Source: Africa CDC

On June 20, 2024, Gavi's 2026–2030 Investment Opportunity and the African Vaccine Manufacturing Accelerator (AVMA) were launched at a Global Forum for Vaccine Sovereignty and Innovation in Paris co-convened by the Government of France, Gavi and the African Union (AU) with Emmanuel Macron, President of the French Republic, Gavi Board Chair, Prof. José Manuel Barrosol and Moussa Faki Mahamat, Chairperson of the African Union Commission as co-hosts along with the Africa Centres for Disease Control and Prevention (CDC).

Gavi at the Forum

Source: Gavi

Prof José Manuel Barrosol, Gavi Board Chair pointed out that there is a symbiotic relationship between sovereignty and cooperative partnerships, which are often otherwise viewed as antithetical terms but are not so in the realm of public health. While rooting for multilaterlaism, Prof. Barrosol urged for not allowing «the misleading narrative of fragmentation and retrenchment to become a  a self-fulfilling prophecy”. In the face of global challenges of climate change, Anti-Microbial Resistance (AMR), outbreak of infectious diseases, new approaches are needed including solutions based on partnerships so as to ensure “equity, access and development and strengthen health security and sovereignty.”

Dr Sania Nishtar, CEO of Gavi had the grace to mention those who make it possible for vaccines to actually reach the children in need. Anne Marie Mbengue Seye, Afrivac, Gavi CSO Steering Committee also did so in a panel discussion hosted by Dr Nishtar (see section on challenges below). Dr Nishtar also screened the images of the persons she lauded for their work - Vaccinator Abdul Qader and Health Worker Agnes who travelled on camel-back and climbed a rope ladder to reach remote communities in Sudan and Uganda, respectively as well as Aboubacar and his family who took part in the vaccine trial for the Ebola virus. In her words, «We owe our health security to people like him».

Also finding mention was Pais Veniama, a paramedic from Kenya who shared that in 2019, the malaria vaccine had brought down the under-5 hospitalization rates, which had brought “a new sense of peace to the hospital wards”.

Dr Nishtar highlighted that Gavi’s vaccine stockpiles are now the largest to date, offering protection against diseases like Ebola, cholera and yellow fever. The preventive vaccine stockpile for Ebola was approved for the very first time, ten years after the outbreak of Ebola had shocked the world. It shows Gavi’s ability for an agile and rapid response during a crisis to a longer-term strategic commitment.

Sustainable and innovative financing model

Source: Gavi

Over the next 5 years, countries will fund a record percentage of the cost of their vaccines contributing over $4 billion by 2030. More than 1 in 4 of the Low Income Countries originally supported by Gavi will be fully funding their own vaccination programs.

Gavi's operational costs remain lean and the Return on Investment (ROI) is $54 to every dollar invested.

Looking to the future, Gavi’s goal in its Strategy 6.0 is to vaccinate 500 children.  The HPV vaccine, which could lead to the complete elimination of an entire category of cancer for the first time in history as per Catherine Russell, Executive Director UNICEF, will protect 120 million girls and young women from cervical cancer. Over 50 million children will receive the new malaria vaccine. There is a new health system strategy to drive integration of immunization into Primary Health Care (PHC) even further and this will facilitate 1.4 billion contacts between families and health services by end-2030. The required new funding for Gavi to fulfil these milestones is $9 billion. Early pledges, including during the forum raised $2.4 billion.

The challenges to disease reduction are climate change and the rising risks of AMR. The last was also cited by Dr. Jean Kaseya, Director-General, Africa CDC who mentioned that he had in fact raised the issue of including AMR in the Global Fund with its CEO, Peter Sands given that it kills more people than does HIV, TB and malaria put together.

Significance of AVMA

Emmanuel Macron, President of the French Republic commended the African Union for its willingness to consistently put in efforts towards bolstering African sovereignty on the health front given the competing priorities of security, poverty, and food problems, among others.

Moussa Faki Mahamat, Chairperson of the African Union Commission pointed out that the African continent still imports 99% of high-priced vaccines, spending $3 billion dollars that could be saved by local manufacturing. The aim is to increase local manufacturing from the paltry 1% currently to 30% by 2030 and 60% of the total vaccine doses required on the continent by 2040 as laid down by the African Union’s Partnerships for African Vaccine Manufacturing (PAVM). The minimum goal is to support at least four African vaccine manufacturers and produce over 800 million vaccine doses over ten years. AVMA will strengthen African health sovereignty at all times, including for pandemic preparedness and response.

