank you for an excellent Set of presentations. My name is Robert Stein glass I work in charge of immunization at USC ID is M chip projects soon to be RMNCH project and I'm also the Head of immunization at JSI So my my I'm very very pleased to see that the discussion is moving beyond Access to vaccines. I know that in the draft business strategy. There's a lot of discussion about Having available services Strengthening routine immunization as part of the health system making services more Not just available but people more aware and The services acceptable and good quality potent vaccines. These are all good Promising things in my opinion Catherine and Robert Clay both mentioned something. I wanted to just follow up on USA ID, of course is a technical agency As well as a major financial investor and I wanted to find out Since they both mentioned country offices or missions of USA ID Whether USA ID itself needs any Thing from Gavi or from its partners in order to make that case better to influence The country offices of USA ID so that they do invest in the technical approaches that are needed to strengthen the routine immunization System again commensurate with USA ID is enormous financial contribution to Gavi in order also to protect that investment Thank you, and thank you very much for this panel. I'm Laura shamp I also work at at JSI and John Snow Incorporated but have been doing new vaccine and routine immunization Technical support in Africa and India over the last 20 years and prior to getting into public health I studied international economics and African development and one of the interesting things I'm finding over the last few years particularly working in East Africa is the needs in these countries for Pretty much what Nicole was saying financial Advocacy skills building because in a lot of cases the problem that they're facing is is being able to effectively argue with their government's presidents etc and increasing Proportion of the budget that needs to go to preventive health specifically for immunization Not only for the vaccine line item But also then for the recurrent operational costs that have an additive Component as they have more services going out to the public So I guess my question for for Seth or maybe for the Gates Foundation also is is there a way that we can? Promote more institutional partnerships around financial advocacy to help these countries either through Extensions of the HSS window or potentially other windows or building some sort of of partnership You know alternative partnerships that will help Provide some of that financial literacy that's kind of needed with with the countries to be able to to be more effective in their Financing and accountability and with with that then how do we also provide the technical assistance necessary for that with you know Obvious caveats about Transparency and governance and issues with political economy and that kind of thing How do we do it in a way that's that's considered to be non-bias really just for promoting the health of children and populations, thanks great, so two good questions and certainly One of the challenges that both Gavi and Global Fund are facing is that they're interlocutors at the government level or often ministers of health And they're not the ones that necessarily manipulate the budgets and do the supplantation that we talked about So how do you make a case that's not only works on a technical level with the people that need to do better around vaccines? But also with the financial and the political people who actually hold the purse strings And and are there things that we can do to help use the data you have to make that case better? And just to add on to that in the US you certainly you have to make for many a national security argument So what is the national security argument for a Gavi investment for a member of Congress for whom? That's a major priority Well, I mean on that question the first thing that's important is we need to have Ministers of finance in the conversation so one of the reasons of having Co-financing even at the lowest level at the beginning is to get that conversation to get a line item negotiated and so When Gavi was first started for example 68% of countries had a line item for for For immunization today 90% to it's not you know totally there But there's been a big increase and that's important and we do have a program in financial advocacy The Saban Foundation the African Development Bank We hope that the World Bank is going to take more of a role It hasn't been in as engaged in this in this last period as they could be But to work with countries to have those discussions and to try to explain the importance of prevention As a as an investment because as you know the problem with Vaccines as they start off screaming, you know If you when you bring a vaccine like the meningitis vaccine to the meningitis spell people are lined up for they come And all of a sudden, you know the disease disappears. It's a miracle. It's amazing But over time when the disease is constantly gone people begin to forget about it. What's the demand the demand is for? Treatment that's what always the demand is and so how do you keep that and by the way? This is true in the US as well, you know prevention doesn't get the attention it should it's always a stepchild So having that type of education and engagement is absolutely critical To making this move forward and it has to happen at all levels It's something that we will try to do more of during this next period because the Minister of Finance You were polite he's usually the lowest in the in the you know This is seen as a cost to the Minister of Finance not an investment for the country Not about increasing productivity or any of the other issues that has to be changed as well Yeah, I would I Would say we could take a chapter from the Commission of investing in health And I know Seth you were on that Commission Maybe you want to reflect a little bit on that but here we have Larry Summers Actually getting up