Gavi is a unique global health partnership that has revolutionised access to vaccines in lower-income countries since 2000. Gavi’s CEO Dr Sania Nishtar discusses the organisation’s evolving role in global health, from its traditional focus on childhood immunisation to new challenges in vaccine delivery post-COVID.
Gavi is a unique global health partnership that has revolutionised access to vaccines in lower-income countries since 2000. Working with governments, UN agencies, private sector partners and civil society, Gavi has helped immunise more than one billion children, averted 18 million deaths and generating over US$200 billion in economic benefits. The organisation is known for its efficiency, keeping operational costs below 3%, and employs an innovative co-financing model where recipient countries gradually increase their contribution as their economic capacity grows, eventually becoming self-sustaining.
Gavi’s CEO Dr Sania Nishtar discusses the organisation’s evolving role in global health, from its traditional focus on childhood immunisation to new challenges in vaccine delivery post-COVID. Topics include the concerning rise in "zero-dose" children who haven't received any vaccines, Gavi's expanded mandate in emergency response and vaccine manufacturing, and its upcoming strategy for 2026-2030 which aims to vaccinate another billion children in half the time it took for the first billion. The conversation also explored Gavi's work in the Pacific region, particularly the challenges faced in places like Solomon Islands, and the organisation's upcoming replenishment campaign seeking $9 billion in funding.
Dr Nishtar is a cardiologist by training and has built an extraordinary career spanning medicine, civil society, and government. Before joining Gavi in March 2024, she served as a Senator in Pakistan and as Special Assistant to the Prime Minister on Poverty Alleviation, overseeing the implementation of Pakistan's largest social protection program, which reached around 15 million households. She founded Heartfile, an influential health policy think tank in Pakistan, and has chaired numerous high-level international commissions for organisations like WHO and the World Economic Forum. In 2017, she was one of three finalists for the position of WHO Director-General.
Devpolicy Talks is the podcast of the Australian National University’s Development Policy Centre. Our producers are Robin Davies, Amita Monterola, Jackie Hanafie and Finn Clarke.
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Sania Nishtar: Post-COVID, we see a lot of backsliding. There was an initial recovery, but we see a lot of backsliding now. We see an increase in the number of what we call zero-dose children - these are children who have not received even a single dose of vaccine. One of our priorities is to get routine vaccination back on track in countries that are backsliding, and to make sure we have the necessary investments in place to reach those communities where children remain unvaccinated.
We don't run like a charity. When we start introducing vaccines, countries start co-paying, and their share increases as their economic development goes up, and at some point, they exit from our support and become fully self-sustaining and self-financing of vaccines. We are perhaps the only organisation which has a well-tested co-financing, sustainability-driven model, which is totally unprecedented in global health.
Welcome to Devpolicy Talks, the podcast of the Development Policy Centre. We’re part of the Crawford School of Public Policy at the Australian National University, on Ngunnawal and Ngambri country in Canberra.
I'm Robin Davies.
This year we re-launched our podcast after a more than two-year hiatus.
In this new season we’re bringing you a mix of interviews, event recordings and in-depth documentary features relating to the topics we research at the centre – namely Australia’s overseas aid, development in Papua New Guinea and the Pacific, and regional and global development issues.
This is our fifteenth episode in 2024, in which I interview the still relatively new CEO of Gavi, the Vaccine Alliance.
Dr Sania Nishtar is a cardiologist by training and has built an extraordinary career spanning medicine, civil society, and government. She was appointed CEO of Gavi in March 2024. Before that, she served as a Senator in Pakistan and as Special Assistant to the Prime Minister on Poverty Alleviation, overseeing the implementation of Pakistan's largest social protection program, which reached around 15 million households. She founded Heartfile, an influential health policy think tank in Pakistan, and has chaired numerous high-level international commissions for organisations like WHO and the World Economic Forum. In 2017, she was one of three finalists for the position of WHO Director-General.
Gavi is a unique global health partnership that has revolutionised access to vaccines in lower-income countries since 2000. Working with governments, UN agencies, private sector partners and civil society, Gavi has helped immunise more than one billion children. Gavi estimates it has averted 18 million deaths and generated over 200 billion dollars in economic benefits. The organisation is known for its efficiency, keeping operational costs below 3%, and employs an innovative co-financing model where recipient countries gradually increase their contribution as their economic capacity grows, eventually becoming self-sustaining.
