[DC:] How did you become involved in GAVI?
[Dagfinn Høybråten:] I was the Minister of Health for Norway for five and a half years and strongly involved in public health and preventive health measures. One of my main achievements in Norway was a ban on smoking in public places, such as restaurants and bars, for which we were one of the first countries in Europe to implement. I have been focused most of my public life on the prevention of diseases.
When I left the cabinet in 2005 and became an opposition leader in Norway’s Parliament, I was asked to join the GAVI board. Since 2006, I have been on the board of GAVI; and since last year, I have been on the board. I have been in public service for nearly 30 years, and working with some of the most effective and cost-effective interventions in public health to save children’s lives. It is the most meaningful thing I have ever done.
[DC:] How does GAVI’s mission work? How does it bring together private and public partnerships?
[DH:] GAVI was begun in 2000 because the world was really falling backward in vaccinations. The goal was to scale up the incidence and use of vaccines, to introduce the vaccines without the shameful delay that was usual before—15 or 20 years oftentimes—between when a vaccine was introduced in the industrialized world and it came to the poorest of the poor. What GAVI does is gather around its board table all those partners that play a part in vaccinating the world: non-governmental organizations, the private sector, civil society, research, and the countries themselves. This includes 73 developing countries and about 20 industrialized countries.
We search for vaccines on behalf of these countries based on the needs of their health plans and immunization programs, and work to achieve reasonable prices and long-term commitments. We have been able to mobilize resources upfront by using the financial market, through special financial considerations for vaccinations. This has made us able to vaccinate more than 350 million children and prevent 5.5 million unnecessary deaths in the course of our immunizations.
We have also focused on sophisticated vaccines, and the two most important are now being rolled out country by country—the vaccine against rotovirus (diarrhea) and the pneumococcal vaccine against pneumonia. These are the two biggest killers of children under age five worldwide; they almost never kill adults. We now have vaccines to prevent that. We know that in 2015, we will have vaccinated approximately 250 million additional children, saving an additional 4 million lives.
There is a huge market for new vaccines, but the purchasing power in developing markets is quite lean. GAVI delivers that purchasing power.
[DC:] You have said, “Achieving our goals depends not only on increased donations, but also on a healthy vaccine market.” What do you consider a healthy vaccine market?
[DH:] It is a market where it is possible to achieve the lowest possible prices for high-quality vaccines, and be able to cover security and delivery. These three elements are necessary for a healthy market. It doesn’t matter if you cut vaccine prices down to zero if you cannot have the vaccines delivered. We have to keep the quality at a level that authorities demand.
What we can do when there is a market failure but a huge demand for those vaccines, such as the rotovirus and pneumococcal vaccines, we can help correct the market by providing purchasing power and long-term commitments to manufacturing these vaccines.
[DC:] You have said that the most partners in this program are the countries themselves, but that there is no such thing as a free lunch. How do you determine how much a country contributes to buying these vaccines?
[DH:] It depends on several criteria measuring the gross national product (GNP). Those countries with the lowest income pay a small amount of the co-payment. As their economy grows, they pay a bit more, and as it grows beyond a certain threshold, they graduate from GAVI, as China did a few years ago.
The whole idea behind this is to make our support to national immunization programs sustainable—not creating a dependency, but stimulating a country’s growth and public health programs. Luckily, that is the case in many countries now, to use increasing economic prosperity for health in general, and for these cost-effective programs specifically.
[DC:] You mentioned private organizations, and civil society organzations such as the Bill and Melinda Gates Foundation; GAVI also recently thanked the LDS Church for their contributions. What role do these organizations have in helping countries with the vaccines?
[DH:] They play different roles; some play philanthropic roles in helping fund our programs, and of course, Bill and Melinda Gates Foundation stand out in this as one of our biggest partners. But we are also reaching out to public and private sector organizations that can increase and diversify our donor base.
We feel we have a very appealing case. For instance, in Spain, one of the largest banks, La Caixa, has agreed to assist the alliance with insurance, and their clients are given the opportunity to contribute to GAVI. We have created a fund together with the UK government, which is matching donations equally from private organizations.
