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Immunization Focus - the GAVI quarterly

NEWS - December 2002

En Français

Political priority, president Abdoulaye Wade arrives to open the meeting.
© M. Diop

An investment for life

In a signal of their commitment to immunization, government ministers from more than 60 of the 75 countries eligible for GAVI support assembled in Dakar, Senegal for the Second Partners' Meeting last month. The President of Senegal, Mr Abdoulaye Wade, opened the meeting with a call to delegates to redouble their efforts in increasing children's access to vaccines in developing countries. Almost 400 participants -- including those from non­ governmental organizations, the vaccine industry and UN partner agencies -- discussed the progress of the Alliance so far and confronted the challenges ahead.

Ms Carol Bellamy, executive director of UNICEF and chair of the GAVI Board, said that one of the Alliance's greatest challenges is to ensure that countries can assure the sustainability of their immunization services into the future.

Reflecting the importance of this issue, the central political event of the meeting was the signing of the Dakar Declaration on Financial Sustainability by the health and finance ministers of an initial group of 13 GAVI­supported countries. The declaration calls on all governments and partners to recognize that ``immunization and the sustainability of immunization is a national priority, a global concern and a shared responsibility'' (1).

First results

The presence of finance ministers at a health meeting reflects the seriousness with which countries regard their investment in immunization as a highly cost­effective tool to improve their population's health.

The first six countries to prepare Financial Sustainability Plans for their immunization services -- Cambodia, Côte d'Ivoire, Ghana, Guyana, Kyrgyzstan and Mali -- presented their plans to GAVI and the Vaccine Fund. The plans set out each country's assessment of their financial needs for immunization in the medium­term future and their plans for mobilizing resources, national and external, to finance these services after the initial period of support from the Vaccine Fund ends.

Dr Tore Godal, Executive Secretary of GAVI, summarised the Alliance's progress to date (2) and outlined the tasks ahead. Sixty­four of the 75 eligible countries whose annual income per head is below $1000 have now been approved for support by GAVI and the Vaccine Fund, and 180 million doses of vaccine have been supplied. Some $130 million of funds have been disbursed. Most of this money has been spent on new vaccines but a quarter of the total has gone to improving countries' health systems and infrastructure and $4.5 million has been spent on auto­disable syringes to improve injection safety. Over the five­year initial funding period, more than $900 million of funds have been committed by the Vaccine Fund.

A key achievement in the Alliance's work so far has been the sharp increase in access to hepatitis B vaccine, which has now been provided to 10.5 million children. Dr Mark Kane of the Children's Vaccine Program at PATH reminded delegates of the appalling burden of this virus, which causes liver cancer in up to a quarter of all those who become chronic carriers. Epidemiologists estimate that about 1 million deaths could be prevented worldwide each year with wider use of hepatitis B vaccine.

A vaccine to reduce the global cancer burden

1: China acts on hepatitis B
Immunization against hepatitis B has long been available in China, but only to those who could pay. In the poorest provinces coverage has been below 40%. As deaths from liver cancer are estimated to be between 280 000 and 400 000, there has long been a need for better protection. China's former minister of health, Dr Chen Min Zhang, now deceased, had said on his deathbed that his greatest wish for China was to see universal vaccination against the virus. His friends formed a foundation and began advocating for his dream.

GAVI and the Vaccine Fund then became involved and, in a joint initiative with the Chinese government (see main text), funded an initiative to immunize children in the poorest areas. The government then decided to extend free vaccination to all Chinese infants. An additional benefit is that the plan has stimulated the growth of an industry to make auto­disable syringes in China, says Kane.

During 2002, in a historic agreement between the government of China and GAVI and the Vaccine Fund, a $75­million project began to vaccinate Chinese infants in the poorer western provinces and "poverty counties'' against the virus, with half the money coming from the Vaccine Fund and half from the Chinese government. China now plans to extend free hepatitis B vaccination to all infants nationwide (See Box 1).

The impact of the initiative for global health is expected to be dramatic. ``After tobacco, hepatitis B is the second greatest preventable cause of cancer,'' says Kane. ``This is one of -- if not the -- greatest anti­cancer successes in history.''

But, as Dr Godal made clear, there is no room for complacency. Countries and their international partners have probably saved about 100 000 lives so far through the GAVI initiative, and this should be celebrated. But a total of 2.6 million deaths could be prevented each year if existing vaccines were reaching all children. The Partners have yet to make much progress if they are to achieve their target of reaching 80% of children in all districts in at least 80% of all developing countries by 2005 with three doses of DTP. And this is just the first part of the challenge.