Gavi and Africa

Dr. Jean Kaseya, Director-General, Africa CDC noted that 70% of Gavi resources are for Africa since its inception and till 2022 Gavi has invested around $122 billion saving 11 million lives from premature deaths due to lack of vaccines, immunization. In this light, he dubbed local manufacturing of medical products in Africa as «the second independence of Africa contributing to health, safety, creation of jobs as well as peace and security». He also stated that for him, personally, the launch of AVMA at the forum was a «political launch», the «real launch» of which will be done in Africa by the CDC. He also commended the One Health campaign for pointing out - on the margins of the G8 meeting in a communique on June 13, 2024 – that the total share of G8 and the European Union’s contribution to Africa is at its weakest since 1973.

Funding for AVMA

Over the next decade, Gavi will invest a billion dollars towards the development of African vaccine manufacturing.

Nana Addo Dankwa Akufo-Addo, President of Ghana noted that the Gavi Board meeting hosted in its capital city of Accra, is when AVMA was formally approved. Currently, Gavi covers 80% and the national governments of Africa 15% of the costs of the vaccines and it is hoped to be completely self-financed by 2030.

The pledges for AVMA raised during the forum amounted to $1.2 billion. Although the Bill & Melinda Gates Foundation also made a commitment, quite inexplicably, in Bill Gates’ video message to the forum, the sum and substance was about Gavi, of which the Foundation had been a co-founder, and which he described as the Foundation’s “best investment”, with no mention of AVMA or Africa.

Pledges for AVMA Germany – US$ 318 million European Commission – US$ 233 million Italy – US$ 150 million United States – US$ 150 million France – US$ 100 million Canada – US$ 65 million United Kingdom – US$ 60 million Japan – US$ 30 million Norway – US$ 26 million Bill & Melinda Gates Foundation – US$ 10 million Luxembourg – US$ 3 million Ireland – US$ 710,000                                      Source: Gavi

Besides the Gavi investment, it is the African Development Bank (AfDB) that has put its formidable financial muscle behind AVMA and other initiatives on the African continent.  It has extended $3 billion each for the African Pharmaceutical Action Plan under the aegis of the African Pharmaceutical Technology Foundation (APTF) and Strategy for Quality Health Infrastructure in Africa, which is a partnership between World Health Organization (WHO) and AU. It is through the APTF that access to patented tech, processes, systems needed for local manufacturing will be made possible.

Nana Addo Dankwa Akufo-Addo, President of Ghana also called for the AVMA treasury operations to be conducted through the AfDB, which he pointed out has a global AAA rating and works in the interest of Africa as does Afreximbank Bank (African Export–Import Bank, Banque Africaine). Given that the AfDB’s 60^th anniversary had its Board meeting theme as “Africa’s Transformation, the African Development Bank Group, and the Reform of the Global Financial Architecture”, this request from Ghana is a strike for respecting African sovereignty within the global financial landscape as well.

AVMA  - Milestones

Dr Amadou Sall, CEO of the Dakar Pasteur Institute, Senegal (which also partners with Morocco, Tunisia and Algeria) and the Chair of the Pasteur Network stated that AVMA is a model of a "holistic, collective approach". The following section showcasing the same is a summary based on the forum proceedings and is by no means an exhaustive calendar listing of AVMA’s journey.

Process towards sovereignty in manufacturing for the health sector was initiated in 2021 by the African Union with Senegal, South Africa, Ghana and Rwanda.

In 2021, African Union through Africa CDC launched a framework for action, “A New Public Health Order for Africa.”

In February 2022 under French presidency there was a summit between EU and AU. In May 2022, Leon Mutesa, Director, Center for Human Genetics, University of Rwanda became Rwanda’s representative on the Board of the International Vaccine Institute headquarters.

In 2022, under Germany’s presidency, Senegal (then chair of AU) and South Africa were invited to the G7 Leaders’ Summit. The G20 Compact with Africa launched in 2017, to attract private investments has a G20 Finance Track with the Africa Advisory Group under South African-German Co-Chairmanship as its steering body. Germany has engaged with Ghana, South Africa, Senegal, Rwanda in training experts in regulatory frameworks and developing pilot plants for vaccine technologies.

