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Bill Gates' injection of funds into vaccination has catalysed action after a two-year review of the process by which international agencies support vaccination programmes in developing countries. The creation of the Global Alliance for Vaccines and Immunization (GAVI), and potential for further funds arising from debt relief, offer a new opportunity to realize the potential for vaccines to improve health around the world. It is important to develop strategies through which developing countries can work with their international partners to ensure long-term benefits from this renewed political support for vaccination.

Ten years ago, inspired by the declared success of Universal Childhood Immunization (UCI), the World Health Assembly set an ambitious agenda for the 1990s ( WHO 1989). Polio was to be eradicated by the year 2000. Deaths from measles were to be reduced by 95% from prevaccination levels, and neonatal tetanus eliminated, by the year 1995. All this was to be done in ways that would strengthen the primary health system ( Kim-Farley 1992). At the 1990 World Summit for Children, politicians announced a high-profile vision of children's rights that ‘brought the goals for children and development to the highest levels of political visibility’ ( Kim-Farley 1992). The Children's Vaccine Initiative was established that year by the Rockefeller Foundation, United Nations Development Programme, UNICEF, the World Bank and WHO ( Halstead & Gellin 1994). The initial vision was the development of a multiantigen vaccine that could be delivered by mouth soon after birth and protect the world's most needy children against the major infections ( Henderson 1995). While such a ‘magic bullet’ is still far away, vaccines are licensed against hepatitis B and Haemophilus influenzae type B, and conjugate vaccines are in advanced clinical trials against pneumococcal and meningococcal disease. The widening gap between the range and coverage of vaccination services in rich and poor countries highlights the need to review international support of vaccination.

In the last 20 years, nearly all countries with per capita incomes over US $600 have made the most of the powerful tool of vaccines. Latin America used programmes with a narrow focus to generate political enthusiasm and financial support for vaccination. Polio campaigns were effective through the 1980s not only in eliminating polio virus, but also in mobilizing popular support for vaccines and surveillance ( de Quadros 1995). The demonstration of a dramatic reduction in a disease that had afflicted people of all social classes in northern nations not long before was a powerful tool to lobby for international support. At the same time, strong leadership in the Americas led to sustained commitment from international agencies and the co-ordinated use of funds to strengthen primary health services ( PAHO 1995). Latin America now has an infrastructure that has shown it is able to attain high routine vaccine coverage, conduct extremely effective measles elimination campaigns, introduce hepatitis B and Hib vaccines, and obtain appropriate data to monitor the progress of each intervention.

Other middle-income regions and countries used a broader approach, and also made impressive progress. Countries in the Western Pacific region introduced hepatitis B vaccine almost 10 years ago, with high coverage, and many are introducing Hib vaccine. The gulf states of the eastern Mediterranean region have achieved high levels of measles control, and are advanced in their control of rubella and congenital rubella ( WHO 1999).

As noted by Dr Godal, there have thus been many successes. We should not, however, be afraid to note the problems. Funding for World Health Organization (WHO) vaccination initiatives other than polio saw little growth in the 1990s, from $15.5 million in 1994 to $18.1 million in 1997 ( Brooks et al. 1999 ). This was in contrast to the tenfold increase in funds specified for polio eradication, from $4 million to $43 million over that period.

In much of sub-Saharan Africa, the infrastructure for sustaining routine services is severely eroded, with poorly functioning cold chains and insufficient transport. High staff turnover means that there is now a generation of EPI managers in Africa whose main experience is in running national polio campaigns. Institutional memory has been lost regarding the organization of regular outreach services ( Cutts 1998) and methods for improving coverage in urban areas through routine services ( Cutts 1991). The 1980s focus on using all opportunities to vaccinate children in contact with health services ( Hutchins et al. 1993 ) has been weakened as donors reversed previous policies about the use of one vial for one child, the more expensive new vaccines having increased concerns about vaccine wastage. Other targets have quietly gone by the wayside, as neonatal tetanus has disappeared from the WHO agenda, and politicians rather talk about the success of measles elimination in the Americas than about the 500 000 deaths that continue to occur each year in Africa. It is surprising that measles control is not mentioned in the GAVI aims.