in front of Ministers of Finance the World Bank talking about how health is a solid important investment For as an economic strategy, and I think making sure that our communication Vehicles or our spokespersons are those that are respected listen to Goes a long way something the Minister of Health can talk all he wants But we need to really empower those Ministers of Finance get people that they listen to making the case And I think Larry has done an incredible job in Promoting global health in the community. We've established an office of health systems at USAID a couple of years ago We have economists that are there those economists are working with our more technical oriented Programs such as MCH and HIV AIDS and whatnot and we're finding there's a lot of demand for people of using those skills to both Better educate them but also to be thinking about things through that lens and looking at financial sustainability as well as other parts of sustainability and if I may just on Robert's question, I think You know what we for this ending preventable child and maternal deaths We've actually gone out to five countries in what we call a deep dive We've actually gone to countries really looked with the teams is our portfolio lined With the interventions that are going to have the biggest impact to get us to the result that we want and we're using You know the best evidence that we have and we're going through a very systematic process of aligning our portfolio To achieve the results. I and what we're finding is that over and over immunization comes out right at top of an intervention that we're really achieved that result and And I think we have been a bit relaxed thinking that others were doing immunization. Maybe it was UNICEF. Maybe it was WHO, whatever We've taken our eye off the ball And I think that process for us internally has really elevated immunization as a as the key As a key priority for our for our goals. So it's been based on evidence So I think what Gavi can do is continue to generate solid evidence of the impact of these Vaccines for our programs and how it saves lives and I think using that And you know tools like the list model and others that can help project out where we're going with with these Important vaccines is very helpful and helps change our portfolio Can I just on the on the Commission report which if you haven't read it to really interesting One of the key factors that they talked about and they had some Nobel laureate Economist doing this is interesting to have them engaging with the health people Was that the way we measured health was wrong? We measured health purely on what did it do to productivity, but people value health themselves They're willing to pay out of their pocket and that's the way we measure in economics a lot of things willing this to pay And so if you look at the full value of health, which is productivity and willingness to pay numbers It turns out that a full 20% of GDP growth during the last decade You know has come from health investments and it turns out the benefits are you know Even more dramatic than have originally been done It was a good investment before without new measurements, but it's even better investment And so it's important to kind of capture that in the argument that we're making so I just actually want to agree with three comments and then add to one is The Saban Institute actually has a sustainable immunization finance Project that really looks at this type of country-level advocacy and it's promising but something like that would need to be taken to scale So there is something that exists But we would need to see how that operates in different markets because each market is in fact unique The other piece that I agree with Todd as well as Seth is it is also about the ministers of finance in addition to health as well as other political leaders as within the system and then obviously the evidence base is crucially important the two pieces that I would add though is that when we think about the country-level dialogue It's not just minister of health minister finance there are the bilateral or the country offices of the donors and Conversation among all of these parties needs to be much more intentional and much more regular because it's that kind of circular pressure and that kind of pressure from country mission headquarters whether it's a sovereign government or whether it's a multilateral agency that can really help to just create that Recirculating pressure and reinforcing that this is in fact a priority which sometimes can be disconnected Between off-site locations and headquarters and the last piece that I would say goes back to this broader advocacy Advocacy by any market is going to be different and be unique. It is very different in the global south There's just a difference in the weight that voice carries But what I would say is that we have to be open to the fact that advocacy at country level may not be Vaccine advocacy it may not be immunization advocacy. It may be rights advocacy It may be a broader child health frame And so that means that multiple partners and multiple initiatives have to be open to promoting a broader agenda Understanding that there will be trickle down or there will be kind of you know times when their levels high times when the level when their Agenda kind of rides the wave But I think the combination of those things are the type of activities that will get us on the agenda at country level Which then again reinforces sustainability in the model that God is doing so well at And just to follow up a quick question on that both Seth and Robert mentioned the the need to look for the larger federated Countries at a sub-national level. So do the same Conversations need to happen with governors and state ministers of health. Is this a how do you take? The conversation and there's been some experience with polio in Nigeria How do you move out of the capitals and into the the the state capitals where the decisions are often even more important? I would just