Our discussion was wide ranging, covering Gavi's evolving role in global health, from its traditional focus on childhood immunisation to new challenges in vaccine delivery post-COVID. Key topics included the concerning rise in "zero-dose" children who haven't received any vaccines, Gavi's expanded mandate in emergency response and vaccine manufacturing, and its upcoming strategy for 2026-2030 which aims to vaccinate another billion children in half the time it took for the first billion. The conversation also explored Gavi's work in the Pacific region, particularly the challenges faced in places like Solomon Islands, and the organisation's upcoming replenishment campaign seeking $9 billion in funding.
Interview
Robin Davies [03:55]
Could you introduce yourself for the beginning of the podcast? Please give your name, title and a little background.
Sania Nishtar [04:00]
My name is Sania Nishtar. I'm the CEO of Gavi, the Vaccine Alliance. I'm a physician by training, a former senator from Pakistan, a former Minister of Social Protection of the Government of Pakistan, and of course, a significant part of my career I've spent as a civil society advocate.
Robin Davies [04:30]
How is your professional background likely to influence the way you play your new role? You're still within your first year as CEO of Gavi. You don't come from the multilateral system, though you've done a lot of work with WHO in an advisory capacity. In Pakistan, you've held multiple portfolios, worked particularly in non-communicable diseases, and you've been responsible for the introduction of a universal health coverage initiative. It seems you bring a health systems perspective to this job. Is that right?
Sania Nishtar [05:05]
Yes, I bring a health systems and delivery perspective to the job, and also a country perspective. I think my most important learnings were during my tenure as the Minister of Social Protection, especially during COVID when I was tasked to distribute $2 billion to communities in Pakistan during the hardships of COVID and amidst the lockdowns. At that time, I had to cobble together a brand-new system of delivering cash totally in an end-to-end digital manner to communities. I realised the power of innovative systems that can improve delivery and eliminate abuse and leakages.
To answer your question about what I bring to the table: I bring a commitment to delivering better in low-resource settings by leveraging technology. I bring, in humility, an understanding of health systems in developing countries, which are complex and messy, where public and private sectors both operate, where there's chronic underfunding of the public system and chronic lack of oversight of the private sector. I wrote about these maladies in a book called "Choked Pipes" over 15 years ago.
I'm very much focused on delivering better. Because I come from a background of having run a very large institution, I'm focused on the hygiene of the organisation - the systems, processes, policies, procedures, safeguards, and checks and balances. These are the two new things I bring to the table.
Robin Davies [07:20]
You were special assistant to Pakistan's Prime Minister during the pandemic from 2018 through to 2022, so in a sense, you're now walking around the other side of the table. Pakistan was dealing with particularly the COVAX facility, which was managed by Gavi. From that experience, are there particular priorities that you bring to the role?
Sania Nishtar [07:45]
You're right. I'm now on the other side of the table. During COVID, in my capacity as the Minister of Social Protection, I was responsible for the distribution of cash, but because of my background in health, I was asked by the Prime Minister to serve on a three-member cabinet committee which oversaw the distribution of the vaccines. We had to deal with Gavi and with the other multilateral system to ensure access to vaccines and then subsequently their distribution.
In terms of lessons and how we are responding to them now, one key lesson was that there wasn't enough liquidity in the system to procure the needed vaccines very quickly and to place orders quickly. To respond to that, Gavi now has set up what is called the First Response Fund, and we saw that coming into play during mpox, when we were able to order the largest consignment of vaccines just within 30 days of the emergency being announced. Based on the learnings, we acted quickly - we set up the institutional mechanisms, put the policy frameworks in place, set aside the money, structured the fund, and are now able to respond. Mpox was the proof of the pudding.
The other learning from COVID-19 was related to the access issues that Africa faced. Africa was, to a very large extent, excluded from access to vaccines. Learning from that experience, Gavi has put in place what is called the African Vaccine Manufacturing Accelerator, which was launched on the 20th of June this year, aimed at bolstering sustainable commercial vaccine manufacturing on the continent.
