Rising costs pose challenge for poor nations’ vaccinations

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This article is part of our special report Nutrition and Child Survival.

SPECIAL REPORT / Rising drug costs and supply uncertainty threaten efforts to achieve universal immunisation after decades of steady progress in vaccinating African infants against crippling and deadly diseases, health workers say.

In the world’s poorest region, sub-Saharan Africa, the rate for basic vaccinations has risen fifteen fold since 1980 – from 5% of children to 77% – backed by an outpouring of aid from the EU and other donors and public-private schemes to provide low-cost vaccines in developing countries.

Yet a growing number of recommended immunisations for children under five and limited competition have contributed to the rising costs even as the price for some traditional vaccines has fallen through collaborative schemes to help the world’s poorest countries.

The European Union, a leading source of developing nation assistance, has pledged to make health a priority of a new development aid framework that focuses on the lowest-income countries, mostly in sub-Saharan Africa. As part of a broader push to reduce childhood disabilities and illness, the European Commission has also proposed a new framework to improve nutrition for infants.

But concerns about the decline in assistance from Europe and other leading donors also weighs on concerns about future support.

“There has been a large amount of funding that has been given by donors over many years and significant improvements have been made,” said Shingai Machingaidze, a researcher at the Vaccines for Africa Initiative at the University of Cape Town.

“Unfortunately, there are many issues that have to be configured with immunisation programmes: infrastructure, human resources and preparing the vaccines. Putting all these together, the coverage has just not reached what was hoped for and anticipated, which is universal coverage for all children,” Machingaidze said in a telephone interview.

Machingaidze and other South African colleagues last month published a report showing that the cost per child of vaccination regimes has risen from $6 (€4.60) in 2000 to $25 (€19) to and could rise far higher – to $58 (€44) – when new vaccinations for pneumonia and diarrhoea are included.

“These costs are just far greater than African countries can afford to pay per child,” Machingaidze said. “So even with donor funding it’s still a very large amount of money that’s needed to ensure that every child in Africa gets vaccinated.”

Public-private alliance

Developing countries enjoy substantial discounts on vaccines through a public-private partnership, the GAVI Alliance. Founded in 2000 as the Global Alliance for Vaccines and Immunisation, the group now helps fund affordable vaccines for more than 70 nations.

The Geneva-based organisation received $110 million (€77 million) in direct funding from the European Commission from 2003-2012 and 11 EU states have also contributed, along with other public and private donors.

GAVI and its partners, which in addition to European donors include the WHO, the UN children’s agency Unicef and the World Bank, has helped vaccinate 370 million children in 73 countries since it was founded in 2000.

The alliance leverages this vast market, plus ties with suppliers and public and private donors, to provide low-cost supplies of leading vaccines for hepatitis B, rotavirus, diphtheria, tetanus and other diseases.

But GAVI has come under criticism from advocacy groups for failing to bargain for even lower prices. The medical chartiy  Médecins Sans Frontières (MSF) contends that GAVI has worked too closely with major pharmaceutical firms in Europe and the United States rather than diversifying its supply chain.

Doctors group seeks more cost control

MSF’s Access Campaign, established in 1999 to press for better access to low-cost vaccines, also advocates public investment in the development of vaccines that are easier to administer and can be stored in formidable environments where storage and refrigeration are problematic.

Kate Elder, the vaccines policy advisor for the Access Campaign, praised GAVI’s achievements but says costs are still too high for poor countries and medical charities.

“We all have the same goal – we all want to get kids vaccinated,” Elder said in a telephone interview. “Yes, GAVI has been able to reduce prices … and yes that is laudable. But the point is we could actually go a lot further. We know that these vaccines are bringing blockbuster revenues for pharmaceutical companies.”

“There is much more room to push down the cost of these vaccines even further,” she said.

MSF’s “conservative” estimates for vaccine regimes are in similar to those estimated by the South African researchers, prices Elder said were unsustainable for the poorest nations and charities like here.

Elder urged donors to throw support behind efforts to replicate India’s success in building domestic pharmaceutical industry that turns out low-cost vaccines that still qualify under World Health Organization (WHO) safety standards.