absolutely absolutely yes It gets very local and money trickles through systems in different ways And you have to figure out where money gets locked where the decision points are and where you apply that pressure again It's unique. It takes a lot of analysis. It takes a lot of evidence, but also Recycling up what's working? Those stories are just brilliant and they don't always get told and they can have such impact Just just I think this highlights the importance of global diplomacy And I think for a long time health did their own work on their own side But we didn't really take advantage of of our Diplomats overseas and so we have really focused a lot more on our ambassadors and Particularly in countries, you know, some of our programs are 80% health now 90% health in some countries largely PEPFAR, but ambassadors are engaging much more and they reach a whole different audience and then the health community so they're talking to minute to the presidents to prime ministers ministers of finance and Having an ambassador really bring up these issues can can can actually add a lot of weight and credibility They also travel and they bring press with them. So they go out to states. They talk to governors they talk to all kinds of people and Again, they can be an important Part of this equation. I think one of the challenges we have to keep in mind is that Gavi was the first of these large partnerships set up followed by the global fund and There was a great embracing of the light touch of these, you know, our overhead rate is 3% Everybody loves that But we don't have anybody odd country level and I remember Richard Feecham saying a global fund plan with eight staff 14 I was going to say it generously, but And the reason I bring that up is that then you rely on your partners That's the nice thing about the alliance But when you say to WHO is a great partner on technical issues, you need to engage with the prime minister You need to engage with the minister of finance that's not their skill set and so the challenge then is how do we do a better job in these countries and this I think is going to be the challenge We're going to hit in some of these federated states and we haven't yet worked through what that's going to look like I've just hired a new deputy at Gavi Anuradha Gupta who has managed the largest public health program in the world in India She will certainly have some thoughts on this, but you know, how do we work with different types of partners? How do we help support state-level activities? And as Nicola said and the the Gates Foundation uniquely has you know in Nigeria You know picked a state and is working in some others where they've really intensified their engagement and state That's very important for polio has very low immunization coverage But again for them, it's meant they've had to have a person in country almost continuously different people and working in a different way So we're all struggling a little bit with what does this look like? But it's clearly going to be a different model than originally envisioned with eight people in the global fund. Yeah Catherine sure I was just gonna get back to this question about the US field presidents and coordination with Gavi And I think in my initial comments I referred to the USA missions But in the recommendations, you know, I also heard from people and wanted to just you know flag that where the Excuse me the US Centers for Disease Control and Prevention have field epidemiology training programs. That's an opportunity for staff You know teaching and those and you know working with with colleagues or you know Just where there are other CDC personnel on the ground to also be aware of Gavi and the work that Gavi is doing and identify opportunities for collaboration Similarly where the Department of Defense Overseas labs are working on vaccine related issues whether you know through the Navy labs or through the Walter Reed Initiatives that similarly these are also opportunities for collaboration. Yeah, and certainly within three miles of this beautiful new building there are a number of African ambassadors the United States and I would hazard to say that some of them probably talk to heads of state more to the ministers of health So maybe there's a way to actually talk to some of the people here to be able to make a case back home or to engage with Congress and make The case for Gavi in a way that's that's maybe more impactful than having some of the advocates do it So more questions we have a couple over here, and then we have to you guys have to ask some questions over here Terry, I haven't heard from you yet. So you better speak up Hi, I'm Paul Perlman. I'm Paul Perlman with the National Cancer Institute Center for Global Health I'm interested in some of the sustainability questions particularly surrounding the middle-income countries and the graduating countries and one of the things Where I think there's potentially an area to work is in technical capacity building specifically in the development Vaccines and production of vaccines an example that's sort of near and dear to my heart is the HPV vaccine When you look throughout the world, it's still even with subsidies too expensive Especially when you look at India, for example, and one of the questions I have is you know The National Cancer Institute owns the rights to that vaccine the it's open. It's openly able to be licensed So what role can we play in getting some country ownership for regional production to get those prices down? Thanks, it's one of her hand up over here. Sorry. Thank you. I'm Tammy Holman from all africa.com Is there any evidence that? Intensive media coverage in African countries Nigeria for example has or could Create public demand for political will for immunization And if not if that evidence doesn't exist now, how would you design a test for whether that could become an important tool in your kit bag? So you mean the Advertising to build consumer demand for the vaccine is a way to build political energy coverage of the the