Field Notes

• Field Notes

Field Notes

Global Immunizations at the Tipping Point

By: Alan R. Hinman and Samantha Kluglein

Immunizations have saved the lives of millions of children around the world.  Continued use of existing vaccines and introduction of newer vaccines offer the promise of saving even more millions of lives.  However, this progress is not automatic; it requires continued commitment of resources at global, national, and local levels.

The current international attention focused on attainment of the Millennium Development Goals has raised awareness among international agencies and bilateral donors on the significant contributions of immunization to maternal and child health.  In The Path to Achieving the Millennium Development Goals, UNDP credits immunization programs as the source of “rapid progress toward achieving maternal and child health targets”.   Millennium Development Goal 4 (MDG4) calls for a reduction in child mortality by 95% in 2015 compared to 1990.  Considerable progress has been made, in large part due to the extraordinary reduction in measles mortality in sub-Saharan Africa (92% comparing 2008 to 2000).  Momentum has further escalated with the launch of the “Decade of Vaccines”, following a $10 billion commitment to research and delivery of vaccines by the Bill & Melinda Gates Foundation.  Health Affairs recently devoted an issue to vaccines and laid out the human, economic, and moral case for the prospect of saving 6.4 million children’s lives over the Decade of Vaccines.
  
There is extraordinary agreement in the international community that immunizations represent outstanding investments in health and development.  The recent successful GAVI pledging conference in London, gathered $4.3 billion in commitments from bilateral and private donors, significantly more than the target of $3.7 billion. Support from the GAVI Alliance has enabled substantial improvement in immunization coverage in 72 GAVI-eligible countries. Increased use of a new pentavalent formulation (DTP-HEP B – HIB), has ensured that almost all GAVI-eligible countries have successfully introduced both hepatitis B and Hib vaccines.  Newer vaccines, with tremendous potential to further reduce child mortality have been developed and are at the point of introduction - pneumococcal conjugate, rotavirus, meningitis A, and human papillomavirus vaccines.  There is extraordinary demand in developing countries in Africa and Asia for access to the new vaccines – particularly meningitis, pneumonia, and diarrhea. GAVI recently reported a record 50 countries applied for vaccine funding (for 75 vaccines) during the Alliance’s latest application round – nearly double the previous record in 2007.

New support generated at the pledging conference will allow GAVI to fully fund approved applications. However, ensuring the sustainability of these programs presents a challenge.  Although the increased GAVI support will enable countries to introduce new vaccines, it will not provide adequate support to build and sustain the infrastructure that is necessary in order to be able to continue to provide current vaccines as well as providing the new vaccines on a sustaining basis. We need a balanced immunization strategy that sustains and strengthens routine immunization/infrastructure, achieves existing initiatives (e.g., eradicating polio and reducing measles deaths by 95 percent), and enables introduction of new vaccines to ensure the fullest realization of benefits. While the United Nations Global Strategy for Women’s and Children’s Health calls for donors to align aid in agreement with country national plans, it does not take the next step and call on national governments to provide for key maternal and child health interventions, e.g. immunizations in their national plans and budgets.

Convincing African governments to assume their responsibility represents a significant hurdle for the international community.  There is insufficient commitment on the part of many national governments to support their own immunization programs.  The Africa Progress Panel (APP), an international group of high-level advocates, comments on Africa’s performance on Millennium Development Goal 4. In a 2011 report, the Panel comments that Africa has progressed “at an insufficient rate to attain the MDG target between 1990 and 2008.”   Referring to international pledges made at the MDG Summit, the report notes “these generous pledges, provided that they materialize, contrast markedly with the reluctance of African governments to fulfill their own commitments.  Many of them fall short of the Abuja target of allocating 15 percent of their public expenditure to health; 19 countries spend less on health now than they did when they signed the Abuja declaration in 2001.”  
 
The lack of commitment to immunization programs by national governments is dramatically illustrated by their failure to fund operational costs for supplemental measles activities. Since 2000, the Measles Partnership has provided vaccine for nearly one billion immunizations and has funded 50% of the operational costs to carry out mass campaigns delivering vaccines to children throughout Africa and Asia.  The Partnership asks countries to fund the remaining 50% of operational costs. Africa achieved a 92% reduction in measles mortality for the period 2000-2008. Although some countries commit to fund their share of operational costs, many fail to fulfill their pledge, while still others never make a commitment. Unless we can continue our success with immunizations, we will be unable to meet MDG4.

In its 2011 report, the APP pointed to the failure of the development community to support holistic development policies for Africa. The Panel found that the majority of African countries are not on-track to meet the MDG targets as a result of “inadequate policies, unmet commitments, lack of focus and accountability and insufficient dedication to sustainable development by both African states and their international partners.”    The private and public sectors have strikingly different perceptions about the role of public health in development.  India clearly illustrates this paradox; a country without a national immunization program provides the enabling environment for a rapidly emerging vaccine manufacturing sector.

The Public Health Foundation of India has called on the government to increase spending and strengthen national immunization programs, noting that although India is a leading producer and exporter of vaccines, more than one-half of children in India are not fully immunized and one-third of the world’s unimmunized children reside in India.  This failure is, in part, due to “little investment by the government.”   Regional and global development agencies have identified gaps in education and public health as significant barriers to sustainable development in Africa. In contrast, the Africa Competitiveness Report 2011, jointly published by the World Economic Forum, the World Bank and the African Development Bank, states that “while business leaders…point to an inadequately educated workforce as a serious obstacle to doing business, poor public health is placed far down the list…”    Public health ranks at or next to the bottom on a list of 15 factors for both North Africa and sub-Saharan Africa.  Yet this report signals hope.

Traditional development agencies and high-level advocates are highlighting the need to embrace one of public health’s most fundamental yet effective tools – childhood immunizations. When global economic conditions threatened to distract the attention focused on child mortality, high-level advocates rallied and expressed their support for continued focus and commitment.  Former UN Secretary General Kofi Annan and former US President Jimmy Carter co-authored a widely released op-ed calling for increased commitment from national and international donors to sustain and extend the progress that has been made in reducing child mortality through availability of traditional, new and underutilized vaccines.  President Carter also contacted several current and former African heads of state urging increased national commitments to immunizations.

There is evidence that international high-level advocacy has fostered regional advocates in sub-Saharan Africa.  In 2010, for the first time, the Chair of the African Union urged national leaders to support immunizations within their countries.  At the national level, Heads of State, Prime Ministers and First Ladies have become visible advocates in many African countries. Fifteen African and Asian countries participate in the Sabin Vaccine Institute Sustainable Immunization Financing Program, exploring strategies to establish stable internal funding for their national immunization programs.

National governments need to accept their responsibility to sustain and strengthen ongoing immunization programs. Without evidence of national and regional commitment, the international community will eventually fatigue.  The current momentum must be harnessed to enlist political leaders, development agencies and the business sector, to take full advantage of the extraordinary opportunities and challenges.  External support is available; the stage is set; most of the actors are in place; all that is needed now is for political and industrial leaders to take their rightful and necessary roles.

Alan R. Hinman, MD, MPH is Sr. Public Health Scientist at The Task Force for Global Health. Samantha Kluglein, PMP is Communications and Project Manager at the Task Force for Global Health.