At the Italy-Africa summit in January 2024, Italy unveiled the Mattei Plan for Africa as a long-term strategic development cooperation policy. Africa also featured in a session under the aegis of the recent G7 under Italy’s Presidency.

Ambitious initiative for R&D led by WHO chief Tedros Adhanom Ghebreyesus and Charles Gore, Executive Director, the Medicines Patent Pool (MPP):

In April 2023, establishment of the mRNA Technology Transfer Hub in South Africa under the aegis of WHO, MPP and Act-Accelerator/COVAX as well as support from Germany. In this consortium, Afrigen Biologics is the entity mandated to establish mRNA vaccine production technology, South African Medical Research Council (SAMRC) is providing the research and Biovac is the first manufacturing spoke.

In December 2023, the first end-to-end mRNA production facility in Africa was inaugurated in Rwanda.

In February 2024, the International Vaccine Institute announced a new African Regional Office in Rwanda and Advancing Vaccine End-to-end Capabilities in Africa (AVEC) Project Office in Kenya.

In June 2024, a Korea-Africa summit saw the Africa CDC and the Korea Disease Control and Prevention Agency along with the International Vaccine Institute resolve to work together. A Biomanufacturing Training Hub operates from Korea.

The National Regulatory Agencies of Rwanda, Botswana and Ghana are moving towards, among other countries, maturity level 3 that is defined by WHO as “a stable, well-functioning, and integrated regulatory system capable of effective oversight and quality assurance”.

Challenges

Bassirou Diomaye Faye, President of Senegal noted that Africa, despite representing 20% of the global population, being without a strong manufacturing industry for vaccines reflects the scale of efforts that need to be put in to address this gap. Ndidi Nwuneli, President and CEO, ONE Campaign reiterating this noted that it will take courage and bold action to attain the AU’s ambitious goal of local manufacturing of 60% by 2040 as this is 73 times what it is today in the continent. Africa can only grow the market if it strategically selects what Africa and the world needs and produces it at a competitive price. There is a need to work with CSOs on the ground to ensure transparency and accountability as well.

Need for Innovation

Paul Kagame, President of Rwanda noted that manufacturing vaccines in use already does benefit Africa but it does not really move the needle in terms of equitable access and health outcomes. New vaccines and therapeutics using technological platforms as also making use of Artificial Intelligence (AI) applications will be necessary to target Africa’s disease burden, which Dr Chrysoula Zacharopoulou, Minister of State for Development and International Partnerships of the French Republic pointed out includes cholera, polio, measles, rubella, malaria, HPV and tuberculosis. Other diseases include yellow fever and hepatitis.

Peter Sands, CEO, Global Fund, among others, pointed to the importance of also ensuring regionalization of tests, treatment and vital preventative tools including insecticide-treated nets for malaria.

The need to reduce the environmental impact of production was highlighted by Thomas Triomphe, Executive VP, Vaccines, Sanofi, who stated that it will continue to invest in yellow fever vaccine using a unique vero-cell-culture technology.

Dr Amadou Sall, CEO of the Dakar Pasteur Institute, Senegal and Chair of the Pasteur Network announced investments for innovative antigen platforms for measles-rubella and mRNA vaccines.

Dr Yeong-Ok Baik, CEO, EuBiologics, South Korea mentioned that the new oral cholera vaccine (OCV), Euvichol-S has a simplified manufacturing process due to reducing its components, thereby significantly increasing production capacity and reducing operational costs to make available a low-cost vaccine.

Marisol Touraine, Chair of Unitaid Executive Board underlined the need of organizing health systems not only from a technical and medical perspective such as innovative solutions for temperature-resistant treatment, and to manage postpartum hemorrhaging (PPH), but also social innovation to strengthen systems.

Address the demand side

Makhtar Diop, Managing Director of the International Finance Corporation (IFC) agreed that the local production should not end up as a “white elephant” because of absence of demand, a point raised by Stavros Nicolaou, Senior Executive responsible for Strategic Trade Development, Aspen Pharmacare Group, South Africa, which had re-allocated its humungous sterile capacities and capabilities for the production of the Covid vaccine only to find no takers for it at the time within or outside the country. You can read more about it in this Reuters report.