importance of vaccines the Payback of vaccines both personally and economically great Sorry, I just want to question right behind you This side's being quiet. I don't know why Hi Peter Hale from the foundation for vaccine research here in Washington First of all, good luck with your replenishment conference on May 20th in Brussels. I wish I could be there We are fans of Garvey and you do deserve increased support Seth you said something and Todd you touched on it also, you know, you asked the question What more could we be doing in this country to generate enthusiasm? Increase support from US US government and You did suggest that your other groups. I mean Garvey we all agree is it's kind of a best-kept secret Other funds out there have much higher awareness So I do think that one of the things that you could do is just raise your visibility Here in Washington, as you know, I spend most of my time on Capitol Hill Garvey doesn't come up that often No, no do vaccines. I mean we've got we've got a problem So it was a generic problem creating enthusiasm around vaccines and all the exciting work that you're doing and that we're doing and so forth But in the case of Garvey, I do think you could benefit from raising your own Visibility here in Washington. It's a PR challenge. I'm not sure how you do it, but other groups have done it So wish you luck one more question over here Put your hand back up. Yep. Sorry Hello, my name is Alice up another and I work for the Saban vaccine Institute sustainable immunization financing department So I had two questions to dr. Berkeley and also a comment to Nicole Bates So my first question is I know that dr. Berkeley mentioned that there's an interest to increase funding for to improve vaccination coverage and my question is for the subset of graduating countries is there also to evaluate the progress of Financial sustainability. Is there any indicators that are evaluating management of funds and also management of the EPI program to ensure that coverage levels are being reached because Maybe sometimes we think that more funding is equivalent to better performance But maybe management also accompanies that and another question that I had was I know that dr. Berkeley mentioned that ideally Countries would be spending five to six percent of their national budgets on health on EPI, right? So on In a peripheral analysis of Gavi eligible countries What we found is that that average is actually one to two percent currently both graduating and Those that are lower and lower middle-income countries and I do know that currently There is something called the comprehensive multi-year plan that Gavi uses to evaluate countries five years plans on financial sustainability so my question is has there been any Analysis on whether the government contributions within these CMYP's comprehensive multi-year plans are actually increasing at a faster rate than the donor and total Mages because what we found in a peripheral analysis was that actually government contributions are not increasing in a fast rate in comparison to the overall cost within these multi-year plans and in addition to that What is is there an oversight of the data quality and our country's being motivated to collect and report accurate data on their financial? funds that are allocated to the Immunization programs, so I know currently there's several forms of data being collected. There's Gavi's under progress reports There's those that are within the CMYP's themselves But also W2N UNICEF's job reporting form and unfortunately, I think they're all quite discrepancy Is there any effort coming within Gavi to improve the monitoring and evaluation in country of their financial data? And finally I apologize for that Can you wind it up because that was 4 out of 2. No, no, no, but that's and now I have a comment for Nicole Bates So I know that you were mentioning the importance of maybe Evaluating the funds or flow of funds in countries so Thus far SIF has been able to conduct with in our countries something called the budget process and so Through the budget process we're able to evaluate the flow of funds from what is being proposed to what's being actually executed So we have successfully identified some bottlenecks While conducting this exercise, so thanks. So a couple good questions comments. Do you want to? Nicole once you start off and we'll work our way this way. Sure. So I'll take these quickly first on communications at country level Intensive media cover media coverage is obviously very important as is interpersonal communication to generate demand So UNICEF plays a really strong role of doing that at country level, but then there's also Official formal media that said I think there are a couple things to keep in mind local language and local voices and local faces key as opposed to Western faces and Western voices and Western language If we really want buy-in and ultimate ownership and that's from the beginning to the end of the effort stories again are in Valuable we have to articulate the impact the one thing that I would say and this is more from a polio lens Is that we need to be a little bit careful about the unintended consequences of a lot of coverage of something because sometimes there are Extreme views or there could be bands on access that could be Motivated if an issue is politicized and so on media coverage could be incredibly helpful We have to be thoughtful of whether it is could also be harmful I think using those local voices can help to mitigate that risk But it's just a calculation that needs to be made, but that voice is hugely hugely valuable In terms of support and advocacy you were talking about Gabby kind of being best kept secret on the Hill There's actually a philosophical debate for a lot of issues Do you need everyone to know or do you need the right people to know? Right and so especially on the specific investment versus the broader agenda and I don't have the answer to that They're just different opinions on on what that is and that kind of informs