In the run-up to this June’s GAVI sponsored donors’ pledging conference for new and underused vaccines, The Lancet Infectious Diseases crunches the numbers on vaccine costs and the constraints they place on rapid introduction of pneumococcal and other vaccines. For the First World manufacturer, $3.50 per dose is a huge discount. For the Third World finance miniser, $3.50 is a fortune. What will happen to countries like Angola and Congo when they ‘graduate’ (lovely euphemism) from GAVI eligibility in a few years?

Supposing that the donors open their checkbooks enough to fund both pneumococcal and rotaviru vaccines. Where will tha leave human papillomavirus vaccine funding outside the industrialized world?

The Lancet Infectious Diseases, Volume 11, Issue 3, Pages 165 - 166, March 201

Vaccine progress reveals resource gaps in developing countries

Original Text

Talha Khan Burki

In 1990, the baseline year for the Millennium Development Goals, more than 12 million children died before reaching their fifth birthday. By 2009, this number had been reduced to 8 million. Sturdy progress, certainly, but if Millennium Development Goal 4—which aims to reduce child mortality by two-thirds by 2015—is to be achieved the present rate of decline will not suffice. A new report by Save the Children, No Child Born to Die, warns of three resource gaps—immunisation, health workers, and financing—that are impeding progress towards the attainment of Millennium Development Goal 4.

The first of these refers primarily to the US$3·7 billion that the GAVI Alliance needs to mobilise over the next 4 years. The amount is based on demand forecasts for those countries that receive assistance from the alliance. Receipt of the money would allow for an additional 230 million children to be immunised with pentavalent vaccine, which protects against diphtheria, tetanus, pertussis, Haemophilus influenzae b, and hepatitis B, 90 million with the new pneumococcal vaccines, and 53 million with the rotavirus vaccines. All of which GAVI reckons would prevent about 4 million deaths by 2015. “The pace of our work is accelerating, we're increasing the number of children we want to reach”, explains GAVI's Jeffrey Rowland.

US$3·7 million for vaccines could prevent about 4 million child deaths by 2015

On June 13, the UK will host a pledging conference for GAVI, at which Rowland hopes the present set of donors will agree to double their contributions. The effect that missing the $3·7 billion target might have on future donations remains to be seen, but $1·8 billion would at least allow GAVI to continue its planned activities until the end of 2013; much less than this and the organisation would have to consider which vaccines to prioritise. Rowland is optimistic this will not be necessary. “The momentum leading up to this conference is incredible”, he told TLID, adding that countries such as Canada, France, and Norway, along with the Gates Foundation have affirmed their commitment. 2010, points out Rowland, saw no reduction in donations to GAVI, despite the economic crisis.

Rowland has larger ambitions for the pledging conference. He would like to see the private sector take on a larger role in GAVI, for one thing. “We hope we'll have a couple of announcements from the private sector in June”. Then there is the role of the pharmaceutical industry. GAVI is the largest purchaser of vaccines for developing countries and, as such, it has been able to bring about price reductions. Rowland cites the example of the pentavalent vaccine. “Over the past couple of years we've lowered it from an average weighted price of $3·55 to $2·55”. The saved dollar, he adds, facilitates the purchase of millions of dollars worth of vaccine. “We expect pharmaceutical companies to commit to lowering their prices”, he said.

GAVI began rolling out the 13-valent pneumococcal vaccine in December, 2010. Nicaragua was the scene of the launch, and as TLID went to press, the vaccine was being introduced in Kenya. More than 40 other countries are to follow, if all goes according to plan. The project represents the culmination of a pioneering agreement with the pharmaceutical industry. Under the advanced market commitment, GAVI guaranteed to purchase a suitable pneumococcal vaccine at a specific price ($3·50). GlaxoSmithKline and Pfizer took up the offer, and two Indian manufacturers are to follow in 2013—14. “This really has provided a mechanism, albeit on a pilot basis, for very rapid access to new vaccines into countries that historically might have waited 10—20 years”, Pfizer's Mark Swindell told TLID. He noted that the vaccines are being rolled out within a year of their first approvals in developing countries.

Pfizer has committed to supplying the 13-valent pneumococcal vaccine—which is expected to prevent 7 million deaths over the next 20 years—until the end of 2022. Swindell believes that the price was judiciously set so as to be sustainable for the industry and affordable for GAVI. “We have significantly discounted the vaccine for use in the developing world—the price for the pneumococcal vaccine in the USA today is over $100 a dose.”

