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2001 contents page
THE IDEA EXCHANGE
be distracted from good routine immunization: Catriona Waddington
opens a debate on whether GAVI and governments have got their priorities
Equity is the key to our policy
Tore Godal responds
are all agreed that the biggest challenge is to immunize all the
world's children. We are striving to achieve equity. And that means
doing two things. First, we need to reach out to all children. Second,
we need to narrow the gap between children in the richer countries
and children in the poorest. In industrialized countries, a child
can now expect to receive vaccines against 11 or 12 diseases. In
the poorest countries, children will be protected against six or
seven diseases if they are lucky.
We have learnt some lessons. Despite
the spectacular gains in routine immunization coverage with the
basic six vaccines in the 1980s, progress was not maintained in
the 1990s and, by the end of the last decade, one in four children
was still not receiving those six vaccines routinely. Business as
usual did not seem to be enough; new incentives were needed if coverage
was to increase. GAVI is trying to create such incentives, both
for strengthening existing services and for the introduction of
new and under-used vaccines.
Catriona Waddington raises concerns
about National Immunization Days. As far as this relates to GAVI
policy, let me be clear: the Alliance is first and foremost about
strengthening routine services. The positive side of NIDs is that
they can, and do, reach out to virtually all children(1).
To our knowledge, they are the only approach that achieves this.
If we are serious about equity, we must support governments' use
of immunization days as a means to reach the unreached, but only
for this purpose, and as a complement to a good routine service.
We know that NIDs can have negative
effects on the routine service. They must be planned as a regular
programme in effect, they can be incorporated into the routine
system. Disruption to the rest of the system can, I believe, be
reduced if, where appropriate, immunization days are conducted at
regional level rather than nationally. Recent analyses have suggested
that a planned programme of immunization days can actually help
to strengthen a health system(2).
Equity is also at the heart of GAVI's
push to give more children access to new and under-used vaccines
such as hepatitis B and Hib. Many middle-income countries are using
these vaccines now, but they are still strikingly absent from the
poorest countries. There are of course real questions about how
such countries can sustain the resources to buy these vaccines.
Realistically, the poorest countries are going to need international
support for their immunization programmes until they move out of
the poorest bracket, and that is why the Alliance is working hard
to find mechanisms by which such support can be sustained beyond
the five years we're committed to.
The vaccines are more expensive per
dose than the traditional six vaccines, but they are cost-effective
in terms of their cost per healthy year of life gained. And, in
terms of their cost per capita, they can be justified even where
public spending on health is below $10 per person per year. But
we know that even routine immunization with the basic six vaccines
is not maintained in the poorest countries if international support
falls away. So all of us recognize that the international community
has a duty to maintain its support, while governments have a responsibility
to convince donors of the case for doing so.
question of how GAVI and the Vaccine Fund have allocated support
between the purchase of new vaccines and the strengthening of existing
services is an important one. The GAVI Board has already noted its
concerns about the balance of resources disbursed in the first two
rounds. It is currently determining whether corrective measures
need to be taken, for example by increasing the size of the "share"
awarded to each child in the birth cohort, or by expanding the criteria
for which countries are eligible for support to strengthen their
Dr Tore Godal is Executive Secretary
Every Child. Gavi Strategy for Sustainable Immunization Services.
(2) Disease eradication:
friend or foe to the health system? http://www.who.int/vaccines-documents/DocsPDF00/www552.pdf
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