The COVID-19 pandemic was a crucible for the public health world, and perhaps none were tested more than Gavi, the global nonprofit that makes vaccines its business. Faced with ensuring that the COVID-19 vaccines reached as many people in the developing world as possible, the organization created a new entity, COVAX, that served as the conduit for purchasing and distributing vaccines for the lowest-resource countries in the world.
Dr. Seth Berkley, who has headed the organization for years, is stepping down in August when his current term ends.
In a conversation with TIME, Berkley reflects on his tenure and what he, Gavi, and the world can learn from what went right in the world’s response to COVID-19—and what went wrong. (This interview has been condensed and edited for clarity.)
TIME: Why did you decide to step down?
I came in 2011 for a three-year term, and then they asked me to renew for another four years, and then another four years. Then they asked me to do an additional year because of COVID-19, so I’m 12 years into it now, and my term is done.
That’s more than a decade at Gavi. How are things different now compared to when you started?
The original idea for Gavi was that there were powerful new vaccines that were being made and used in wealthy countries. They could have the most effect in the poorest countries that didn’t have good health care systems, but there was no way to get them there. That was the problem Gavi was trying to solve.
Gavi was born in 2000, as an experiment that combined public and private partners. Could it work? If you fast forward to what’s happened, we now provide vaccines for about half the world’s children, and we just passed 1 billion unique children having been immunized. So one-eighth of humanity has gotten their childhood vaccines through Gavi. And countries have gone from having only six vaccines to 19 different vaccines, such as those against pneumonia, diarrhea, and even cancer vaccines like HPV for cervical cancer and hepatitis B for liver cancer. That’s led to a 70% reduction in vaccine-preventable diseases, which is contributing a more than 50% reduction in mortality for children under 5.
What contributed to Gavi’s success?
Everybody pays, so the model is that you put a little bit in if you’re very poor, and as you get richer as a country, you pay more, and then you transition out of Gavi. So 19 countries have transitioned out of Gavi since the organization started, and what allows them to transition out is market shaping. We started with five vaccine manufacturers in high-income countries. Today, there are 24 manufacturers, and the majority of these are in developing countries. The price points have dropped dramatically, and that’s allowed countries to continue to afford vaccines even after Gavi has stopped supporting them.
That’s been the secret sauce of Gavi: driving, over time, to get more affordable prices so countries can afford them. But in the interim, we subsidize them and provide a kind of guaranteed demand for the manufacturers. I think this has turned into a reasonable market and a reasonable way to work.
How did that system hold up during COVID-19?
First of all, the system for a pandemic was not in place. That’s point No. 1. And that’s important for the future, because you want to make sure that system continues and learn where it didn’t work, where there were real failures, and where there were real successes.
Point No. 2: Nowhere in the world is there a really standardized delivery system for people of all ages for vaccines. We had built a vaccine system, but it was primarily for infants and young children, and more recently for adolescent girls for the HPV vaccine. So it wasn’t a system that was built out across all aspects. It had to be adapted and adjusted.
But the big problem wasn’t that. The big problem was that we had to go and raise money. We had no money and no bandwidth for this. And that took time.
The pandemic really put Gavi’s model to the test, and you worked with other organizations—including the World Health Organization, UNICEF, and the Center for Epidemic Preparedness—to create COVAX, which provided a way for developing countries to purchase COVID-19 vaccines at lower prices. Some have criticized COVAX for not acting fast enough in distributing vaccines to people who needed them in the developing world. What happened?
The donors were ultimately very generous—we raised $12 billion for COVAX. But there was terrible vaccine nationalism and export bans. The U.S. ultimately came in as a very generous supporter, but initially, the U.S. did not join COVAX.
Before COVID-19, the system built for vaccines worked really well to provide everybody in the world with the vaccines that they need. But during the pandemic, there was hoarding, and everybody wanted the vaccines for their own countries. There was no interest in sharing with other countries. That was the problem.
It wasn’t as if we didn’t anticipate that, so we had the first vaccine in the developing world delivered 39 days after the first vaccine in the U.K., and nothing like that has ever happened before. And we had hundreds of millions of doses that were planned to roll out and started to roll out and then, bang! Delta happened. India didn’t announce it publicly, but it stopped exporting vaccines. That hurt the African countries the most. And the vaccines we were getting from non-Indian manufacturers were slowed down and delayed.
