SPECIAL FEATURE - November 2002
More children, better protection - yes, but how?
As the GAVI partners prepare to meet in Dakar this month, fresh approaches to increasing immunization coverage and saving many more lives are on the agenda
OF the children born each year, only about 70% are immunized with even the basic vaccines such as DTP (a).In too many districts of too many countries, the percentage is much lower, at around 50% or less. Yet the Alliance partners have committed themselves to reaching 80% of children in all districts of at least 80% of developing countries with routine DTP by 2005. That means countries will have to immunize at least another 10 million children each year.
It is a tough challenge. But it is not the only one. In fact, even if this so called "80/80" target is met, there is a growing recognition that countries may need a much broader set of improvements to enable them to cut child mortality and realize the full benefits of existing immunization tools. As well as increasing the numbers of children receiving full DTP immunization, there is an urgent need to protect children more effectively against other important vaccine-preventable diseases such as measles and yellow fever. Between them, these two diseases continue to kill an estimated 800 000 people per year, and there are other killers too. Routine immunization alone may not be enough to control them.
At the same time policy-makers in countries and their international partners are looking for ways to meet an even more complex challenge: how to build immunization services into the broader and more sustainable health system that must continue well beyond the lifetime of GAVI itself.
The partners in the Alliance, such as WHO and UNICEF, have long sought ways to meet these challenges. But later this month in Dakar, Senegal, at the GAVI Board and at the second Partners' Meeting, the issues will be high on the agenda. "This is a critical moment for raising awareness of this issue, "says Michel Zaffran of WHO's vaccines and biologicals department, and WHO representative on the GAVI Working Group. Some completely fresh approaches are now being considered, including extending the partners' involvement with national health systems beyond immunization, to strive to meet wider health needs.
A bit of background. There have been several parallel debates over the best ways to protect more children, and these have often overlapped and become confused. The first is about how services should be delivered. There has long been a perceived split, albeit artificial and now outdated, between those who favour the so-called "vertical" approach to immunization and those who favour the so-called "horizontal" approach. Defined simplistically, the vertical approach is usually focused on a clear global target, often with international leadership, and tends to be run as a time-limited project with a top-down management. For example, the Global Polio Eradication Initiative, which since 1988 has been working zealously to rid the world of a crippling virus (see this issue, page 2), has been described by some as a relatively vertical programme.
More horizontal approaches are defined as those that aim to strengthen each country's health system across the board, ideally by empowering countries to agree their own immunization priorities and to finance and implement them sustainably. Horizontal programmes are relatively rare but some commentators have suggested that aspects of GAVI's work, for example its use of un-tied grants for strengthening immunization systems, favour the horizontal approach.
Of course, the "vertical" and "horizontal" are not mutually exclusive. Most commentators believe that a programme must have aspects of both if it is to succeed; for example, using expertise in controlling specific diseases, but also in delivering integrated and sustainable services. An OECD report (1) recently concluded that both targeted and system-wide approaches must be used together to give children the best disease protection. Dr Daniel Tarantola, Director of WHO's department of vaccines and biologicals, sums it up: "The old, somewhat outdated differentiation between vertical and horizontal programmes is not applicable; what we are aiming for is the best of both worlds." Dr Tore Godal, executive secretary of GAVI, agrees that the two approaches can be made compatible. The important point is that people who use the health system can receive an effective and integrated service.
Avoiding conflicting goals
Local delivery: a lay worker with basic training gives medication to a child with malaria in her village. Can immunization be built into a broader framework alongside such services?
Meanwhile, immunization programmes in low-income countries are already working to achieve a growing list of goals to save children's lives and improve their health. Governments have signed up to several international targets in child health and immunization. The United Nations Millennium Development Goal pledged to cut deaths in children under five by two-thirds before 2015. The UN General Assembly Special Session on Children, in May this year, reiterated this commitment, highlighting full immunization as a key route to accelerating disease control. Its targets include ridding the world of polio, halving measles deaths and eliminating maternal and neonatal tetanus by 2005.
GAVI, meanwhile, requires countries to produce long-term national immunization plans with built-in financial sustainability. In the early months of the Alliance, there was a risk that in some countries, the GAVI demands might be seen as conflicting or competing with work on the targeted goals. In 2001, the GAVI Board was asked to put its weight behind some of these targeted goals as well as its own original targets, so that there would be no perception of competition between the various activities of national programmes (2). "This was an opportunity to try to unite the world of immunization under the GAVI umbrella," says Dr Tracey Goodman, of the EPI team at WHO. In June 2001 in London, the GAVI Board added a new milestone to its existing ones: to declare the world free of polio by 2005. The Board also specifically agreed to redouble its own efforts to increase children's access to immunization. Again, this year in Stockholm, the Board confirmed that "increasing access to immunization is fundamental to reaching the GAVI milestones".
