GHF2006 – PS08 – Access to Vaccines: Obstacles and Solutions

Session Outline

Parallel session PS08, Thursday, August 31 2006, 11:00-12:30
Chair(s): Paul-Henri Lambert, Switzerland & Jean-Marie Okwo-Bele, Switzerland
Access to Vaccines: New Approaches
Jean-Marie Okwo-Bele, Immunization, Vaccines and Biologicals, WHO, Geneva, Switzerland 
Immunization: Obstacles to Financing
Jacques-François Martin, President, Parteurop, Lyon, France
New Life for an Old BCG
Stefan H.E. Kaufmann, Immunology, Max Planck Institute for Infection Biology, Berlin, Germany

Session Document

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Session Report

Submitted by: Patricia de Guzman (ICVolunteers); Contributors: Irene Amodei (ICVolunteers), Tatjana Schwabe (ICVolunteers)

This 2000 photograph depicted a mother holding her child, while displaying a polio vaccination record that indicated the child having been properly vaccinated. Image courtesy Chris Zahniser, B.S.N., R.N., M.P.H., a STOP Transmission of Polio (STOP), The Public Health Image Library (PHIL)

More than 2,600,000 deaths have been prevented in 2003 thanks to the Hepatitis B vaccine currently available. This is only one impressive example of the benefits of good vaccination and immunisation programmes. Although vaccination programmes are very cost-efficient, costing as less than 1,000 USD per life saved, the world still faces over 100,000 neonatal tetanus deaths and over 400,000 deaths from measles per year. The international community has a very ambitious plan: to completely eradicate diseases which are preventable by global vaccine coverage. How can such a goal be accomplished?

According to Mr. Paul-Henri Lambert, co-chair of this symposium, vaccine development is 10 to 20 years ahead of drug development. Although vaccines are the first step in ensuring global access to health, many challenges, especially with regard to finances, remain. The symposium reviewed the implementation of immunisation at a global level, addressed the financial issues regarding the implementation of vaccine programs, and analysed the availability of new vaccines to understand whether research is helping to facilitate access, specifically in the context of tuberculosis vaccines.

Dr. Jean-Marie Okwo-Bele, the Director of WHO Department of Immunisation, Vaccines and Biologicals in Geneva, Switzerland, first presented the global progress achieved so far and then discussed the challenges faced with respect to access to immunisation services. Vaccines have been widely used since the 1970s and continue to be one of the best health investments for various reasons, including their safety, sustainability, and high cost effectiveness. The Global Immunization Vision and Strategy (GIVS) is helping to achieve the goal of reducing vaccine preventable childhood mortality by 25% by the year 2015. The following provides a quick summary of some immunisation advances achieved so far:

  • DPT (diphtheria, tetanus and pertussis)Progress with the level of DTP3 combination vaccine coverage has been good, increasing from about 20% in the early 1980s and to over 70% in the mid-2000s. The number of countries in which DTP3 coverage remains below 50% has decreased by half within the last 15 years.
  • MeaslesGlobal measles mortality for all ages has been reduced by half within a 15-year period from 1999 to 2004 to currently just over 400,000 deaths per year. The dramatic decline in the number of reported measles cases (91% reduction) in 19 African countries from 2000 to 2003 is attributable to accelerated measles control activities. Four regions (the Americas, Europe, the Eastern Mediterranean and the Western Pacific) have set measles elimination goals and two regions (Africa and Southeast Asia) will try to reach measles mortality reduction goals. The overriding global goal established by the World Health Assembly was to reduce measles deaths by half by the year 2005.
  • Polio While polio prevention has not been reaching the set target dates, good progress is still being made. Polio presently exists only in some districts within about 10 countries and efforts are being undertaken to completely eradicate this disease in the near future. One possible reason why prevention targets have not been achieved was raised during the question and answer session question. It is possible that either a generalized vaccine is being administered efficiently, but is not fully effective for an entire population or that only a small portion of the population is not receiving the vaccine, thus creating a pool for new infections.

Overall, vaccination and immunisation activities have achieved success due to good partnerships and governance, and strategies among institutions ranging from the local to the global level. Dr. Okwo-Bele reminded the audience of several problems to be addressed in order to ensure global vaccination.

