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Don’t be distracted from good routine immunization

Catriona Waddington opens a debate on whether GAVI and governments have got their priorities right

ON the same day, three things happen. In a West African country, a small girl is immunized during a high-profile National Immunization Day. In an East African country, a young boy receives the vaccine against Haemophilus influenzae type B (Hib) – which his Ministry of Health has only just started giving. And in a Southern African country, a district public health official urges caution over the support of National Immunization Days (NIDs) and so-called "under-used" vaccines.

Given that neither the boy nor the girl would have received these immunizations without NIDs and the introduction of under-used vaccines, why would anyone take the stance of the health official?

The official was right to advise caution. Whilst NIDs and new vaccines for a country can be exciting, there is a real danger that they distract from the core immunization task – to have a strong health service which can give generation after generation of children the six basic immunizations on a routine basis.

Many countries still have much to do to increase coverage of the basic six immunizations – for example, the average coverage with three doses of diphtheria, tetanus and pertussis (DTP3) in countries receiving GAVI funds is currently only about 65%. The district public health official favours concentrating on increasing coverage of the basic six immunizations. She worries that the introduction of new vaccines may be a distraction from this priority. And she is concerned that countries may be investing disproportionately in NIDs at the expense of their routine services.

What has this got to do with GAVI? GAVI and the Vaccine Fund currently allocate money through two main "windows" – one for new and under-used vaccines, the other to strengthen existing immunization services. Funds for existing services are not for the vaccines themselves – they are to strengthen the existing system. The money might be spent on the cold chain, training or transport, for example. In rounds 1 and 2 of GAVI funding, $51.2 million was allocated. Of this, 83% was for new and under-used vaccines and only 17% to strengthen existing services. Put another way, most of the money is being used to pay for vaccines, rather than in developing countries to strengthen the vital routine services. Is this the balance we really want?

GAVI does not have a particular policy on NIDs – each country has its own policies. But the Alliance has argued that access to all vaccines can be improved by learning the lessons of NIDs in the Polio Eradication Initiative(1). And many countries are already using NIDs alongside routine services to increase coverage with measles vaccine. The danger is that there is "NID-creep" – in other words, that the role of, and reliance on, NIDs gradually becomes broader and broader.

Arguing in favour of routine sounds rather dull. Why should routinely available services – defined here as appropriately trained health staff with the requisite resources, accessible to a population – be so important?

Here are four reasons:

  • By its very nature, immunization for children requires a strong health system. Each child needs several contacts with the health system to be fully immunized and there is a constant stream of newly-born children who need immunizing. The job of maintaining a "fully immunized population" is therefore a never-ending one requiring sustained effort. So countries with low rates of immunization need to develop their routine health services – in the end, this is the only way that children can be sure of being fully immunized.

  • At their best, NIDs are great – they can be fun, exciting and productive, in that many children turn up (or return) for immunizations. Moreover, they can play a vital role in eradicating diseases. But a downside to NIDs can be their power to disrupt. A large NID can use up the time of many people (and the availability of equipment such as vehicles) for weeks – and it can be very expensive, particularly if health staff receive extra payments for their extra work. So these NIDs have a hidden cost – the price of distracting nurses and other resources from regular immunizations. And the public is also distracted – there is a danger that immunization is seen as a special event, rather than one that happens automatically when a child reaches the appropriate age.

    This is not to argue against all NIDs – of course they have a place for immunizing very hard-to-reach populations or to "catch up" when some children have been missed. But NIDs are rarely an alternative to supporting the health system's routine work – indeed if the routine system works, there is no need for them.

  • Caution about the "under-used" vaccines is necessary because we have to be sure that they are the best buy for countries with small government health budgets. The six basic vaccines are relatively cheap and their cost-effectiveness is widely accepted. But how does, say, Hib compare with spending money on malaria control, TB drugs or condoms?

    Difficult choices have to be made – just because an effective drug or vaccine exists, it doesn't mean that it is a good buy for a government. The international community is currently promoting the importance of a number of public health measures – there also need to be clear messages about how to prioritize among the many important claims on expenditure.

  • Finally, the boy in East Africa received one of the "under-used" vaccines which GAVI supports. Without GAVI, he would probably not have received it. But we still need to be cautious – is there a risk that vaccinating for Hib may start and then stop when GAVI funding ceases? In the past, before GAVI, there have been examples of immunization starting and stopping after funds dried up. There are few public health benefits from a short-term vaccination programme and there are negative effects on the morale of health workers and the public if it stops. Some may lose trust in vaccinations as a result. Hib is a relatively expensive vaccine – is it realistic for us to expect continuity?

On the face of it, NIDs and new vaccines seem attractive. But the biggest challenge of all is to immunize all the world's children with the most cost-effective vaccines and then to build on this regular system by adding new vaccines, as they are developed and as they become affordable. The public health official may be arguing a difficult point, but she is probably right that in the long term, strong routine immunization will be the most effective way to reach our shared goal of improving child survival and health.

Catriona Waddington is a health economist and consultant on GAVI to DFID, the UK government's Department for International Development.

Equity is the key to our policy: Tore Godal responds

Immunization Focus March 2001 - Contents

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