drSethBerkleyVaccinating children doesn’t just save lives. It is also one of the most effective ways of fighting poverty.This is one of the reasons why the GAVI Alliance was created, to help countries vaccinate an additional 370 million children and preventing 5.5 million deaths since its inception in 2000.This is also why GAVI has raised US$ 7.6 billion to ensure that an additional 250 million children will receive protection from a range of deadly, yet preventable, diseases by 2015. While the vast majority of these funds go towards purchasing life-saving vaccines, it is also important that a portion — more than $100 million in 2012, is fed into cash programmes to support immunisation services and to strengthen health systems. For many countries, this is thefirst step in providing the necessary infrastructure to ensure that the vaccines reach children.

This was recently driven home to me when I met parents and nurses at the Fuoni Primary Health Unit, a clinic on the Tanzanian island of Zanzibar.There, I heard about how mothers, and some fathers, in Tanzania will walk in excess of 20 kilometres to have their children vaccinated. Sometimes, in remote regions such as near the Arusha National Park, the nurses must make equally arduous and often quite dangerous trips. If those children that are hardest to reach are also to receive vaccinations, such trips are necessary. Children in the more remote areas of the country include those of the Maasai tribes, whose continual movements may prevent their parents from hearing about the vaccine clinics. Braving lion-infested savannahs, wading through rivers, and trekking across terrain too rugged even for 4x4 vehicles, these incredible nurses literally go the extra mile.

As theywalk through the searing heat carrying their coldboxes — vital tools to keep their precious cargo of vaccines cool so that they will work - it is worth remembering that this entire cold-chain is held together by what for many countries is one of the weakest links in the chain-cash investment. The system may not face the same mortal dangers as those health workers, however, the dangers are very real because being cash-based makes some GAVI programmes potentially vulnerable to misuse. For this reason, in 2009, GAVI introduced its Transparency andAccountability Policy (TAP).

The aim of the policy is simple, to ensure that cash support is used according to the purposes of the programme and in accordance with best practice for financial management, consequently, it seems to be working. Since 2009, the TAP unit has identified five cases of misuse. GAVI suspended funds to these cash-based programmes after financial irregularities raised credible concerns about the use of these funds. In 2010 in Mali, irregularities were observed which led to two cashbased programmes being immediately suspended pending investigations. Then in 2011, programmes from three more countries — Cameroon, Cote d’Ivoire and Niger — came under the spotlight, prompting further investigations.

By 2012, GAVI had had more than $18million of its cashprogramme funds misused and, most recently, a programme in Sierra Leone has also now been suspended over concerns about misuse. Some of these cases may be due to weak financial management in the countries concerned, however, others are a result of criminal acts.The latter is a damning indictment of some individuals who were willing to put children’s lives at risk in order to line their own pockets. However, what makes this policy so remarkable is that even when the cash-based programmes were halted and all unspent funds immediately frozen, the children in these countries nevertheless continued to be immunised with GAVI funded vaccines. In other words, although there will always be negative consequences from weak controls and misuse, the innocents are, to some extent, protected from the greed of others.

This shows that these safeguards work, putting checks in place without jeopardising the effectiveness of existing vaccination programmes. For new programmes, they also enable GAVI’s Transparency and Accountability Unit to carry out a Financial Management Assessment (FMA) of a programme to ensure adequate financial controls are in place and identify potential problem areas even before any cash is handed over. These checks and assessments are then repeated on an on-going basis to ensure that standards are maintained according with the Paris Declaration on Aid Effectiveness, a set of principles drawn up with the Organisation for Economic Co-operation and Development to make aid more accountable, transparent and effective. Besides detecting misuse, these policies also enable GAVI to continue with its work of improving access to childhood vaccines in an open and fair way. For example, a new country-by-country approach was recently added to the arsenal to enable GAVI to respond to crises, whether they be man-made or natural short-term emergencies, longer term immunisation, or other challenges in a tailored way. This ensures that whatever the situation, all GAVI-eligible countries receive support fairly.

To date, 47 FMAs have been carried out in GAVI-eligible countries that receive cash grants and, by October 2011, GAVI lifted its suspension of cash support to Mali. GAVI’s investigation concluded that funds had indeed been misused over a two-year period. Four individuals, who had been under suspicion, were arrested by local authorities and the US$ 563,000 in question was reimbursed to GAVI. Therefore, not only is GAVI’s Transparency and Accountability Policy helping to identify any misuse of funds and providing swift action when it does, it is also helping to tighten any existing cracks to make it more difficult for anyone to put children at risk by abusing these vital funds in the years to come.