Rowland agreed that $3·50 was a good price. “But it's not good enough”, he added. “Pharma should be doing everything it can to lower its prices even further, we think pressure on pharma to do that is a good thing, not just for pneumococcal vaccines but for the vaccines that are coming down the line.” Last year, GAVI approved a new vaccine investment strategy that includes human papillomavirus, Japanese encephalitis, typhoid, rubella, and meningitis A. If vaccines for HIV/AIDS or malaria should become viable, there is no doubt that GAVI would wish to back them too. Rowland praised the advance market commitment scheme for its long-term, market-based approach. 80% of funds in the advanced market commitment are still available to purchase vaccines. “The objective is to create competition and to get emerging market manufacturers onboard”, he stated. All of which should serve to drive down prices.

If this situation did come to pass then it would certainly ease the transition for several middle-income nations. “The plan is for countries for which it is economically viable to ‘graduate’ from GAVI assistance”, explained Rowland. There are 16 such countries, including Angola, Azerbaijan, Honduras, Moldavia, Republic of Congo, Sri Lanka, and Ukraine, none of which will be eligible for GAVI assistance after 2015. The threshold for assistance is a national income per head of $1500 or less. In No Child Born to Die, Save the Children worries that “there remains a risk that some of the countries in greatest need of increased support fail to qualify for donor assistance”. Rowland counters that it is appropriate for these countries to assume increasing financial responsibility for immunisations. The move will save GAVI an estimated $1·4 billion during the next few years.

Still, even if GAVI is able to secure the requisite funds, this will not, on its own, be enough to achieve Millennium Development Goal 4. “The amount of money certain developing countries are putting into health care is grossly inadequate”, stresses Save the Children's Simon Wright. Just five countries in the African Union are meeting their 2001 commitment to spend 15%—scarcely an ambitious amount—of their revenues on health. The poor state of health-care systems in developing countries is a key factor in persuading staff to find jobs abroad. According to WHO, there is a crucial shortage of 3·5 million health-care workers in the nations with the greatest need. No Child Born to Die cites the example of Freetown, Sierra Leone, a city of 2 million served by six obstetricians and gynaecologists.

The UN Secretary-General's Global Strategy for Women and Children's Health has outlined commitments for expanding the number of health workers where they are most needed. “We're anticipating a follow-up in December at the UN General Assembly”, revealed Wright, “and that's where we want to see a much more specific commitment to come from donor countries to help support that expansion.” One option is to target aid towards the recruitment and training of staff. Incentives or conditions of service can be invoked to ensure health workers are evenly distributed.

Wright advocates an easing of the macroeconomic policies that poor countries are encouraged to follow. The International Monetary Fund, for example, frequently requires states to which it makes loans to limit their expenditure on public services. “We wouldn't agree with that”, Wright said. “We think certain countries should be encouraged to grow their public sector, and even use aid money to do that”, although he acknowledged that this does bring into question issues of sustainability.

Community health workers, properly supported and recompensed, can often take on many responsibilities commonly discharged by medical professionals. A programme in Nepal trained a cadre of such workers in newborn care. Deaths among newborns fell by 30% in areas covered by workers trained in the scheme compared with those areas covered by workers outside the programme.

Finally, there is the financing gap. Between now and 2015, an additional $17·5 billion per year—mostly due from nation states—is needed to attain the Millennium Development Goals on child mortality and maternal health. Only 19 of the 68 so-called countdown countries, in which the progress towards the goals is monitored, are on track to attaining Millennium Development Goal 4. But if governments are willing to make investments, the results can be substantial. For example, Bolivia, by instituting the Universal Mother and Child Insurance Scheme, has put itself on course for the two-thirds reduction in child mortality stipulated by Millennium Development Goal 4. And in Sierra Leone, a country recovering from civil war that has nonetheless been able to roll out an immunisation programme, last year's decision to abolish health-care charges for pregnant women led to a doubling in the numbers of hospital births. “The Millennium Development Goals are achievable”, Wright emphasises. “That the financing gap has not been filled is a reflection of the lack of prioritisation of health from developing countries and from donors”.

In the short-term, the pledging conference looms. There seems to be something of a consensus that $3·7 billion is not an unrealistic aim, although perhaps it will not all be forthcoming in June. “The GAVI model has been working”, said Rowland. “Vaccines are cost-effective and offer a high return on investment”, he concluded.