Address vaccine hesitancy

Anne Marie Mbengue Seye, Afrivac, Gavi CSO Steering Committee underlined the need to create a climate of trust for the vaccines that are to be manufactured in Africa. This can be done by identifying Champions for mobilization and for demand. Mbengue cited Wava in Nigeria, which bolstered the capacities of 1000 women for ensuring Covid vaccination. In Senegal, district godmothers as they’re called play a critical role to identify children and promote vaccination for them. In DRC, an international NGO did so, too, for over 100 women who in 5 months identified 2000 children who’d never been vaccinated. Addressing vaccine hesitancy requires that opinion and religious leaders are also roped in, so as to reach everybody. This serves a dual purpose; it enables communication with targeted vulnerable populations and also ensures that it remains attuned to their cultural beliefs and values and will be in their own mother tongue to prevent miscommunication of the message.

Prof Muhammad Ali Pate, Coordinating Minister of Health and Social Welfare, Nigeria called attention to the imperative to optimize efforts to counter the relentless, aggressive drive demarketing vaccines, often from outside the continent. He urged Gavi and its alliance partners to pitch their voices to those within the country to remarket the vaccines in terms of its value addition and not focus only on vaccine production and distribution.

Naha Mint Hamdi Ould Mouknass, Minister of Health, Mauritania mentioned the outbreak of measles as a proxy indicator of the failure of routine immunization reaching those in need and rural areas being a neglected category. Prof Pate stated that Nigeria, too, has seen outbreaks of diphteria and measles. This shows the pressing need to reframe conversations around routine immunization so as to get parents to make vaccination a routine.

The words of Farrah Losper, Board Chair, African Vaccine Manufacturing Institute (AVMI)’s summarize the long road ahead: “Need political will and policy, regional cooperation between African countries and preference for [the full spectrum of] vaccines and therapeutics manufactured in Africa for pooling demand, harmonizing standards, economies of scale.”

Conclusion

French President Macron spoke of health being now a geopolitical issue. But how it is to be dealt with was answered by Ahmed Robleh Abdilleh, Minister of Health, Djibouti.

Abdilleh described Djibouti as a transit nation, with nearly 25-30% migrants and refugees constantly on the move or staying within its borders. Yet, it succeeded in reaching these vulnerable groups during Covid-19 with 63% migrants getting the Covid-19 vaccine by working with neighbouring countries for cross-border vaccination. In future, there are plans to forge a Joint Strategy and Program for pandemic preparedness with neighbours. The PHC offers a minimum package of essential health services including vaccinations for polio, tuberculosis, measles for vulnerable populations such as nomads, and those in remote, inaccessible regions as well as the refugees and migrants.

Mokgweetsi Masisi, President of Botswana heralded the framework of the new Public Health Order for Africa that will cater to every individual regardless of their background and circumstances and bemoaned “the prioritization of corporate interests over saving human lives” as “a disservice to humanity”. French President Macron mentioned that «cholera offered the sharpest illustration of why we need to continue what we’re doing because there’s a cheap and effective vaccine against it but only one manufacturer of it». Sanofi had ceased production in 2022 and now, a global cholera outbreak, has afflicted half of Africa and also the French territory of Mayotte (Figure 1) leading Macron to commit

€

10 million for a global initiative to combat it.

Figure 1: Cholera cases and reported deaths from WHO regions of Africa and Europe as of 26 May 2024

David Cameron, Secretary of State for Foreign, Commonwealth and Development Affairs, United Kingdom (UK) noted that earlier it was about the monies required to purchase vaccines. But Gavi changed the way it worked by making use of that purchasing power to drive down the prices of vaccines and deliver them across the globe. “Do not think in terms of lives saved but about lives lived”, he urged painting a visual picture of teachers in full classrooms.

Dr Tedros Adhanom Ghebreyesus, Director-General of WHO, “a proud founding partner of Gavi”, described Gavi's Strategy 6.0 “as the most ambitious in its history: to protect more people, against more diseases, faster than before”. Expanding production of vaccines in Africa would require the strengthening of national and continental institutions such as the African Medicines Agency (AMA) and the Africa CDC.