Robin Davies [10:10]
COVID changed everything for all of us, but particularly for Gavi. It was an organisation previously focused on childhood immunisation, beginning to take on some additional responsibilities. But post-COVID, as you say, it has a very different role. Its market shaping function has expanded into supporting vaccine manufacturing, and there's now an expectation that Gavi will always be involved in emergency vaccine supply. The canvas has really grown. I'd like to break that down in subsequent questions. First, going back to the original Gavi mandate relating to childhood immunisation, what's the landscape that you're facing now post-COVID in terms of countries' reduced performance on childhood immunisation?
Sania Nishtar [11:05]
Post-COVID, we see a lot of backsliding. There was an initial recovery, but we see a lot of backsliding now. We see an increase in the number of what we call zero-dose children - these are children who have not received even a single dose of vaccine. One of our priorities is to get routine vaccination back on track in countries that are backsliding, and to make sure we have the necessary investments in place to reach those communities where children remain unvaccinated. These are very difficult pockets in different parts of the world which are either geographically difficult to reach, or where there's a lot of hesitancy, or they're so marginalised that they're constrained in accessing services. Part of the new tools we are going to employ is the use of artificial intelligence and data triangulation from various sources to identify difficult pockets.
Robin Davies [12:20]
You referred to vaccine hesitancy. Certainly, in the COVID response in this region, we saw that was a very large issue in Papua New Guinea, even among health workers. And of course, in our own country, the US, and many others, we're seeing the rise of vaccine scepticism, even among parliamentarians and decision makers. What do you see as the role of Gavi, which I know is essentially a delivery organisation, in combating misinformation, disinformation about vaccines, or indeed even playing an advocacy role where there is hostility to vaccinators in situations of armed conflict?
Sania Nishtar [13:14]
This is a problem we are increasingly facing, and it is impacting routine immunisation as well. One of the impacts is manifesting itself in the rise of communicable diseases, vaccine-preventable communicable diseases, even in developed countries. When you see outbreaks of measles or outbreaks of whooping cough in Western developed nations, it's an indication that routine immunisation coverage is not at the level it should be, and clearly it needs to be countered.
I think all entities have a role. Governments have a role to have the right communication campaigns in place, to have the right champions talk about the right things, and to bring to bear the important evidence. Gavi is there to facilitate. One of the things we're doing at Gavi is to package the right evidence from countries, to bring to bear the importance of evidence and information from credible sources so that countries can dispel these myths. But the onus of responsibility is not just on Gavi, because we don't have the advertising budgets which often need to come into play to dispel these myths. It has to be a multi-stakeholder effort.
Robin Davies [14:55]
Even before COVID, Gavi's mandate was beginning to expand in a couple of ways. The human papillomavirus vaccine was introduced into the portfolio, so suddenly we're no longer dealing with just young children, and then the malaria vaccine, the RTS,S vaccine, was introduced in some pilot countries, again not restricted to children. How did that change the burden on Gavi of vaccine delivery?
Sania Nishtar [15:20]
Even before the pandemic, the HPV vaccine was introduced in the Gavi portfolio. And being here in Australia, the birthplace of the HPV vaccine, it's really inspiring to be talking about these things because it is Australian science that gave the world the HPV vaccine and the rotavirus vaccine.
The portfolio was expanding and will continue to expand. We've got the dengue vaccine on the anvil; we've got the tuberculosis vaccine on the anvil. In terms of what it means for Gavi, you have to cater to the life course, so the immunisation delivery systems and policies and mechanisms no longer have to be confined in countries to childhood settings. Bringing a life course perspective to vaccine delivery means a number of different things at the health systems level.
Gavi's work had begun to expand even before the pandemic, and subsequent to the pandemic, now there's a broad-based realisation that we do have a role to play in health security. We have the instruments and mechanisms in place, as opposed to other global health entities, to mobilise quickly during emergencies. We've just talked about mpox and how our First Response Fund came into play and ordered the largest consignment of vaccines just within 30 days. We made operational funds available for DRC within 48 hours.
With the threat of climate change and temperatures rising, unfortunately, I don't see our workload decreasing. When temperatures rise, vectors behave in a strange way. Diseases appear in unexpected locations, and we maintain vaccine stockpiles against many diseases which come into play during outbreaks. This is clearly a very different modality of operation compared to operating to deliver routine vaccines. And then, of course, there is the market shaping aspect, which now extends to vaccine manufacturing in certain parts of the world. That's a whole new ball game.
