In the fourth paper in the Series, Dr Orin S Levine (International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA) and colleagues discuss the future of immunisation policy, implementation and financing.
The authors applaud the Expanded Programme on Immunisation (EPI) which has saved millions of lives, with support from WHO, UNICEF and other donors. Estimates suggest that vaccines avert more than 2•5 million child deaths a year and, if vaccine coverage was increased prevention of up to 2 million additional deaths per year might be possible. But the authors say: "Diseases such as pneumonia, diarrhoea, meningitis, and measles, which are currently preventable by vaccination, still account for about a quarter of child deaths in low-income countries."
They add: "New vaccines are likely to be more complex and expensive… Deciding which new vaccines a country should invest in requires not only sound advice from international organisations such as WHO but also a well informed national immunisation advisory committee with access to appropriate data for local disease burden."
Practical challenges to achieving the full impact of immunisations include improving the timeliness of vaccination and educating parents to improve their understanding of the benefits and issues surrounding vaccination. Reaching all people with immunisations requires strengthening delivery systems by improving human resources, and management of finances, information and supplies. Quality surveillance of vaccine effectiveness is essential for vaccines to have the continued backing of populations and policy makers, and yet, these systems are underfunded or absent for many of the new vaccines.
Levine and colleagues also discuss how the high cost of many vaccines is hindering vaccine access everywhere. In the USA, the cost to fully vaccinate a child has risen from $155 in 1995 to $1170 in 2007, and reimbursement and insurance schemes have left up to 14% of the country's children underinsured for all vaccines. In developing countries, challenges are even more stark. Many African countries are currently struggling to find about $0•50 per dose to purchase a new meningococcal serogroup A conjugate vaccine for prevention of epidemic meningitis and are asking donors to support this vaccine's cost.
Concerns are also raised by Levine and colleagues that middle-income countries will struggle to be included in the successes of the next decade in vaccines. They are not the poorest countries so will not qualify for aid from GAVI; and do not have the ability to self-finance like high-income countries. They say: "Most of the world's impoverished individuals are now living in middle-income countries…Resolution of financing issues for middle-income countries might also affect sustainability of financing for low-income countries through the GAVI Alliance. For example, if lower prices meant that more countries would finance their programmes with national funds, then fewer countries would need GAVI Alliance support and donors would be better able to sustain the GAVI Alliance's funding."
The authors conclude: "Financing of new vaccines and systems for their delivery are stronger than ever before but have more challenges... Novel methods are needed to finance the increasing number of new vaccines that have the potential to save lives in countries that are too poor to afford them."
Dr Orin S Levine, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Please e-mail to arrange interview. E) olevine@jhsph.edu
Journal
The Lancet