GAVI Partners Gather to Assess Progress, Plan Future Activities
By Saul Walker
The Global Alliance for Vaccines and Immunization (GAVI)(1) was founded almost 3 years ago to reinvigorate basic vaccination coverage as a central element of sustainable development in poor countries. From 19-21 November 2002, over 300 participants from developing nations, donor agencies, industry and NGOs gathered for the second GAVI Partners meeting in Dakar, Senegal, to review progress, identify challenges and discuss ways forward.
The scale of the challenge they face was emphasized in a report launched at the meeting by WHO, UNICEF and the World Bank. The State of the World’s Vaccines and Immunizations(2) estimates that vaccines save 3 million lives each year but that a further 3 million could be saved through improved vaccination coverage and better access in developing countries to a wider range of vaccines. The report highlights major inequalities in access to immunization services across the world: For example, while DTP vaccination rates average over 70% globally, in sub-Saharan Africa they reach only 53%, with some countries below 20%.
The meeting began with a strong statement of political commitment to reverse these dismal trends, with Ministers of Finance from 13 developing countries signing the “Dakar Declaration”(3). The agreement commits signatories to continuing efforts to improve immunization in their home countries, and calls upon governments around the world to recognize that sustained vaccination efforts are “a national priority, a global concern and a shared responsibility.”
In the opening plenary presentation, GAVI Executive Secretary Tore Godal reviewed the achievements of GAVI and its sister organization, the Vaccine Fund(4), which raises money and then disburses grants for vaccination programs. Since its inception, GAVI has distributed 180 million doses of vaccines (primarily Hepatitis B, DTP, HiB and yellow fever) and 200 million auto-disabling syringes, the latter to improve immunization safety by preventing re-use of injecting equipment. To date, 66 countries have had applications approved for GAVI support totalling $900 million, of which $130 million has been disbursed. As a result of these activities, GAVI estimates that over 100,000 lives have been saved.
Godal emphasized that the power of vaccination to prevent disease and reduce mortality means that vaccine expenditures should be considered investments rather than costs. In this respect, he said, the world still greatly undervalues immunization as a tool for health and development.
Underscoring this point, Vaccine Fund President Jacques-François Martin pointed out that the sustainability of these efforts is far from assured: GAVI will use up all the money in its coffers by 2006, and further financial commitments are urgently required. At the same time, grantee countries and international donors must find ways to sustain the programs launched with GAVI funds, which provide a five-year catalyst grant (with the release of funds along the way dependent on vaccination milestones being achieved). GAVI is now working closely with recipient countries to develop sustainability plans for improved vaccination programs.
Ensuring Vaccine Supply
A key issue addressed both in the report and by several conference speakers is the growing difficulty in guaranteeing a sufficient, dependable supply of vaccines for developing countries. Over time, unpredictable demand, low profit margins and a move to higher-priced new vaccines in developed country markets have reduced the number of manufacturers producing basic vaccines—from 8 to 4 in the past four years, according to Carole Bellamy, UNICEF’s Executive Director and Chair of GAVI’s Board of Directors. So, as GAVI has successfully increased demand for vaccines, demand threatens to outstrip supply (see Figure 1)—with the result that programs for DTP and tetanus toxoid have already been scaled back for 2003, and several other programs are also in jeopardy. In view of the escalating shortage, said Bellamy, UNICEF is now reviewing its procurement policies—recognizing that pushing for the lowest possible prices can be counter-productive in the end if it drives manufacturers out of the basic vaccines market and endangers long-term security of supply.
Fig. 1: Source: Divergence of products for public sector immunization programmes. Milstien, Julie, S. Glass, A. Batson, M. Greco and J. Berger. Presentation to the Strategic Advisory Group of Experts of WHO’s Department of Vaccines and Biologicals, Montreux, 15 June 2001. www.VaccineAlliance.org/reference/ppt/sage136.ppt. DTwP contains whole-cell pertussis vaccine.
Manufacturers based in middle-income countries, particularly India, have increasingly stepped in to fill the gap and are now supplying the majority of basic vaccines used by developing countries. However, the few such producers pre-qualified by WHO (in terms of meeting Good Manufacturing Practice standards) still cannot reliably meet demand. Consequently, much discussion at the meeting focused on how to improve long-term forecasting of the demand for basic vaccines (against which manufacturing capacity can be scaled), increase the number of pre-qualified middle-income country manufacturers and increase industry confidence that a sufficient, predictable return can be made by producing vaccines for developing countries.
Middle-income country manufacturers at the meeting emphasized their willingness to play a bigger role, but pointed to some of the challenges they face. According to Luis Saturnino Herrera Martinez of the Developing Countries Vaccine Manufacturers’ Network(5) and the Cuban vaccine manufacturer Centro de Ingenieria Genética y Biotecnologia (CIGB), access to new technologies, capital investment and changing regulatory requirements are key concerns.
Building Effective Delivery Systems
The problems of ensuring that vaccines actually reach those who need them were highlighted by workshops looking closely at the logistics and realities of vaccine delivery—which account for up to 70% of the actual cost of immunization programs (see Figure 2). Stock management, transportation, cold chain maintenance, safe injection practices, record keeping and waste disposal all present major challenges in countries with minimal healthcare infrastructure or trained staff, and where numerous health demands compete for a very small pot of money. Many speakers highlighted the need for greater support at this level as essential to the success of immunization programs.
* Based on a selection of in-depth developing country-specific costing studies.
** The share of vaccines varies, depending on different country vaccination schedules, and will be greater with the introduction of new vaccines.
*** Personnel costs are likely to be the main cost driver of immunization programs. These costs vary across countries depending on differences in wage levels and whether shared personnel costs are included.
Source: State of the World’s Vaccines and Immunization, 2002. A joint publication of the WHO, UNICEF and World Bank
Increasing Access to New Vaccines
As it looks forward, GAVI hopes to play a key role in bringing not only basic childhood immunizations but also new vaccines into developing countries. To this end, GAVI has recently launched Accelerated Development and Introduction Programmes (ADIPs) that will implement strategies to develop, produce and introduce new vaccines for rotavirus and streptococcus pneumonia(6) Raj Shah of the Bill and Melinda Gates Foundation presented the ADIPs as the next stage of GAVI’s role in catalyzing the continued strengthening and development of vaccination programs in developing countries.
Looking further ahead to AIDS vaccines, IAVI President Seth Berkley gave an overview of progress and challenges in the field, while a panel of speakers from GSK Bio, IAVI and the Program for Appropriate Technology in Health (PATH) considered the future challenges for HIV, TB and malaria vaccines. Panelists emphasized the importance of building a solid foundation for effective immunization programs, not only for today’s vaccines but for future ones as well. Walter Vandermissen (GSK Bio) spoke for many industry participants in commenting that the world’s willingness and ability to use current vaccines in developing countries are key to improving industry confidence that there will be future markets for these new vaccines. “Such confidence is essential in influencing R&D decisions today,” he said.
Saul Walker is IAVI’s European Policy Coordinator, based in London.
1 www.vaccinealliance.org/ home/index.php
2 State of the World’s Vaccines and Immunizations. WHO/ UNICEF/ World Bank, November 2002. www.who. int/vaccines-documents/ DocsPDF02/www718.pdf