Campaigns and routine services
Meanwhile, each year, children are dying of vaccine-preventable diseases in their hundreds of thousands. Parents are demanding measles immunization for their children and outbreaks of yellow fever and meningococcal meningitis in a number of African countries have created strong demand for protection of those at risk. There is a clear need to increase the effectiveness of immunization against these diseases. Once again, however, the question of how has become a debating ground.
Routine immunization of infants is accepted by most as the essential basis for controlling most vaccine preventable diseases. But epidemiologists now agree that, for some diseases, effective control also requires campaigns or "pulse" immunization (see Box 1). To protect the whole population against measles, yellow fever and certain other infectious agents, supplementary campaigns that reach everyone in the target group are needed. Campaigns often follow the model of the polio initiative: on special national immunization days, vaccinators, supported by teams of "social mobilizers", go from house to house and vaccinate all children under the age of five.
1: Why do you need campaigns as well as routine immunization?
- Measles: The virus is highly infectious and kills an estimated 770,000 children a year. Unless more than about 90% of each year's one-year-olds are immunized, the virus steadily accumulates a "pool" of susceptible people and outbreaks of disease occur (see Immunization Focus, November 2000). Because the vaccine is given later than the DTP schedule, families have to make a separate visit to receive it. Many fail to return and so it difficult to maintain high coverage through the routine services. To prevent coverage from falling too low to prevent outbreaks, routine services must be supplemented with a second opportunity to receive the vaccine, sometimes called "routine campaigns".
- Yellow fever: many of the countries at risk have not routinely immunized their infants against this disease, and now, particularly in West Africa, urban outbreaks are becoming a problem, affecting adults and children alike. National campaigns are being done to "firefight" the virus. Routine immunization is a preferable approach and some countries are now ready to begin doing it, but it will take at least three decades before enough cohorts of infants are protected to provide population immunity. So, say WHO officials, a combination of effective campaigns in high-risk districts and regular routine infant immunization country-wide is best.
- Meningitis: in the "meningitis belt" of Africa, devastating outbreaks of infection have put control of this disease high on the political agenda. Research is under way to develop vaccines that would provide longlasting protection but at present, existing vaccines have to be given at the time of each epidemic in mass campaigns.
- Maternal and neonatal tetanus: the vaccine is given routinely but mass campaigns are also done in high-risk settings to help achieve the 2005 elimination goal.
The polio initiative is a focused, time-limited effort, and can use heroic tactics and substantial resources to reach previously unreached children. For some, the approach is one that GAVI could learn from. "This is about reaching out to underserved populations, whether they are geographically isolated or living on the seventh floor of a tower block in Cairo," says Tarantola. Dr Bruce Aylward, who heads the Global Polio Eradication Initiative, adds that the initiative has accumulated experience in forging partnerships between national and international players, and in monitoring and evaluating its work. And it has shown the true cost of reaching underserved populations.
But campaigns have their detractors too. Some argue that they are costly, unsustainable, and that they take away resources and manpower from the routine immunization services. Some accuse campaigns of being too "vertical". In reality the evidence is mixed. Several studies have tried to assess the impact of the polio eradication initiative on routine immunization services. The polio initiative encompasses much more than campaigns, of course, including surveillance and monitoring, but its campaigns and its wider activities have been assessed more than those of other programmes to date. A report commissioned by the US Agency for International Development (3), based on a study of three countries, concluded that funds for routine immunization programmes grew during the course of polio eradication efforts. However another study, which analysed the impact of the polio approach on three countries' health systems, reached more qualified conclusions (4). "With good planning and organization, campaigns can actually strengthen a system, but where planning and coordination are poor they can weaken it," says Bo Stenson, one of the study's authors.
The debate has, however, divided those who favour campaigns and those who favour routine immunization, as if the choice is to have either one or the other. In truth, says Goodman, both routine programmes and campaigns are necessary; regular campaigns can become part of the routine, for example in controlling measles.
Health priorities - or jobs?