Robin Davies [18:05]
First, just on the impacts of climate change. We're very much aware in this region that that could lead to increasing incidence of dengue, Zika, chikungunya and so forth, which are currently not vaccine preventable. Well, maybe dengue sort of is, but it seems clear that over time, vaccines will emerge for each of these virus-caused diseases, and so the burden grows ever greater on Gavi. And then there's the emergency response function and the expanded market shaping function. How does that all come together in your new strategy, your new five-year strategy for 2026 through to 2030?
Sania Nishtar [18:45]
In our sixth strategy, which will span from 2026 to 2030, we are accelerating our work. The last 1 billion children that Gavi vaccinated took 24 years, but the next 1 billion will be vaccinated in half the time. We're accelerating our work because we realise that this is the last leg of the Sustainable Development Goals. During this period, we'll be vaccinating 50 million children with the malaria vaccine, 120 million girls with HPV vaccine. In the process, we'll be saving an additional 8 million lives and accruing an additional 100 billion dollars of economic benefits.
We have new thresholds and a new eligibility mechanism in the next strategy, which will allow us not only to assist with the Gavi-eligible countries which fall below a certain GNI income threshold, but our new strategy will also allow us to provide catalytic support to another set of countries, which we call the mixed countries - the middle-income countries who are above our GNI income threshold but below the World Bank threshold for low-income countries. For that set of countries, we will be providing catalytic support to introduce new vaccines. We will help with backsliding.
We also have a special strategy for some of the small island developing countries. I visited Solomon Islands over the last two days - very humbling to see the kind of challenges they face. The special island development strategy is another avenue through which countries will receive support. So, to answer your question: an expanded portfolio, accelerated work, a wider horizon of countries with which we engage with different purposes. And all this is in addition to the global health security work and our work in humanitarian settings, where we mobilise, provide health system support, and provide support for vaccines. The vaccine manufacturing piece is, of course, another dimension of the market shaping work that we do.
Robin Davies [22:00]
Can I ask just for your reflections on your experience visiting Solomon Islands just before you came to Australia?
Sania Nishtar [22:10]
It was very humbling to visit the Solomon Islands. I've lived and worked and trained in a developing country, and I'm generally familiar with health systems challenges in low-resource environments. But what I saw in the Solomon Islands was truly humbling for a number of different reasons.
Firstly, because of the scatter of their geography and the cost of operating in that geography, and the manner in which some interest groups have captured that opportunity. I saw a lot of monopoly operations across the islands. In fact, I was speaking to members of the parliament earlier this afternoon, and when I mentioned this to them, they said this is one of the things we can fix - to have healthier competition between entities operating and delivering for the government. Healthier competition will certainly bring down costs. I learned, for instance, that to deliver vaccines and other products from one island to the other in Solomon Islands costs thousands of dollars.
The second very unique thing that I saw firsthand was the impact of climate change. When flooding happens in Solomon Islands, hospital wards get flooded. I salute the resilience of those health workers who continue to operate in that environment, to see those water marks palpably in verandas and in ward rounds.
The third thing which I picked from there was the absolute and stark scarcity of infrastructure and resources. I was very struck knowing that in the capital city of a sovereign country, in the best hospital, you don't have an intensive care unit. You don't have dialysis for patients with chronic renal failure. There is no surgeon to open the chest. I understood why the Gavi board member from Australia continued to talk about visiting the Western Pacific, so that we could see these things firsthand. It was really very humbling to be there.
Robin Davies [25:00]
You talked about the middle-income country catalytic support. It's always been very controversial in Gavi that such a strict GNI per capita threshold has been applied, and countries in Southeast Asia and the Pacific have been particularly affected by that. Australia has always been an advocate for reform of the policies. Do you think that the new arrangements for the next period essentially address that issue? They may not change the GNI cutoff, but do you think the creation of the catalytic fund and the special arrangements for small island states are satisfactory in addressing those concerns?
