Financing vaccination has been a headache ever since EPI grew out of the smallpox eradication programme. Scandinavian countries were particularly supportive over the years, but others found commitment to long-term control unattractive, preferring quick fix spending. Then Bill Gates produced $US 750 million for global vaccination and led to the creation of the Global Alliance on Vaccines and Immunization, a new form of partnership between WHO, UNICEF, industry and others (http://www.vaccinealliance.org/). Other partners have added a further 250 million to the pot – intended to finance new vaccines for low-income countries over the next 5 years.
In January, the NGO ‘Save the Children UK’ rushed out a report (New products into old systems) on an evaluation of GAVI performed by academics at the London School of Hygiene and Tropical Medicine with contributions from the NGO. They were critical of GAVI based on extensive interviews in Mozambique, Ghana, Lesotho and Tanzania. The key issues they raised were the speed with which governments had to respond in order to submit bids for funds, the late delivery of vaccines, the drive from GAVI to use combination vaccines, the functioning of Immunization Coordinating Committees that each country must have to qualify for support, and the limitation on syringe supply to those that auto-destruct. Clearly these issues fell into two areas – process and technical choices. The restriction of supply to new vaccines or to DPT combined with either hepatitis B or Haemophilus influenzae B has been particularly contentious because of the expense of the combination vaccines. Whilst countries do not pay for them now, there is concern that they may have to in the future. So, underlying even the technical issues is a feeling that countries are being bullied.
It is interesting to put this in context. Hepatitis B vaccination became available in the early 1980s. The places that need it most are Africa, China and surrounding Asian countries where hepatitis B carriage and primary liver cancer are very common. After 20 years most of the world except Africa had introduced the vaccine into routine programmes, but only two countries in Africa had. This was related to the cost of the vaccine but also to the low priority given for the vaccine. Hepatitis B vaccination will bear fruit 20 or 30 years after the programme's launch. This is far too long a time horizon for most politicians. Yet, since GAVI came into being, at least 13 further African countries have introduced the vaccine. So, the process may not be quite right yet but it is having dramatic effects after years of stagnation.
In 1998, the International Agency for Research on Cancer (WHO) held a meeting in The Gambia to report results from the long-term study of hepatitis B vaccination conducted there. The Regional Director of WHO attended and was persuaded by the evidence to commit to introducing the vaccine in Africa. But soon after, the message came back that this was not going to be possible until polio eradication was complete because of lack of resources. That eradication programme was not chosen by African countries, yet they have had to substantially finance it. Appalling as poliomyelitis is, it does not compare in terms of mortality to liver cancer, pneumonia and diarrhoea. The polio programme itself has not assisted the immunization infrastructure as it uses an alternative strategy of mass campaigns (Mohanan Nair 2002). And now, as recently discussed in this Journal (Razum 2002), it is not clear whether and when eradication can be achieved. There is clearly a need for better structures to formulate policy in vaccination and to ensure that we do not end up with another mistake like the attempts at polio eradication. Despite the criticism GAVI offers the best hope of such a forum.
GAVI's response to the Save the Children (UK) report was that they knew it all already. This may be true because they were already putting in place new structures addressing some of the process issues. If you look at their website you will also see that the Agenda for the November Dakar meeting contains much about improving process. There are sessions on strengthening and maintaining Immunization Coordinating Committees, discussions of country experiences in the introduction of new vaccines and logistics as well as social mobilization to improve immunization programmes. Interestingly, they are also calling for proposals to study the demand for pneumococcal and rotavirus vaccines in countries – asking the constituency before making decisions. Of course there will still be problems with politicians' time horizons and competing priorities – but hopefully by broadening the groups involved in the debate, appropriate choices can be made. It is important that partners and critics of the process do not lose sight of the objective: to get children in the poorest countries protected by vaccination against Hib and hepatitis B. GAVI are doing just that.