GAVI sings deal with Indian producer

In a bid to expand its supply chain, the GAVI Alliance announced on 18 April – ahead of World Immunisation Week – that it had forged a new supply deal with India’s Biological E Ltd. that will save $150 million (€115 million) in vaccination costs over four years and shave the cost of the pentavalent vaccine from $2.17 to $1.19 per dose. The vaccine is a single dose for type B influenza, hepatitis B, diphtheria, whooping cough and tetanus.

“This is great news for children in the world’s poorest countries and it shows that our innovative public-private partnership model is working well,” said Dr Seth Berkley, the alliance’s chief executive.

“A decade ago we had just one European supplier and a price of $3.56. Today we have five suppliers, including two in India, and a price that is down to its lowest level yet,” Berkley said in announcing the agreement. “This marks the realisation of a vision that GAVI started a decade ago to create a healthy, competitive and sustainable global market for pentavalent vaccine. ”

More collaboration to reduce prices

But Dr Charles S. Wiysonge, programme manager at the Vaccines for Africa Initiative, also said African nations should be developing what doesn’t exist today – domestic vaccine producers.

“African needs to come to the party and start discussing with manufacturers in other low- and middle-income countries – like Brazil and India and China – to be able to acquire the technology to manufacture low-cost vaccines,” he said in a telephone interview.

Health experts say immunisations are critical to prevent unnecessary illness, suffering and disability – and that the costs pay off in the long run through better health and productivity.

Although need varies by region, vaccines against polio, tetanus, whooping cough, measles and hepatitis B are relatively standard, and the WHO recommends up to a dozen vaccinations in early childhood depending on the risk of viral or communicable disease.

“There are always competing priorities in the landscape of medical needs,” MSF’s Elder said, “but we have to say vaccines are really one of the best public health tools.”

In announcing a supply agreement between the GAVI Alliance and Biological E Ltd of India on 18 April, Mahima Datla, the company’s managing director, said: “This partnership demonstrates the growing role of developing world manufacturers in the sustainable supply of effective, affordable vaccines. We are proud that our work to provide affordable prices for a variety of countries means life-saving vaccines can reach the most underprivileged children in the world.”

Researchers at the Vaccines for Africa Initiative at the University of Cape Town, in medical journal report published last month, said: “Issues of vaccine supply, financing, and sustainability in Africa require urgent attention. Increased political and financial commitment from governments as well as coordinated national and continental evidence-informed efforts by all immunisation stakeholders are needed to both maintain current achievements and make additional progress for EPI [expanded programme on immunisation] in Africa. African leaders must be held accountable for meeting agreed country targets and honouring international commitments made.”

The report also says that poor data collection hampers immunizations in many African countries, leading to underreporting of statistics particularly in remote areas.

“It’s quite a problem,” Dr Charles S. Wiysonge, programme manager at the South African organisation, told EURACTIV. He said that Europeans and other donors could help in improving data collection technology.

“We think that it is important for countries to have good monitoring and evaluation framework, and request assistance if they don’t have the data infrastructure to do that,” Wiysonge said. “We need to be sure that when we say one child is vaccinated, that the child has been vaccinated, and when we say 90% of African children, that they are all vaccinated.”

Dr Margaret Chan, director-general of the World Health Organization, called for more competition to reduce vaccine prices in a speech to the World Health Assembly last year. “Once individual vaccines are prequalified by WHO, the country’s capacity to produce a large number of vaccines at very low prices will revolutionise vaccine supplies and their prices.”

World Health Organization figures show that of the more than 857 million people living in sub-Saharan Africa, 136 million were under the age of five – considered the critical years for immunizations and good nutrition.

The WHO launched its Expanded Programme on Immunization in 1974 to promote vaccination programmes, especially in developing nations. On 12 April 2013, the UN announced a global action plan to expand vaccinations to prevent and control pneumonia and diarrhoea.

Although vaccination rates vary widely, across the continent, average vaccination rates for African infants lags behind the rest of the world. Health experts also cite another challenge: some vaccinations require multiple injections, and often families do not return to clinics for follow-up immunisations.

In addition, researchers at the Vaccines for Africa Initiative at the University of Cape Town say data collection across Africa remains inconsistent, leading to underreporting of statistics particularly in remote areas.

  • 24-25 April: Global Vaccine Summit in Abu Dhabi
  • Through 27 April: Immunisation Week

NGOs and international organisations

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