While there was a delay at the beginning of 2021, by the end of that year, we basically had the supply. We ultimately purchased 11 different vaccines, and for 92 of the poorest countries, there is, as of July, a 56% primary series vaccination rate vs. 65% globally. Today there are only six countries that have less than 10% vaccine coverage.
At the same time, we saw absolutely the worst vaccine hesitancy ever. Normally wealthier countries are where you see vaccine hesitancy, because we take for granted that our children are going to live and that there’s no disease. Whereas in developing countries, parents see death around them and see the diseases from which they want to protect their children.
But in this case, all of a sudden, you had very powerful countries, and powerful leaders, challenging this vaccine. This was about systemic misinformation. That really affected the way people thought about this, and I think will have spillover into other vaccines as well. That’s something we are worried about.
Read More: What Went Wrong With COVAX?
Is there a role that Gavi can play, as a global public health organization, to address nationalism?
How? By going into [then President] Trump’s office and saying, ‘I don’t care if you want to focus on America, first you need to support the rest of the world?’ You have to be realistic in terms of what’s possible, and what is politically possible at the time. A lot depends on political leadership. So then the question becomes, how do we make it less dependent on a single country or political leader? At Gavi, that’s why we went from five vaccine manufacturers to 24. If we get to 40 manufacturers, we might be in an even better place.
How can inequity—whether it’s politically motivated or driven by weak distribution systems—be better addressed?
One of the things we are working on is regional vaccine manufacturing. It’s not a panacea, but if you consider that Africa has only 0.1% of the vaccine manufacturing for the world, even though it has an eighth of the world’s population, this is something we are trying to help with. Every country can’t have its own vaccine manufacturing. So there is now this idea of distributed vaccine manufacturers to expand the number of facilities to cover specific regions.
One of the other challenges the pandemic revealed was to use manufacturing strategically. The question becomes, do you vaccinate all the high-risk people in the world first, before you move to lower-risk populations? Many countries during the pandemic said no, they were going to vaccinate everyone in their countries first, and that’s why the hoarding was so terrible. The challenge now is to have an honest conversation about this and how to fix it.
What were the big lessons from what COVAX got right, and what it got wrong?
The big lessons of COVAX were, first, have money available at the beginning. Have contingent financing—it doesn’t have to be the full amount, but enough to jumpstart the program immediately, to get staff, and to start going to manufacturers.
The second lesson is having the risk worked out. We had to negotiate risk. We took taxpayer dollars and bought, at risk, vaccines that we didn’t know were going to work. We were lucky that most of the vaccines worked—but imagine if most of them hadn’t. Agreeing to do at-risk financing is critical.
The third lesson we learned is that we did not prioritize having delivery systems for the vaccines. This time we did not bundle financing of delivery with the cost of the vaccines, and that led to delays. Had we started with enough financing for delivering the vaccines alongside purchasing them, that would have been a really good thing.
And finally, diversify manufacturing so that there will be some places in the world with lower burden of disease that are willing to share vaccines.
COVID-19 cases are starting to wane, and more people are vaccinated and protected against severe disease vaccines. Will COVID-19 vaccines continue to be part of Gavi’s arsenal?
At the end of this year, COVAX will be reincorporated into Gavi. But the board approved a program for 2024-2025 that will continue COVID-19 vaccines for high-risk populations. As part of our normal review for investment in vaccines, COVID-19 will be included going forward, so [continued distribution of the vaccine] will be considered [along] with those against RSV, and other vaccines against preventable diseases.
Gavi generally runs a funding rate of about $2 billion a year, and during the COVID-19 years, it jumped up to $10 billion because of the large number of vaccines we were delivering. The idea is to reduce the temporary staff and resources that were scaled up to do that, but to keep these systems warm in order to maintain some innovations that would allow us to be prepared for the next [public health threat].
There is an idea for a special program that was floated at the G7 summit to create marketplaces for vaccines to make manufacturing them sustainable over time. The big problem with these vaccines is that they can’t just be scaled up for pandemics, because what do you do with all the resources when there isn’t a threat? Gavi will continue to be involved with finding a way to create a high-quality vaccine manufacturing industry with a small number of manufacturers that can be ready to go if there is another pandemic.
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