Sania Nishtar [25:45]
For one thing, we are revising our GNI per capita threshold upwards, which will allow us more flexibility to include more countries in the fold. We've debated endlessly on the possibility of adding other metrics into this composite measure, and there are pros and cons. After careful consideration, we decided to leave it with GNI per capita. Of course, as you rightly say, averages hide a lot of inequities. Even if a country is above the threshold, that does not mean there aren't inequities that the average is hiding. It is extremely difficult to balance all these considerations with the given envelope of resources that you have. So, you have to draw the red line somewhere, and the drawing of those red lines comes with trade-offs and limitations.
But having said that, as far as the special island developing countries are concerned, we have made a special dispensation for some countries who are extremely vulnerable and where challenges have really been compounding. We're very happy to have made that exception, and Australia has been absolutely instrumental in raising the need for us to create those flexibilities.
Robin Davies [27:20]
If you look at the countries that currently benefit from Gavi assistance, particularly in Southeast Asia and the Pacific, it's essentially Cambodia, Laos, Myanmar, PNG, Timor-Leste and Solomons. Would that menu of countries change in the next period?
Sania Nishtar [27:40]
Firstly, I must clarify that these are recommendations that we as the management are taking to the board. Our board is meeting in the first week of December, so the management is making a recommendation to the board to revise the eligibility threshold upwards and to allow for flexibilities for some small island developing countries. Once the board decision is in effect, then I will be able to tell you publicly, in exact terms, what that decision means for different countries in Southeast Asia and the Western Pacific. But at this point, I can tell you that the recommendation we're taking has been very carefully fleshed technically and has broad-based technical support, and it will have a number of different favourable implications for several countries in this region.
Robin Davies [28:35]
Just a footnote question, is Gavi able to operate in any significant way in Myanmar under the current circumstances?
Sania Nishtar [28:40]
We operate in very different, difficult settings in most of these politically difficult environments, and we have a way of working with the UN entities, with the humanitarian partners, and we try to get vaccines wherever we can.
Robin Davies [29:07]
During COVID, the complexity of the whole global vaccine supply chain became really apparent. Gavi became part of the so-called ACT Accelerator, the Access to COVID-19 Tools Accelerator, along with WHO, the Global Fund, UNICEF as a delivery partner, and then CEPI, the Coalition for Epidemic Preparedness Innovations, was also playing a very important role. That's the kind of architecture within which you exist now. Do you think the whole experience of the ACT Accelerator and COVAX has led to efficiencies or improvements in the way that all of those different organisations work together?
Sania Nishtar [29:55]
I think the COVID experience taught the global health stakeholders an important lesson that we all exist with distinct comparative advantages. To be fair, those comparative advantages were brought into play during COVID. Gavi dealt with vaccines, the Global Fund dealt with therapeutics, with diagnostics, with oxygen. CEPI had another role on the research upstream side. The World Health Organization was the overall steward from the norms and standards perspectives, as the world's health parliament, engaging with governments and getting the rules in order. They had a very important role in surveillance and the various other aspects related to surveillance and the broader public health response, which is often overlooked and is so important in pandemics and outbreaks.
I think the key lesson was that going forward, we need to have effective coordination in place between all these actors and ACT-A was meant to be one of the coordinating mechanisms. Of course, there are always gaps, and you need to learn from gaps and try to bridge them. This time around, during the mpox emergency, there's another regional player in the picture, which is the Africa CDC, and of course, there are other important lessons to be learned from this experience, especially with respect to coordination and comparative advantage and collaborative division of labour.
Robin Davies [31:40]
Following the ACT Accelerator experience, is there greater continuity in the supply chain where, let's say, a vaccine emerges from the CEPI portfolio and then moves through to clinical trials and then manufacturing, maybe at an African hub, and then into the Gavi portfolio? Do you have visibility of all of that now in a way that maybe Gavi wouldn't have had in the past?
Sania Nishtar [32:05]
We have better understanding of the constraints and better alignment on how to address them. But if you're asking if the system has been tested end-to-end to the fullest post-COVID, I wouldn't say that is the case, but we are getting there. We're getting better. The entire mandate doesn't sit within Gavi. We scan the horizon and see what's in the pipeline, and the best that we can do is to bring the market shaping lever into play, to accelerate development, to accelerate its coming into the market. We broker price and we facilitate its delivery, but it's not one entity which manages the spectrum end-to-end.
