Are global vaccination programmes helping the most needy?

The debate on the skyrocketing price of vaccines is hotting up. Medecins Sans Frontiers have recently criticised the Global Alliance for Vaccines and Immunization (GAVI) for removing vaccine subsidies from countries that remain in need of aid. GAVI - a public-private partnership between UN organisations, the vaccine industry and the Bill & Melinda Gates Foundation amongst others - negotiates vaccine price reductions of up to 95% for developing countries. It also contributes to the cost of purchasing the vaccine. GAVI argues that withdrawing support from countries as their economic situation ensures their support is appropriately targeted. However, with a majority of the world’s poor living in middle income countries, does removing support from countries that make marginal economic advances really help those in greatest need?

In 2015 17 countries will ‘graduate’ from GAVI support, due to marginal rises in their per capita income. These countries will see dramatic increases in the amount they need to pay to pharmaceutical companies for their vaccination programmes. MSF highlight the case of Honduras, which will see a 1000% increase in the amount it pays for PCV and rotavirus vaccines (which prevent meningitis, pneumonia, and severe gastrointestinal illness). The country currently pays $1.43 for the vaccines, but this will leap to $15.50 in 2015.

The problem with GAVI’s approach is that it ignores distribution of income. Countries with high levels of economic inequality may see rises in their per capita income, but that revenue remains concentrated within a small section of society. According to the World Bank, Honduras has the world’s most unequal economy. Other countries set to lose GAVI support, such as Bolivia and Angola, are almost as unequal. By removing support from these countries, GAVI are making the poorest members of these countries liable for income enjoyed only by their wealthy elite.

A report from the Center for Global Development has pointed out the problems with this approach: “New vaccines that are often available in low income countries, such as those against rotavirus, pneumococcal disease, and Hib, have yet to be introduced in many middle income countries.”

One of the study’s authors, Amanda Glassman, criticised the withdrawal of GAVI support from lower middle income countries: “The sheer numbers of unvaccinated children may explain why we see frequent vaccine-preventable disease outbreaks in Lower Middle Income Countries and why it has been difficult to eliminate polio in some of these countries, for example.”

Globally debate between NGOs, governments and pharmaceutical companies on how to make vaccines affordable is intensifying, as the costs charged by pharmaceutical companies skyrocket. The price of some vaccines has risen2700% in a decade. MSF’s vaccine policy adviser Kate Elder told the Global Vaccines Summit in April 2013: “Looking at this upward trend we are highly concerned if things continue to go in this direction it will threaten the sustainability of immunization programmes.”

This price rise is not entirely a like-on-like comparison: the number, quality and technology of vaccines have also seen significant improvements over the last decade. NGOs like MSF argue that such developments mean aneven greater need for collaboration between organisations to ensure that the financial and logistical challenges of supplying vaccines are met. The challenges of reaching remote communities, maintaining the ‘cold chain’ to preserve the vaccine, and being able to afford the medication mean that lives are threatened by organisational delays.

Even if GAVI will not contribute to the cost of purchasing the discounted vaccine with graduating countries, it has been suggested that they could at least allow certain governments to continue to purchase the vaccine for themselves, using the discounted rate negotiated by GAVI.

However, GAVI may be reluctant. Their unwillingness to extend the discounts they receive to other organisations has already been criticised by Medecins Sans Frontiers, who are campaigning for GAVI to allow MSF and other NGOs to have permission to access vaccine discountsnegotiated by GAVI.

In response, GAVI said it was ‘addressing the issue’ but that it would be a lengthy process to avoid offending the pharmaceutical companies supplying the discounts. GAVI added“Obtaining such low price agreements with vaccines’ manufacturers for the world’s poorest countries is only possible when there are stable forecasts, long-term commitments to large volumes with secure financing agreements from donors and recipient governments working together. Any adjustment to the current way of working will require careful consideration and the support of key constituencies.”

MSF is arguing that GAVI has not been making enough progress, saying “We ask GAVI to fast-track this process so that MSF can vaccinate more kids as soon as possible.” As MSF and other NGOs are in a position to efficiently provide vaccines alongside their other medical services, their argument that allowing them access to GAVI’s discounts would save lives is persuasive.

The financial benefits of vaccination programmes are also significant, with a study from the Center for Disease Control estimating that, for every dollar spent on vaccination programmes, six dollars are saved in direct medical costs. Including indirect costs of failure to vaccinate, such as loss of productivity, a dollar investment can create an eighteen dollar return. Furthermore, the World Health Organisation estimates that 3 million people a year currently die due to vaccine-preventable diseases: decreasing the viability of vaccination programmes will worsen this situation.

GAVI and many other organisations and governments have had notable successes in the fight to provide vaccination services. But without adequate strategies to ensure that ‘graduating’ countries and established NGOs can access the discounts negotiated by GAVI, the temperature of the debate is set to rise.