investments at time But what I would say and I see a couple of familiar faces in the room We have the UN Foundation who runs an incredible campaign called shot at life here in the US They've partnered with Walgreens. They've partnered with real life magazine just fantastic in terms of raising visibility and getting Moms involved in blogging and local events and things like that powerful powerful work that helps to mainstream this agenda Results is incredibly powerful here and the US and UK and Australia and Canada doing great work Path is another great partner where they actually help to bridge the evidence base and what's happening technically at country level with the political message So you put those together you start to generate the energy and the stories that can be shared politically or even publicly and then just a quick Thank you for for that comment on the budget analysis at country level. They're hugely important again when those analyses are done How are they translated and how are they shared so that people understand when you're having a political conversation? You guys may go on today You may not talk about Gaby for the rest of the day Policymakers certainly are not after they meet with us And so we really need kind of this quick stories that key information that gets people to remember us and to stick out as they consider A thousand other things on their agenda that others would say are equally important Robert Just a quick comment on the visibility. I think it's not just vaccines and Gaby I think in general child survival had a heyday in the 1980s with with Gobi and Jim Grant and there was really the talk of the town And I think with you know the Global Fund with AIDS and malaria that's kind of taken over the space I think we're with the call to action that we had two years ago. I think we started to readdress that I think there's been a lot more focus now on child survival We're having an anniversary event in June and we're talking right now about how do we showcase? The role of vaccines immunizations within that event and it's it's it's reaching out to the Hill It's reaching out to public. It's it's a it's a broad effort to really try to bring back the So the awareness that we had in the 80s and one to show you know to tell the success story It's an you talk about Gaby being a best-kip secret, but you know what's happened with children overseas Child mortality reduction that Seth talked about is an incredible story And I think that message needs to get out much more into the general public to see what progress that we've had and along with that the role that vaccines has played So let me go from the backwards and let me start with the the questions around Management of funds in country, which is obviously a critical issue and it's a bigger issue. I mean many of the countries that Have problems have problems because of management issues and you know Gaby is not going to fix Nigeria's management system On the other hand we can work with countries to try to build better systems and have them have better accountability And that's absolutely critical to be able to make sure that you know The programs go on and particularly in the future There is evidence that country spend is going up one of the problems Gaby Traditionally had been focused on new vaccines and hadn't been paying attention to overall And so if we pushed co-financing sometimes money came out and co-financed our vaccines But they got taken out of the line item for routine vaccines, which is doesn't do good for anybody So we've now changed and we're looking at kind of the the comprehensive Immunization system and that's absolutely critical even if we were only interested in new vaccines Which we're not and Robert when he originally talked he's also the father of routine Immunization and one of the things that we're trying to move is this critical component that if you're doing special immunization activities You're doing campaigns. They're not coming at the expense of routine Which traditionally it was with polio the more campaigns you do when you're paying people and you know There's there's incentives for them to do that. They're not doing the routine immunizations And then you end up with very low coverage rate. That's not helping We need to have you know all of this linked and we need to at least make sure that when we do campaigns that they are Certainly not hurting ideally helping the routine coverage rate. So we've really changed in the way We're thinking about that data quality is critical. It's a priority. We're working on it We're working on it with the IHP plus. We're working on it with the World Bank with the global fund WHO But it's gonna remain a problem and and so we use surveys a lot. We do you know a lot sampling Certainly the Gates Foundation has worked hard around polio to build up better data systems And now we're taking those systems and trying to use those for routine immunizations Visibility in DC I agree with what Nicole has said but I do think we want more visibility and that's something we're working on we recently hired a an experienced and talented star who will do more for us here in terms of engaging and I think that's an Important part of what we have to do in terms of media. I agree media is very important We don't have a problem in our countries like we do here with the anti-vaccine groups There are some and I could go into more detail if you want but in general people see these diseases They know about them, you know, their aunties have had kids die They've seen people in there in their neighborhood die. And so when vaccines are available They want them the challenge is getting people educated. What's available? What they're for what they do and the media plays an important role with the caveats that that Nicole talked about is getting the local face The local language and having people understand and lastly the question about local production You know, we have had some some big successes in doing that recently There was a rotavirus vaccine that