Robin Davies [33:10]
I should ask about what is one of the main reasons that you're visiting Australia. We've talked about the next strategy for 2026 through to 2030 and there will be a replenishment conference at some point during 2025 to mobilise resources for that period. I think this is the fourth replenishment, and funding has grown by roughly 50% with each replenishment since the first one and was around 10 billion US dollars last time. With all of those challenges that you've described, what's your funding target looking like for the next period?
Sania Nishtar [33:55]
We're asking for $9 billion. We've already kicked off the fundraising drive, the replenishment, and at the kick-off on June the 20th in Paris, we actually had quite an extraordinary start. The United States pledged 1.58 billion, Spain pledged, France committed not to reduce, and subsequently, we've had a pledge from the European Commission of 290 million, so we've roughly raised about one-third of the 9 billion.
Going forward, we are cautiously optimistic, because it's a very difficult environment to fundraise in. There are conflicts raging and wars in different parts of the world. Climate change funding is crowding out funding for global health, and there are internal political situations of many donor countries, and internal economic crises in many traditional donor countries. The trend of internal migration is repurposing ODA to cater to incoming refugees, and then, to top it all, many of us are going into the replenishment mode at the same time. WHO is currently fundraising, the IDA fundraising is on, Gavi is in the run. The Global Fund will be coming soon.
It doesn't make replenishment easy, but we remain cautiously optimistic, because wherever I have been, we have received bipartisan support for Gavi, which is very humbling. And of course, Australia is a very important donor for us. Australia has been a leader in global health - your leadership in immunology, your leading work on vaccines, the support to the Pacific in financing terms, in political terms, your stellar global health technical institutions. Australia has such an important footprint on global health. We are really hoping that it will continue with its leadership role, by supporting Gavi and by increasing its contribution, because our scope of work has increased.
Robin Davies [36:30]
Have you set a benchmark that you would hope Australia would meet in terms of that increase?
Sania Nishtar [36:35]
We're asking for a 20% increase over and above what was contributed last time.
Robin Davies [36:40]
How do you express the case for that particular level of increase from Australia?
Sania Nishtar [36:45]
We make a case for that level of increase by recalling that Gavi is an organisation which delivers results - 1 billion vaccinated, 18 million lives saved, 200 billion in economic benefits to date. It's an organisation which delivers results with very low cost. Our operational costs are less than 3% and sustainability is hardwired in our model.
We don't run like a charity. When we start introducing vaccines, countries start co-paying, and their share increases as their economic development goes up, and at some point, they exit from our support and become fully self-sustaining and self-financing of vaccines. We are perhaps the only organisation which has a well-tested co-financing, sustainability-driven model, which is totally unprecedented in global health. Even in these economically difficult and challenging environments, this year, countries will contribute more than 278 million in co-financing contributions. Over our next strategy cycle, countries will be co-paying 4 billion US in contributions.
So, it's a lot of value for money to contribute to Gavi. When a donor country has to contribute in a financially constrained environment, you have to look for, for lack of a better expression, the best bang for buck, and we believe that Gavi gives you that possibility - delivering at low cost, delivering concrete results and a clear exit plan. We often joke in the organisation and say our success is in running ourselves out of business.
And because your question was about how we make that case for the increase - it is the expansion of our work, the additional mandates that the board gives us, the additional vaccines that we are delivering from a life course perspective, our expanded role with respect to global health security, expanded market shaping role with respect to vaccine manufacturing. All these considerations, and of course, the inflation factor, makes a very strong case for increase.
Robin Davies [39:25]
And I suppose also the additional flexibilities that might benefit the small island states or middle-income countries in our region, subject to board decisions on those.
Sania Nishtar [39:35]
Of course, and from Australia's perspective, this would be a very important consideration.
Robin Davies [39:40]
Part of your resource mobilisation machinery is the International Financing Facility for Immunisation, which is a very unique mechanism that has delivered resources to Gavi via the bond markets. Do you see IFFIm playing a continuing role?
Sania Nishtar [40:00]
We see IFFIm playing a continued role. In fact, we are pitching to Australia to channel half their contributions to IFFIm as well this time around.
Robin Davies [40:10]
Thank you very much, Sania. I really appreciate your giving us the time during a very busy visit.
Sania Nishtar [40:15]
Thank you very much. It's been a pleasure speaking to you.