Civil society does more than this, and we are intimately involved in working with civil society organizations, including faith-based organizations. They head up our advocacy both in donor countries, but also create legitimacy for vaccines in the countries receiving them. They oftentimes have a means of securing vaccines for hard-to-reach children because they are in places where the governments or infrastructure is weak.
[DC:] Does GAVI also help to train the frontline health workers that distribute these vaccines?
[DH:] Yes, we do. We give introduction grants to the countries receiving vaccines, and some of this money goes to training health workers. We also have support for health systems to strengthen them, because it doesn’t help much to have the vaccines stored in a warehouse in the capital of a country. You need to get them in a cold train, because they need to be kept cold all the way, until they finally reach the vaccinator and the child.
[DC:] Ghana just launched a program to simultaneously attack diarrhea and pneumonia. How long does GAVI expect to help Ghana with this until their program will be sustainable?
[DH:] Ghana is one of the countries with lower economic growth in Africa, so they will be part of GAVI for a few years. Then they will be able carry on, and we will carefully assess the introduction of new vaccines and their ability to run their programs. Ghana really has a promising start, and we think they are actually leading the way for many countries in Africa. They are really an amazing example of what an African country can do.
[DC:] Haiti is slowly starting to rebuild after the 2010 earthquake, and GAVI recently introduced there the pentavalent vaccine (which protects against diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenza type b). What challenges do you see ahead for Haiti?
[DH:] The country was so hard-hit two years ago, it will have great challenges in rebuilding its health systems and infrastructure, and vaccinations are such a critical part of that. Sadly, because of the earthquake, cohorts of children have been lacking the access to vaccines. Now, the country is taking on the task to make up for that through a campaign that began early this spring, followed by the introduction of the pentavalent vaccine. I was personally invited for the start of this campaign, and my clear impression is that there is a leadership in Haiti now that, through our partners, will take on this task and stay with it until they are back on track with these basic vaccines.
[DC:] GAVI’s CEO Dr. Seth Berkley called measles the “canary in the coal mine.” Can you explain?
[DH:] If you have an outbreak of measles in the country, it may be an important sign that the immunization program in general is faltering. That is why it is very important to fight these outbreaks of measles, and there is a lot good research proving that measles vaccinations have led to a 74 percent drop in measles mortality in ten years.
[DC:] Can you discuss the importance of the HPV vaccine, which prevents the majority of cervical cancer cases?
[DH:] In all, cervical cancer takes about 270,000 women’s lives annually. Almost 80 percent of the disease burden is in middle- to low-income countries, whereas most of the vaccines so far have gone to industrialized countries. This is very unfair. We want to make the HPV vaccine available to low-income countries as well. That is why we decided that countries could apply for support for the HPV vaccine last November, and this year we will be deciding on the next move for this vaccine.
The vaccines are always given to 12 to 13-year-olds, so it is different from the vaccines given to infants, but it is still a very important part of fighting preventable diseases.
[DC:] What do you see in the future for GAVI? How does GAVI define success? Is it accomplishing the Millennium Development Goals? What challenges do you see lying ahead?
[DH:] Our mission is to help fulfill the health-focused Millennium Development Goals. We have defined it specifically to fighting deaths by preventable diseases and enhancing the quality of life for people through immunization. We went to the world last year with a compelling case: if you fund us, we can vaccinate 250 million children by 2015, and avoid about 4 million unnecessary deaths. We are on track to do this, and we are sure we can do it. It is hard, but we have the means, and we will work with partners to make it happen.
When we look at the future beyond 2015, we are about to discuss the different options we have. New vaccines are coming down the pipeline. We don’t know exactly when we will have a malaria vaccine, but it will certainly be an exciting option for GAVI, because it will be targeted to the countries we have been working with. The same is the case with a possible HPV vaccine.
As it has been in the past, when we have seen diseases being totally eradicated—like smallpox—by vaccines, we will have new opportunities to enlist these powerful new tools in the future and fight other diseases.