1. Access to immunisation services

Child survival intervention through vaccines remains low. 50% of all cases of severe pneumonia can be prevented by Hib and Pneumo vaccines. It is speculated that such vaccines could more easily administered than community-based management of pneumonia which reaches less than 20% of children. Several programmes have successfully addressed the challenge of reaching every district in a country. Through mobile and outreach services in Sudan, nearly 60% of children were immunized in 2005. In some African countries, the Reach Every District (RED) strategy has improved the number of districts with DPT3 coverage, by re-establishing outreach services, supportive supervision, community links with service delivery, monitoring and use of data for action, and the planning and management of resources. In the Democratic Republic of Congo, the Ministry of Health's Expanded Program on Immunization (EPI) implemented the RED strategy in 161 of 515 districts in early 2003, resulting in a substantial decline of the number of not immunised people. Although these results are encouraging, they remain insufficient. Better immunisation coverage particularly in East and Southern Africa, is needed and could be achieved through a mix of interventions such as "nationwide packages."

2. Access to technology

Ensuring availability of vaccines in developing countries with weak infrastructure.

3. Ensuring financing

The cost of immunisation is on the increase, and spending has recently doubled, especially to fund campaigning efforts. Certain countries can not afford these expenditures. Adult vaccination, an issue which was raised during the discussion, could already be dealt with by the logistics currently in place but can not be funded at the moment.

4. Management

Due to the increasing complexity of immunisation programmes, efficient management becomes more and more of a challenge.

Mr. Jacques-François Martin, President and CEO of the consulting company Parteurop, focused his presentation on the importance of financial tools in the implementation of immunisation strategies. He presented the Global Alliance for Vaccines and Immunization (GAVI), one of the first major public-private partnerships (PPP) to have emerged at the end of the 1990s. The GAVI Fund, whose president Mr. Martin was from 2000 to 2004, aims to attract different partners and bringing together various stakeholders in order to circumvent the lack of political will and the weakness of country-level management, which can be major obstacles to global vaccine coverage. Mr. Martin pointed out that GAVI acted as a catalyst by mobilizing people and resources, including industries, and openly dealing with possible conflicts of interest. He stated that "GAVI attracts, not receives money, and this happens because of its strong vision." The result is that the GAVI Fund has so far raised 1,704.39 billion dollars between 1999 and 2005, and 1.6 billion is expected between 2006 and 2015. While Mr. Martin praised the achievements of the GAVI Fund, he also raised the political issue involved: Is it acceptable for a PPP such as GAVI to receive half of its global financing for its immunisation activities from a single private source, namely the Bill and Melinda Gates Foundation?

He concluded that these new financing tools (also including for example the International Finance Facility proposed by the UK government) represent a valuable resource for immunisation projects because they are sustainable and have been conceived with long-term programme management in mind, and they operate with a notion of accountability for the proper expenditure of donated funds through self-monitoring of their performance.

Important challenges, however, still lie ahead, such as the high price of the new vaccines which are or will soon be introduced in developing countries (e.g. HIB, Pneumo, Rotavirus, HPB), the new risk related to the possible emergence of pandemics and, most of all, the need to vastly increase funding dedicated to vaccines.

Mr. Martin suggested some strategies which could improve the financing of immunisation and vaccination programmes:

  • prioritizing planning and forecasting, taking into account that it takes one year to produce a newly launched vaccine
  • advanced purchase commitments
  • tiered vaccine prices, meaning the strategic use of price differentiation based on consumers wealth in a system agreed upon by the global society

Concerning the last point, Mr. Martin conceded possible complications such as parallel imports, coexistence in different market segments in one country, difficulties in convincing emerging economies to accept an intermediate price, problems of a potential monopolistic condition. However, he affirmed that with a strategic allocation of costs it should be possible to address all direct costs to rich countries in order to sell vaccines to developing countries at near marginal costs.

Concluding, Mr. Martin stressed the importance of a global and integrated approach, where investment in immunisation and vaccination is not only a simple means of prevention but also a way to improve the health care system in general.

Prof. Stefan H. E. Kaufmann, an immunologist at the Max Planck Institute for Infection Biology in Berlin, Germany contributed a detailed scientific presentation on the historical use and current improvement of BCG (Bacillus Calmette-Guérin), the vaccine that protects against severe forms of childhood tuberculosis, and the future potential of a new and better generation of BCG. This new vaccine (rBCG delta ureC-Hly), based on recombined M bovis BCG, is particularly efficient to prevent pulmonary tuberculosis in adults and has been licensed to a private company for vaccine development (Vakzine Projekt Management GmbH). Mr. Kaufmann offered his field experience to illustrate one successful pattern that, if supported and properly tested, could help decrease the occurrence of a disease that every year affects around 8 to 9 million people, causing up to 2 million deaths. He was convinced that the new vaccine which his group is helping to develop has advantages and could potentially help make access to TB vaccines easier.

In sum, as Dr. Okwo-Bele stated, the immunisation agenda is an ambitious one. However, more progress is expected, given the experiences and momentum achieved so far. To sustain progress, strong national health systems are needed and investments must be made to increase access to services and provide adequate levels of supplies.

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