Key future tasks for the Alliance include:

  • Increasing access to immunization over the next 2-3 years;
  • Securing sustainable finance over the next 3-5 years;
  • Accelerating the development and introduction of newer vaccines, including those against pneumococcus and rotavirus, over the next 5-10 years.

Dr Godal paid tribute to countries that are already increasing their investment in their future immunization services, such as Ghana and Sri Lanka. Increasingly, governments are viewing health interventions as investments in poverty reduction, rather than expenditures. A key challenge is to build immunization services into a broader, strengthened health system.

The Vaccine Fund

2: The state of immunization worldwide
Evidence is now stronger than ever that children's vaccines are an effective investment in reducing poverty, said Dr Gro Brundtland, Director­General of WHO. Launching the latest edition of a key report, The State of the World's Vaccines and Immunization, (3) in Dakar, Dr Brundtland said that WHO's Commission on Macroeconomic Development had shown that improved health clearly fuels economic growth in the poorest populations. ``Improving health may be the single most important determinant of development in Africa,'' she said. It is also a humanitarian imperative.

But the report reveals just how many gaps must be closed if vaccines are to deliver their full potential for saving children's lives. In Sub­Saharan Africa, as many as half of all children remain unprotected by the most basic vaccines. Research and development of new vaccines does not, on the whole, address the needs of developing countries. Unsafe injection practices may account for as many as 1.3 million deaths a year. Vaccine supply is unpredictable, and new vaccines are slow to reach those who need them most. WHO, UNICEF and the other GAVI partners are addressing these problems, but substantial additional investment will be needed to enable them to succeed, said Brundtland.

Since the initial gift of $750 million from the Bill and Melinda Gates Foundation, the Vaccine Fund has received contributions totalling a further $400 million mainly from governments. The goal, however, is to raise a total of $2 billion over five years and more resources are needed if the Fund is to fulfil its ambitions of becoming a ``permanent instrument'' to support the activities of GAVI, said Jacques­François Martin, the Fund's President.

Vaccine supply and security

Today, the children's vaccine market is changing fast, said Ms Bellamy. Supplies of the so­called ``basic'' vaccines that form the mainstay of the Expanded Programme on Immunization are becoming more scarce as industrialized countries increasingly switch to ``enhanced'' vaccines such as DTP using acellular pertussis (see Immunization Focus, June 2001 and July 2002). The value of market for the basic vaccines has dropped by 40% while the overall vaccine market has doubled. Not surprisingly, therefore, the number of suppliers has fallen, from around seven in 1997 to as low as three or four in 2002. UNICEF is now buying at least 90% of the total supply of basic vaccines such as whole­cell DTP, BCG and measles, and in 2003, the available supply of tetanus vaccine is expected to fall short of demand. In order to safeguard a secure future vaccine supply, governments, industry and other partners must work together using multi­year plans and accurate forecasting of vaccine needs.

Paul Fife of the Vaccine Provision Project, set up at the request of the GAVI Board last summer to look at all issues of vaccine supply and financing, reiterated the importance of forecasting at country level. Accurate forecasting would be essential to ensure a more predictable vaccine supply, he told health ministry representatives. ``The global forecast will only be as good as country forecasts, and this means your ability to do good forecasts is critical.''

Partners' feedback

Participants used the meeting and its many constituency break­out sessions as an opportunity to swap information and experience. Topics discussed include:

Developing countries: a knowledge exchange
Ministers from the GAVI­supported countries commended the initial period of work with the Alliance and the broad progress achieved. There had been problems with the shortage of combination vaccines, and more resources will be needed to increase safety with the introduction of auto­disable (AD) syringes and additional incineration facilities. But these problems must and can be overcome with sustained investment. The health ministry must be at the heart of each country's immunization service development to ensure sustainability. All countries would like to see accelerated progress towards vaccines against HIV, as well as more modest gains, such as reducing the costs of AD syringes. Health ministers from the GAVI­supported countries agreed that it would be useful for them to pool their knowledge and experiences in the areas of immunization and financial sustainability. Based on feedback from the meeting, Immunization Focus will in future include a new feature to foster information exchange among health ministers. Submissions for this feature will be welcomed.

Social mobilization
Participants discussed how to develop new, innovative and culturally sensitive ways to increase demand for immunization and improve service delivery. ``We need to build a better social contract with parents,'' said Susan MacKay of WHO.

Increasing access to immunization
Partners discussed ways to reach more of the hard­to­reach, with an emphasis on district planning and preferential targeting of vulnerable children, and the need for partnerships with all stakeholders.

Ways to integrate high­quality immunization services into a broader system of health services for children and parents -- such as malaria prevention and improved nutrition interventions -- were discussed as means to reduce child mortality.

Immunization Focus December 2002 - Contents

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