Dagfinn Høybråten, the chairman of the Gavi Alliance’s board told EurActiv that his group was “drastically” stepping up the introduction of new vaccines against pneumococcal diseases and diarrhoea. Gavi, a public-private partnership, was targeting countries such as Nigeria and India, as well as Somalia and Afghanistan but funding shortfalls from donor states were “a key obstacle,” he said: “We have a challenge with austerity measures, budget processes, and the financial implications of the economic crisis. Later in the Spring, we will make another substantial ask for the next five-year term to continue this very exciting global health campaign. Of course it is not going to be easy with the economy the way it is in many donor countries but we believe very strongly that we have one of the best buys in development: Very low cost and very efficient interventions that save lives for children and whole populations.”
Even more challenging would be the repercussions of Gavi’s dynamic development model, he said. “This means that as national economies grow in the south - and we are happy that happens - they will eventually have to co-pay more and graduate from [low income status]. We’re not in this for eternity. We’re in this to sustain the country’s own ability to earn enough to pay for basic health facilities. So we will see several countries graduate in the coming ten years. This is a good thing as it shows the dynamic of this model. At the same time, we need to ensure that these countries are given access to fair prices [for vaccines] and supported in other ways so what we have achieved, a higher degree of immunisation, is maintained.”
There was “a huge effort” underway to find an efficient and effective malaria vaccine, Høybråten made clear. Gavi “stands ready” to take such a vaccine into its programmes, he said and such a move could come soon. “In five years from now we will see a totally different picture, and hopefully we will be able to make decisions in course of our next five-year plan for Gavi to introduce an efficient malaria vaccine.”
More broadly, “the vaccine market has very few players and there is increased competition between them that brings prices down,” he said. “Our entry into this market as the world’s largest purchaser of vaccines has created some long-term predictable conditions for investment in, and production of, new vaccines, and also in the development of new industries in lower-income countries. That is creating the opportunity for shaping the market and ensuring that we get lower prices.”
Høybråten said it would be “critical” to have a health-based MDG. “I would like to see some appealing goals ensuring the right to basic health services for every person,” he said. “We are focusing on every child – but it is for every person. One indicator could be the fully-immunised child – the child receiving the vaccines available for everyone. Universal vaccination of all children is our ultimate goal. It is very ambitious but looking back at what has been achieved in the last decade, we now know how to do this through public-private efforts, working with industry and civil society and UN agencies to make this happen.”
Veronique Lorenzo, the head of The European Commission’s DG Devco Health Unit said that “for us, very clearly what makes sense is an umbrella goal for the promotion of universal health coverage. That doesn’t mean ‘everything for everyone from day one’. It is a long path and each country has to decide which segments of the population to cover, for what, and for how much. But it is clearly the most promising avenue for better access for the poorer segments of the population.” Child and maternal mortalities could factor as indicators as sub-targets, and so could reducing disease incidences, but it was too soon to talk about specifics, she said.
Gavi had “set the agenda” for global immunisations, she told EurActiv. “We are doing extremely well with immunisations and Gavi has been extremely successful. It has become a very successful outfit, covering 120 million people in its first decade and keeping that number in the next five years, so it really has had huge success with donors. The problem is that you need a lot more than just financing and the product. The the vaccine is one substantive element but to make these efforts sustainable, you have to build up a health system and this is what we do when we’re not supporting immunisation programmes - building supply chains, service delivery, management information systems, and training people.”
Another issue she highlighted was that immunisation efforts could potentially divert resources from other vital areas. “If you talk to Bill Gates [a key Gavi donor], he is only interested in polio eradication and disease eradication is an effort on a different scale,” she said. “It is a different logic from systematic immunisation.” Immunisation campaigns were “a subsector of health,” she said and funds for them might be raised “perhaps at the detriment of other subsectors, but immunisation is certainly a subsector that has managed to maintain and increase its funding levels and I don’t expect this to change.”
“Some civil society organisations would argue that Gavi could do a lot more, that it is always negotiating with the same producers, and is very close to pharma firms so there’s a margin of interpretation,” she added. The big immunisation debate, as she saw it, was over excluding middle-income countries with great reserves of poverty from vaccination campaigns: “Gavi has a ceiling for supporting low income countries but how do we transition these countries out [of such categories] without people falling off the edge?” she asked.
The spread of medicine-resistant strains of malaria was a concern for the Commission, although these are currently limited to border regions of Thailand, Myanmar and Cambodia. Lorenzo said a vaccine for malaria had been talked about for 20 years and ventured no opinion about its likelihood.
Dr Jean-Marie Okwo-Bele, the World Health Organisation’s global immunisation programme director said that new WHO immunisation statistics out shortly would reconfirm that global immunisation coverage “remains stagnant in most places. Globally this is around 83% but if we consider child immunisation, that is not good enough as it implies large disparities within countries, which makes it harder to reach our disease-control and elimination goals. The level of resources for immunisation has to be looked at very seriously if the global community is to reach the potential of the vaccines that are out there. If you consider global public health measures, vaccination comes next to access to water in terms of the improvement in life and mortality reduction worldwide. Due to vaccinations alone, 2.5 million deaths are averted each year.”