was licensed from the NIH to an Indian company and went through trials and Showed success in those trials and that's rolling forward The challenge on vaccines is not just intellectual property. It's know-how and that's the main thing that that's critical And what we're seeing now are some of the companies that have the know-how are working with companies in the south to do tech transfers and as part of that then they're working in a new business model and I will say that Gavi has changed the business model of vaccines most manufacturers were thinking You know low-volume high-cost vaccines and they didn't know what to do with these countries They care enormously their public health people, but there wasn't hard currency They didn't know what the market whether it was reliable They couldn't build adequate size facilities to produce because they didn't know if there was going to be purchased Gavi's changed all that and now country companies are all thinking about the Gavi model and the Gavi countries as Part of their planning process when they think about new vaccines. So that's the really good story and as part of that they're also forming these strategic partnerships with developing country manufacturers and To produce large amounts of vaccines for the rest of the world and so, you know, we're in the middle of a change period I do think that HPV vaccine will eventually have other manufacturers. I know that there are companies working on it I know there are tech transfer operations going on And you know the challenge for some of these new vaccines are though that the prices aren't necessarily going to drop These vaccines are not as simple as the measles vaccine or others And so yes, we're looking for in improvements in cost But we have to keep in mind the value you're getting by immunizing children and keeping them healthy during their their lifetimes Not just the the fact that we used to have vaccines that you could get six of them for under a dollar And that's what people talk about it's going to cost more but the the benefits are really enormous So we saw earlier this week some major changes in the vaccine market to companies swapping Some of their capacity. It's one of the things we're thinking about looking at here a little bit There are a lot of questions you have on your seats a little evaluation form It's a half-page piece of paper It would really help us a lot if you take a moment before we close to fill that out Include on there any future subjects in which you think we could be focusing some of these kinds of conversations That's enormously helpful to us Seth I'll give you the last word you you have to show up In a few months with an argument here and many other capitals to make the case for Gavi financing Certainly you've articulated a track record of tremendous success. You've shown value for money You've shown that vaccines are a best buy you've got some of the best folks people in the world out on your behalf What is it that you are really looking for in terms of getting financing? What what's your ask going to be and are you are you going to get it? Are you going to actually have another London moment? We exceed it If the prediction is difficult particularly if it's about the future I actually think that we do have a good case and the case isn't just about live-saved It's about diseases prevented. It's about productivity. It's about children living up to their full IQ and being educated the challenge is getting that message out and getting it out in different ways because This is a secret, but you know, I've not met anybody who is against saving children's lives and making them healthy This is something that can sell it can sell You know on both sides of the aisle it can sell in both houses I think the challenge is making sure that the message gets out there and You know the message is complicated because if you ask the average person about development age, you know It's money that's poured in and it's wasted. It's not efficiently spent. It's not well This is an example. In fact, you know, we're lucky. We have data We can show efficiencies and and so in a sense we're we're blessed the challenges is Making that available you asked though about before about how you make this a a strategic case And I think we have to keep in mind and and and we'll see this over and over again Until diseases are eradicated, you know, it is a global world now You can have dinner in Nairobi Breakfast in you know in Europe and lunch in in the United States and that's within the incubation period of any of these diseases and we see these diseases moving around like never before which Means we have to keep our immunization levels up here But we also have to reduce the disease and the rest of the world and so there is a strategic issue Turns out that one of the largest outbreaks in the US one of the most expensive outbreaks in the US was a Swiss Businessman going on a golfing vacation in Arizona now You don't normally think of Swiss business people as being transmitters of disease But the point is that you just can't predict and so I think there's a strategic issue for the United States to try Eliminate these diseases not just the United States, you know and Saudi Arabia has the Hajj They're immunizing against diseases the best way is not to immunize against the diseases That's insurance, but get rid of the diseases to start with and so the more we can talk about that the miracle that vaccines bring Getting rid of these diseases making people live to their full potential the more we can sell this and lastly I do hope the US continues to be a strong supporter They have been there from the beginning as Robert has said they've served on key committees on the board We work together, and we we hope that they will Continue to play that role great. Thank you everybody for coming. We're looking forward to your feedback on the forms Enjoy your day. I know nobody are going off to dr. Berks is swearing in so Congratulations to dr. Berks who has another important job. Good afternoon