The funding promised for GAVI, while impressive, is only a fraction of the total cost of vaccination programmes. For example, just to introduce hepatitis B vaccine in the highest risk countries (HbsAg prevalence > 8%) would cost around $100 million per year ( Batson et al. 1994 ). In the early 1990s, the total estimated cost of delivering the traditional six antigens of the Expanded Programme on Immunization (EPI) was $1.4 billion per year in developing countries ( Jamison & Saxenian 1995). Much remains to be done to eradicate polio, and the challenge of implementing the eradication strategies, including surveillance in conflict-affected countries, still requires substantial resources. The estimated $1 billion available through GAVI over 5 years must therefore stimulate increased investment from other sources at national and international levels that will be sustained for future years.

Experience in the 1980s showed some of the potential pitfalls of intensive investment in vaccination without strategies to sustain programmes ( Taylor et al. 1996 ). In several low-income countries, coverage has stabilized or declined since 1990. External funds had covered training costs, per diems for outreach, supervision and social mobilization. These activities were difficult to maintain when donor funds decreased. Evaluation of UCI was based on vaccine coverage, and the reported achievement of 80% coverage in 1990 led to complacency in some circles that the job was done. In contrast, countries in the Americas defined goals in terms of reduction in disease, thus keeping the pressure on governments and donors to continue support for immunization.

There are some causes for concern in the early stages of GAVI planning. Funds are only guaranteed for three years, then will be reduced by 25% each year. Is it realistic to expect low-income countries to develop sustainable resources for vaccination in this time period? Even under ideal circumstances, where all creditors agree to debt relief to highly indebted poor countries, and those countries invest a large proportion of the savings in primary health care, it will be difficult to develop a sustainable infrastructure within this timeframe. The positive effect of health sector reform in Ghana has occurred against a background of long-term support to district-level management training ( MoH Accra & WHO 1991). In other countries, vaccination has fared less well in the face of decentralization and privatization; coverage in Uganda, for example, having fallen from 79% in 1994 to 46% in 1998 ( WHO 1999). Many African countries also face loss of skilled personnel through the AIDS epidemic and repeated civil conflict. It is time to consider support to these countries in terms of decades, rather than years.

The re-instatement of coverage as a prominent goal for vaccination programmes is a retrograde move. One of the objectives of GAVI is to achieve 80% coverage in 80% of developing countries (GAVI 1999). Such averages could easily allow the poorest groups to be missed, and do not reflect the different levels of effort needed to reach different populations. They also ignore the different impact of a given coverage level on different diseases. Dramatic reductions in Hib disease have occurred at coverages well below 80%, e.g. 36% for 3 doses in the USA ( Anonymous 1990), while much higher coverage is needed to have a marked effect on measles morbidity ( Fine 1993). Lastly, the very declaration of a coverage goal whose achievement is linked to receipt of further resources, puts great pressure on politicians and health workers to inflate reported figures. Coverage surveys do not solve this problem, since they themselves are subject to many biases ( Bennett et al. 1991 ), and home-based records are often unavailable for a substantial proportion of children.

An encouraging step by GAVI is the call for proposals from eligible developing countries for funding. Integrated plans of action that incorporate strengthening of existing immunization services and introduction of hepatitis B, Hib, and yellow fever in endemic countries will be requested, and guidelines issued for their development. The open competition for funds and systematic review of proposals should stimulate ownership of the projects at the national level.

The planning process will provide an opportunity for the poorest countries, and agencies supporting them, to reflect on the level of care that can realistically be sustained in the medium term. Epidemiologists, managers and economists need to work together to answer practical questions about policies and strategies at the national and district levels. For example, in countries or districts with a very poor infrastructure in rural areas, some of which are also affected by chronic or recurrent conflict, it may not be realistic to attempt to provide fixed health facilities to serve all communities. The pulse outreach or campaign approach ( Nokes & Swinton 1995) is an alternative delivery method at school and community levels for interventions such as polio and measles elimination, mass treatment of helminths and other parasites, micronutrient delivery, and some forms of vector control. This approach, despite being inappropriate for curative and delivery care, may be particularly suited to areas of civil unrest ( Cutts et al. 1988 ) or sparsely populated regions. Difficult political decisions will be needed when vaccination programmes are implemented using strategies that do not address the needs of other essential health services. Inter-agency coordinating committees will play a key role in developing health plans that are tailored to the local situation.

Total net disbursement of official development assistance from all sources to the health sector in developing countries was $4 billion in 1990, of which about half was to low-income countries ( World Bank 1993). A single foundation has made $1 billion available just for vaccination over the next 5 years. It is hoped that developing country leaders and the traditional development agencies will take up the gauntlet and demonstrate their commitment and capacity to improve global health.

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