The WHO’s key areas for policy debate around immunisation were thus “how do we reach those who are not currently reached by vaccines, and how do we make sure that countries have the resources to get additional life-saving vaccines that are available on the market for the potential benefit of most of the people there,” he said.
Universal access should be a key principle driving all health interventions, and not just the MDGs Okwo-Bele continued. “Sometimes we look at the capacity of vaccine production to [offer] enough for everyone. We have measures of vaccination performance based on total populations, not segments of them. In nearly all developing countries, access to vaccines is almost free at the point of vaccination. I think these [areas] could be seriously considered when one looks at universal coverage [targets] overall.”
While three-five big manufacturers were needed to produce vaccines in sufficient quantities to secure long-term affordable supplies, “I would call on the donor community to look carefully at how we can support Gavi and also work on other mechanisms like an evolving fund to help more people access vaccines,” he said.
Crucially, “we need to be very clear about accountability at all levels,” Okwo-Bele said. “You need to know what your money is buying and you need to quantify to what extent you’re getting the results you were planning, because vaccine strategies are known. The resources are more or less there - we should get more obviously – but I think making sure that the health services in target countries are able to deliver vaccines and getting other interventions in place is the main bottleneck. Expanding health services is not easy – that’s why we talk about universal coverage – and you need to do immunisation work district by district, making sure that each one has the power, the capacity, the commodities and infrastructure to facilitate the delivery of vaccines.” More work had to be done in countries such as Chad, in Okwo-Bele’s view.
Funding shortfalls were a great threat to the success of immunisation efforts. “If you remove the resources from Gavi, then the programme collapses,” he said. “The majority of Gavi-assisted countries still unfortunately depend on support from Gavi, partly because they are still building momentum for the location of extra resources by their own governments. Sometimes governments don’t put the resources in place and rely on overseas development assistance (ODA). We need to bring sustained ODA for at least the next five years or so and gradually [increase] the specific contribution by each country to supporting vaccination programmes. The co-payment [system] is working.”
EU member states traditionally decline to allow staff to go on the record about live political issues. However a spokesman for the German development ministry answered questions from EurActiv Germany by email. “Immunisation is one of the best investments in future generations with an impact that extends far beyond the health of an individual child,” the official said. “It will be important now for partner countries and the international donor community to commit sufficient funding to jointly consolidate and expand the gains that have been made. By striving to reach every child, everywhere, immunisation programmes promote health and socio-economic equity within and between countries. Investment in vaccines is essential to reaching the goal of eradicating extreme poverty, as well as achieving the Millennium Development Goals.”
The official insisted that even though the current MDG framework was due to end next year, “a lot can still be achieved,” citing the battle to reduce child mortality in particular. “There is a dramatic change sweeping across the developing world,” he said. “New vaccines against the worst forms of the two biggest child killers, pneumonia and diarrhoea, are being rapidly introduced into routine immunisation programmes. Germany is supporting the roll out of these lifesaving vaccines under the current MDG framework, in line with Gavi’s agenda.”
The number of children receiving three doses of the DTP3 vaccine had been the proxy measure for the strength of routine immunisation programmes since the WHO launched the Expanded Programme on Immunization (EPI) in 1974, he went on. “Since then DTP3 coverage worldwide has improved, and now reaches four out of every five children worldwide. However in the last decade new life-saving vaccines have been developed and they are being made available in the poorest countries of the world. Yet only 5% of children in the world have received all of these vaccines. This is why the idea has emerged to move beyond DTP3 as the standard measure of the success of a routine immunisation programme and to introduce a new and ambitious (MDG) indicator: a fully immunised child.”
Making this would happen would require “a consistent supply of appropriate vaccines at an affordable price, a robust health system, which includes a solid monitoring and evaluation system as well as trained health workers, and strong political leadership to ensure that people all over the world continue to be empowered to demand and access these life-saving vaccines,” he said. Germany had backed international efforts to this end by increasing its commitment to Gavi from €10 million to €30 million between 2011 and 2012, he said.
“From poorly trained health workers and under-equipped hospitals to a lack of data to track progress and no fridges to store vaccines, weak health systems represent a critical barrier to increase access to immunisation,” the official continued. German aid thus targeted programmatic and financial support to strengthen health systems. “German commitment to Gavi plays a key role in this effort,” he added. “Before Gavi, coverage was stagnating, developing countries were struggling to maintain vaccination campaigns, manufacturers would not invest in supplying vaccines to the poorest parts of the world. Now with Gavi, vaccines are reaching more and more children, protecting more and more lives. As of 30th November 2013, the Alliance had committed US$ 863 million to countries for health system strengthening.”