Kristin Ingstad Sandberg

The political origins of health inequity: prospects for change

Ole Petter Ottersen, Jashodhara Dasgupta, Chantal Blouin, Paulo Buss, Virasakdi Chongsuvivatwong, Julio Frenk, Sakiko Fukuda-Parr, Bience P Gawanas, Rita Giacaman, John Gyapong, Jennifer Leaning, Michael Marmot, Desmond McNeill, Gertrude I Mongella, Nkosana Moyo, Sigrun Møgedal, Ayanda Ntsaluba, Gorik Ooms, Espen Bjertness, Ann Louise Lie, Suerie Moon, Sidsel Roalkvam, Kristin I Sandberg, Inger B Scheel

A new approach to global health institutions? A case study of new vaccine introduction and the formation of the GAVI Alliance.

There is an emerging research agenda to analyse empirically the forces driving changes in global health governance. This study applies analytical tools from international relations research to explain the formation of international health regimes. The study utilizes two explanatory perspectives: individual leadership, and the interests of key non-state actors in the formation process, using the case of the formation of the Global Alliance for Vaccines and Immunization (GAVI) from 1995 to 1999. The case study is based on material from interviews with key actors, an archival review of documents from the Childrens Vaccine Initiative (CVI), and published literature. Findings show that the regime formation process was initiated by individuals who were primarily affiliated to scientific communities and who led to the World Bank and the Gates Foundation becoming champions of a new coordinating mechanism for new vaccine introduction. Negotiations in the regime formation process were between a small group of founding agencies with divergent interests regarding immunization priorities. The case also sheds light on the authority of the WHO and the resources of the Gates Foundation in driving the process towards the final structure of the alliance. The paper discusses the potential contribution of the international relations approach compared to policy research as a way of understanding the institutional dynamics of global health, particularly in respect of relations between countries and non-state actors.

Vaccines and the Global System/or Why Study Vaccines?

On December 21 2002 President George Bush rolled up his sleeve, presented a deltoid muscle on his left arm and was pricked 15 times with a tiny, bifurcated needle, whose prongs held between them a droplet of vaccine virus derived from an infected calf. The Commander in Chief’s vaccination was the keystone of a public health campaign to immunize 10 million police and health workers against smallpox by the fall of 2003, preparing the nation for a terrorist warfare attack. (Allen, 2007, p. 11)

When Are Health Systems Ready for New Vaccines? The Introduction of Pneumococcal Vaccine in Malawi

Increasing coverage of routine immunisation and new vaccines is key to reaching Millennium Development Goal number four (MDG 4) on reducing child mortality. Malawi, despite a weak health system, is on track to achieve MDG 4, partly because of its high-performing immunisation programme. Among the early adopters of new vaccines, with major support from Global Alliance for Vaccines and Immunisation, Malawi introduced pneumococcal vaccine in 2011 during a time of severe political and economic crisis. This exploratory case study (part of a larger research project on explaining differential immunisation coverage, conducted in 2010 and 2011, using primarily qualitative methods including in-depth interviewing) looks at the decision-making and policy process for vaccine introduction within the broader political–economic context. Based on a framework of benchmarks on preparedness of immunisation systems and assessments of integration with health systems, the study findings suggest that pneumococcal vaccine introduction was more integrated with key health system functions the closer it got to the point of service delivery. Furthermore, although the vaccine introduction succeeded in relation to immunisation targets and prevention of disease, it may have had substantial indirect costs to other targeted health interventions and broader health systems functions at times when basic amenities are in short supply or unavailable. For a donor-dependent country such as Malawi, policy choices are limited to what is on offer – and new vaccines were on offer; other crucial necessities were not. Further research could establish with more certainty the conditions under which vaccine introduction strengthens health systems that are already weak, and when they push systems further into crisis.