‘For me, vaccination is the quintessential public health intervention. If we can’t get that right, we probably shouldn’t be doing other things.’

The Gates Foundation has played an essential role in making vaccination a global health priority, Amanda Glassman of the Center for Global Development tells Caroline Hartnell. But is it too single-minded? Is there a danger that it will squeeze out diversity? Is its influence too great? Not really, in Glassman’s view.

GAVI seems to have been one of the great aid successes of the last decade. Do you think it would have happened without the Gates Foundation making vaccination a priority?

No. I think the commitment of the foundation has been essential and has motivated a lot of other donors to get involved. The leaders have really been Norway, the UK and the Gates Foundation. In the past, the enormous generosity of the Gates Foundation may have led to people thinking, ‘oh, well that’s been taken care of’, but I think in this last funding round that notion has been diminished somewhat, and I think you’ll see more emerging countries as potential donors, as well as private sector donors.

Do you think GAVI and ‘advanced market commitments’ for vaccines are laying important groundwork for ‘cash-on-delivery aid’ models? Will that be an important part of the legacy of these programmes, beyond just vaccine delivery?

We certainly hope so at the Center. It’s a very different model from the traditional ‘push’ mechanisms of public-private partnerships where they invested in research and development, offered subsidies, and hoped they would be able to pick the best solution. Now, we’re seeing a ‘pull’ mechanism which works on the principle of ‘we’ll pay when we get the results that we want’ rather than ‘we’ll pay and hope we get the results that we want’. I think that could be very transformative.

At the same time, these types of schemes haven’t really been rolled out extensively. There have been lots of experiments in performance-based payment and performance-based aid, but they haven’t specified the results so well. So I think we’re seeing an evolution in the field that is positive.

In the areas we’ve talked about, you feel Gates is having a positive influence on global development. Are there any areas where you feel their influence is negative?

People have criticized Gates for being very single-minded about the kind of investments it makes and being directive in those investments. At the same time, their focus on what exactly they want to achieve in the world is the major source of their strength. It’s a very different approach from seeding good ideas and seeing what happens – maybe you lose some of the creativity of new ideas, but I think it has paid off. If you look at the effect on vaccination rates, which has been one of the most prominent investments they’ve made, it’s hard to criticize.

One of the criticisms I’ve heard is just what you mentioned: that it squeezes out diversity both in approaches to problems like vaccination and in attention to other areas.

For me, vaccination is the quintessential public health intervention. If we can’t get that right, we probably shouldn’t be doing other things. There are so many needs in developing countries that it makes sense to start with what’s most cost-effective and do that well.

Do you think Gates might exert undue influence?

Not in developing countries. In most countries, people haven’t heard of the Gates Foundation. They’re focused on health systems issues and they are struggling to respond to population demands and improving health with very scarce resources. They know GAVI and vaccination programmes, but I don’t think anyone in developing countries feels Bill Gates is affecting their investment agenda.

Amanda Glassman is Director, Global Health Policy Program, at the Center for Global Development. Email aglassman@cgdev.org