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2001 contents page
THE IDEA EXCHANGE
Dont be distracted from good routine
Catriona Waddington opens a debate
on whether GAVI and governments have got their priorities right
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
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
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
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 vaccinesseem
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
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