3 questions to Rafael Vilasanjuan, Director of Policy and Global Development at ISGlobal

Interview with Rafael Vilasanjuan, Director of Policy and Global Development at ISGlobal

Focus 2030 : ISGlobal has been actively involved since its inception in the fight against under-funded diseases affecting the poorest countries. As a close observer of the global health architecture for the last 20 years, what is in your opinion the added value of Gavi, the Vaccine alliance ? What has been its impact so far ?

Rafael Vilasanjuan : The Millenium Development Goals (MDGs) gave path to the golden era of Global Health. After the 90s and the aids pandemic, the link between development and health was defined as a major layer to close the equity gap worldwide. There was social mobilization, fresh and new philanthropic booster funds such as the Bill & Melinda Gates Foundation, and very high political will. No meeting of the major powers has gone by without health and equity issues being on the agenda. The idea of translating commitments into action more quickly was also raised.

This was a new beginning, to push for new organizations ready to deliver and search for direct impact. Gavi was among this organizations. Its creation 20 years ago was the beginning of a new idea to reach unimmunized children all over the world. What was needed ? First, a mechanism ready to buy (i.e. with capacity to enter and shape the market of vaccines, always much more difficult than drugs in terms of supply) ; to develop a roadmap of priorities and action in immunization ; adequate governance to ensure that the various actions required are ready to be implemented in countries lacking the fiscal capacity to do so, from vaccines to financial experts, from multilateral organizations to civil society organizations, in order to bring the key players around the same table. ; a well-informed connection to the realities of children through UNICEF, and to the immunization and health capacities through WHO.

The result was the creation of Gavi, the Vaccine Alliance, an impact-oriented organization that has achieved in just two decades 1 billion children vaccinated, the first step to a healthy life and development in more than 70 countries.

It is hard to find a better cost-effective intervention, but above all it would have been almost imposible to reach this impact without Gavi.

Focus 2030 : The impact of global health instruments, such as Gavi or the Global Fund Against AIDS, Tuberculosis and Malaria, to support national health systems is sometimes questioned as their interventions, seen by some observers as “vertical” or programmatic, focus on specific diseases. According to your experience and analysis, how are these interventions aligned with national health systems and policies ? More broadly, how can multilateral health organizations like Gavi help strengthen public health systems ?

Rafael Vilasanjuan : Indeed, there are some misperceptions about the real impact on health systems of some of these Global Health initiatives such as the Global Fund, Gavi, GFF and others. While on the one hand they search for impact indicators in the domains they are ready to act on, the fact is that most of their interventions would be almost impossible without strengthening health systems, and particularly Primary Health Care capacities, as there relies the basis for their work. In this sense, a big part of the resources allocated in countries by the main global health multilaterals is to support a much more robust health system, from strengthening central capacities to improving logistics, health workers know-how and delivery.

In addition, if we take the example of vaccination, we cannot talk about vertical intervention. Achieving routine immunization for children under five in Gavi-eligible countries means to regularly follow-up on the health of children in these countries. While vaccines cover the big burden of the diseases heavily affecting the children, vaccinating also means keeping track of the health status of these children, thus facilitating the real sense of primary health care for all the under five population.

This shows that vaccination not only is the most cost-efficient intervention in health, but also the best possible strategy to keep the health system delivering even beyond vaccines.

Nevertheless, bearing in mind the example of Gavi, a great deal of resources and effort go into ensuring, strengthening and operating the whole chain of the health systems. This has been of particular concern during the Covid-19 crisis, where supply of the vaccine doses was just the starting point of the whole vaccination strategy. Since vaccination required a stronger logistics capacity, health centers were reinforced, cold chains financed, and even new and innovative infrastructures were funded to access remote areas. Although vaccines required additional cold chains, the resources were not dedicated exclusively to doses and, now that the pandemic is over, most of these facilities, larger and much faster than before, are used as routine logistical capabilities by country health systems. These were also supported with new platforms to gather information on health at subnational level and are now being used for surveillance.

The delivery of vaccines also strengthens capacities at community level, both by engaging health workers and liaising with Community Based Organizations, being at the forefront of health delivery. Not lesser also is the role played at the central level to support technical and administrative capacities in Health Ministries. Covid-19 made clear that in fighting the pandemic, global health multilaterals focused their effort on strengthening health services rather than just focusing on a sole disease. Most of these efforts deployed are now part of the strategy to be sure that systems can better surveil and be ready for response, and this applies not just to vaccination but in general to the main global health initiatives.

Focus 2030 : After a decrease in its support to Global Health, following the financial and economic crisis in 2009, Spain has played a major role in the Covid-19 pandemic response, and recommitted to major global health instruments such as Gavi, CEPI, the Global Fund, and even the new Pandemic Fund. To what extent do you think Spain will be able to maintain and even increase its leadership on Global Health ? How do you envision the specific role of Spain ahead of Gavi replenishment ?

Rafael Vilasanjuan : The political landscape in Spain is as unstable as in many other Western countries. The Parliament is so far split between right- and left-wing parties. The coalition of PSOE and Sumar, both on the left side, with the support of the minorities in Catalunya and Basque Country, holds power with a very narrow margin for approving laws. The scenario of a motion to change government from the left to the right, although very unlikely, could keep the legislature moving forward, which would influence new budgets every year, thus forcing on the table the promise to scale up development aid to 0.5% of GNI. Commitments to the main global health instruments, such as the Global Fund and Gavi, have been led by President Pedro Sanchez himself, and executed through development aid. This is evolving, through a new Spanish strategy for Global health, from the president’s initiative to the Ministry of Foreign Affairs and the Ministry of Health. However, due to the different elections, campaigns and changes at the government level, this strategy has not been approved yet. Within the existing framework, Gavi and the Global Fund could be funded with commitments like the ones already done in the past and even the GFF could be a candidate.

However, there is a need to keep up the pressure on the government and better explain that these funds contribute greatly to countries’ health systems, as this is one of the policy priorities of the current MoFA. Technicians tend to argue that investment in these global health initiatives is not having enough impact on health systems strengthening, probably because there is not a culture and history of long involvement in these funds at the technical level.

The other major obstacle is that humanitarian aid (mainly due to wars in Ukraine and Palestine) is high on the priority list and needs additional resources from development aid. It should not be one or the other. This is why it is so important to have a new budget, with increased commitment to funds for development. In 2024 this is no longer the case. From September onwards, the 2025 budget will be drawn up and we shall see whether it is finally approved. Without a new budget, it will be really difficult to increase the current commitments, as there is not much room for maneuver.

NB : The opinions expressed in this interview do not necessarily reflect the ideas of Focus 2030.