Lancet Study Examines Feasibility of Using GAVI as a Model for the Global Fund to Fight AIDS, Tuberculosis and Malaria
Proponents of the Global Fund to Fight AIDS, Tuberculosis and Malaria, a U.N.-backed international fund to provide resources to fight the three diseases prevalent in the developing world, have suggested that it be modeled after the Global Alliance for Vaccines and Immunizations, a program launched in 2000 to improve access to immunizations in the world's 74 poorest countries and accelerate the development of new vaccines. In a study appearing in the Feb. 2 issue of the Lancet, researchers from the Health Policy Unit of the London School of Hygiene and Tropical Medicine evaluate GAVI and outline the challenges the Global Fund may face if it follows the same model.
About $134 million -- including $85 million for vaccines, $39 million for systems support and $3 million for injection equipment -- was distributed by mid-December 2001 through GAVI to projects in 52 countries. Researchers conducted interviews with senior health ministry officials and others who had participated in the preparation of GAVI grant requests in Ghana, Mozambique, Tanzania and Lesotho to gauge their perceptions of the process. They also reviewed reports and minutes of committee meetings and conducted visits to 25 health facilities, as well as vaccine storage facilities throughout the four countries. A summary of study findings follows:
- The "rapid" pace of the application process and "tight" deadlines prevented nations from examining long-term implications and making "evidence-based" decisions.
- Country coordination mechanisms, when controlled by small groups, ran the risk of not securing broad support.
- "Unreliable" information gathering and the tie-in between rewards and the number of people immunized ran the risk of skewing performance figures.
- Nations did not fully account for the "financial sustainability" of expensive new vaccines if GAVI expires after its initial five-year term.
- A lack of supervision and outreach services, "poorly functioning" cold storage systems, unsafe needle disposal protocols and weak immunization systems threatened the efficacy of the program.
Lessons for the Global Fund
The study's findings "cast serious doubt on the feasibility and likelihood" of the Global Fund's success except in countries with "high capacity and already strong" health infrastructure, the researchers say, noting that expanded programs of immunization are "relatively simple" compared to programs to treat HIV/AIDS, TB and malaria. Applications for the Global Fund will require "collaboration and coordination of a much wider group" composed of staff from ministries of health, donor agencies and non-governmental organizations, the authors state, adding that prioritization and planning will be "more complex and possibly contentious" because of choices that must be made about which diseases to target and how to divide funds between treatment, prevention and support systems. The researchers also note that because the fund wants to get off to a rapid start, countries with higher capacity will be in a better position to garner a share of funding, thereby possibly "conflict[ing] with political pressure to divide resources equally among many countries." Performance-based awards will also "induce exaggerated reports of achievements at different levels," the authors note. The researchers also say that their field work showed that personnel shortages, lack of resources and a lack of outreach efforts "will inevitably be obstacles to strengthening the routine diagnostic, curative and preventive services for the three priority diseases." The authors conclude that in light of the "small amount of money currently pledged [$1.9 billion], overly ambitious Global Fund objectives and pressure on over-stretched Ministries of Health and partners to rush through the planning and implementation processes risk longer term failures." They suggest a "limited and carefully evaluated set of initial activities, learning lessons on where and how to introduce new commodities and implement new interventions, is more likely to be successful and could provide useful models for expanding interventions and processes" (Brugha et al., Lancet, 2/2).
Reason for Optimism
In an accompanying editorial, the Lancet states that politicians "no longer have excuses to wait" to undertake international public health initiatives. The Global Fund, the "lessons of GAVI" and a report prepared last year for WHO by the Commission on Macroeconomics and Health have laid out an "intellectual, economic and operational plan for development," the editorial states, concluding that 2002 "must be the year not only to put globalization on trial but also to turn an abundance of theory into practice" (Lancet, 2/2).