Part of the reason that these issues have become so inflamed is that there is an underlying - but separate - agenda of jobs and money and a ticking clock. There is a question about what to do with the "troops" who have worked for years to eradicate polio, once the virus is finally banished. Some have suggested that these individuals and the infrastructure that supports them could move, almost wholesale, into working on the newer goals of meeting the "80/80" target and accelerating the control of diseases for which outreach campaigns are needed. This way, their training and experience will be safeguarded. Others strongly object to this idea. Critics worry that the polio initiative has skewed incentives and resources away from the routine immunization programmes in some countries, with staff receiving more money and hardware for polio-related activities than for their routine immunization programme work. The critics do not see this as a sustainable structure on which to build future immunization services.
Aylward rejects the critics' views, arguing that they are not supported by evidence. In any case, he says, polio staff will be involved in surveillance and other aspects of their existing work until around 2010 anyway. "This is about more than jobs." He argues that the polio infrastructure - and substantial polio funding - is already being used in many ways to facilitate broader immunization goals. Godal agrees that "in many of the hardest hit countries, the polio staff have been helpful in facilitating GAVI". However, he says, the approaches of the polio initiative and GAVI are obviously different. "Polio is a project and it is project-managed; GAVI is about country-led strengthening of immunization services, and so they are quite different from that point of view."
UNICEF and WHO point to a crisis in staffing for most health systems. While the goal must be to strengthen national systems, WHO and UNICEF argue that some governments will need extra staff, some of them externally funded, to meet the current set of child health goals, including those of GAVI, in the short and medium term.
Countries' needs first
Direct action: Aylward immunizes a child at the launch of a national immunization day in Angola
Whatever the advantages or disadvantages of using the polio "troops" for future purposes, most players agree that the first question should be to ask what countries need to do, rather than who should do it. "The question of what to do about the polio infrastructure is completely separate," says Godal. The key question, he says, is what do countries actually need to meet broad and sustainable national goals for immunization within their health systems? Once that has been answered, and the funding and capacity needs have been broadly mapped, then will be the time to work out how it should be done. "We are not an employment agency; our concern is that countries secure adequate staff to deliver vaccines for their children." However, everyone agrees that the issues need to be resolved very quickly.
So now the Alliance is trying to move forward, aware that each year of delay means another unacceptably high loss of life.
One approach, spearheaded by individuals in WHO, UNICEF and the Children's Vaccine Program at PATH, has been explored as a means to support countries in increasing access to immunization at district level upwards. Dr Julian Bilous at WHO, Dr Jean-Marie Okwo-Bele at UNICEF and others in this group have suggested adopting a district strategy for assessing needs, problem solving, planning, budgeting and implementation. Immunization microplans, backed by adequate funding, would be developed. Five critical strategies that are considered common to both immunization and other primary health services would be adopted, including regular outreach for disadvantaged communities, supervision, monitoring and better planning and use of resources.
Okwo-Bele, senior adviser and team leader on immunization at UNICEF, emphasizes the need to meet countries' individual needs. "We cannot have a one-size-fits-all approach," he says. He believes teams need to work at district level to identify the specific barriers to reaching more children, and enable district staff to overcome them.
The GAVI Board is now discussing this proposal and the possibility of including it in a wider approach. It is considering bringing in outside analysts to take an entirely fresh look at what countries' health systems need to increase access to immunization, but in the broader context of the health system. Aware of the urgency, the Secretariat has proposed a 4-month study by management consultants, with input from WHO, UNICEF and other partners, and the Secretariat itself, in providing data and stakeholder views. The study would analyse needs and propose a set of scenarios for achieving the "80/80" target, ranging from a centralized and vertical push to achieve higher DTP coverage to a much more broadly integrated set of services, nested within the wider mother-and-child health system, and potentially covering anything from immunization to malaria treatment to vitamin A supplementation. Finally, with feedback from the stakeholders on each scenario, the management and resource requirements for preferred options would be assessed and detailed planning could begin.
No decisions have yet been taken. But the partners are hopeful. "This is a fresh look," says Tarantola. Now, the emphasis is on answers - and funds to back them - soon.
(a) Diphtheria-tetanus-pertussis. Three doses of DTP ("DTP3") has been used as an indicator of coverage in GAVI-supported countries.
- Health, Poverty and Development Cooperation. Development Cooperation Report. OECD, 2001
- Alignment of GAVI Objectives, Accelerated Disease Control Initiatives and Other Interventions. Working Group Report to the Fifth GAVI Board Meeting, 21-22 June 2001, London
- Levin A. et al. 2000. The impact of the polio eradication campaign on the financing of routine EPI. Special Initiative Report No. 27. Abt Associates
- Mogedal, S. and Stenson B. Disease eradication: friend or foe to the health system? WHO 2000. WHO V&B/00.28
- Polio Staff Time: GPEI/WHO study, 2002.
Immunization Focus November 2002 - Contents