Viewpoint: Immunization against poverty

Abstract

In international development, paradigms shift about once every 10 years. An important shift that is now taking place is from economic development to poverty reduction. The link between health and poverty has been recognized for a long time. The traditional way of looking at this is in terms of ‘wealthier means healthier’ ( Figure 1). While nobody disputes this link, the poverty reduction focus raises the question whether investment in health is important for poverty reduction. Quantitative evidence to answer this question is now emerging and producing astonishing findings. Health and income (a) the traditional view and (b) a new paradigm. In an analysis of geography, health and other factors in relation to poverty, Gallup et al. (1998) found one of the strongest correlations between poverty and malaria. In a longitudinal analysis of health, health policy and economic performance, Jamison et al. (1998) detected important time-frame relations between investments in health, the nature of these investments and economic performance. Bloom et al. (1998) found evidence that a change between dependent and the productive part of a population, i.e. reduction in fertility and increased child survival, can lead to a spurt in economic development. This demographic gift may be one of the reasons for the economic miracle in Asia. This effect is temporary and will turn negative when the cohorts grow old. At the microeconomic level there is also strong evidence for a link. For example, the programme fighting river blindness has given a 20% return on investment ( World Bank 1993). Moreover, families with river blindness spend twice as much on health as others, and their children are twice as likely to drop out of school, girls more often than boys. In a related chronic disease, lymphatic filariasis, patients produced 30% less material per hour than healthy cotton weaver coworkers ( TDR 1996a). Thus diseases and their underlying causes can affect the economies of families in a number of ways: Reduced productivity, impediment of education or retained high dependency ratios. The emerging conclusion is that the right investment in health is at least as important as education. While further quantitative research is needed to substantiate findings, leading decision-makers are are already convinced, as illustrated by the G8 resolutions at Cologne relating to debt relief for for highly indebted poor countries (HIPC). As the communique said, ‘The central objective of this initiative is to provide a greater focus on poverty reduction by releasing resources for investment in health, education and social needs’. The resources that could be available through the new debt relief initiative if not drained away in other directions are significant. According to estimates provided by Jeffrey Sachs (1999), the amounts are about 5 billion dollars annually for over 40 countries with a population of about 750 million. Thus we are considering about $7 per capita or $120 million per country. If health were allocated half of this, health spending could amount to $60 million per country. This has come at just the right time to accelerate our development of concepts and policies. In May a meeting between WHO and international development agencies dealt with the role of specific strategies in health to achieve poverty reduction ( WHO 1999a). In education the simple notion is that poor people are illiterate, so to secure basic schooling for the poor is paramount, and indeed much evidence supports that view. Similarly, the basic assumption in health is that the first priority in is to fight diseases from which the poor suffer most, i.e. their excess burden. Further analyses of what these conditions are, their quantitative relation to poverty country by country and relative importance as targets for investment to reduce poverty have been initiated. This has now become a priority for WHO (1999b). The major conditions linked to excess burden among the poor and their global importance in terms of mortality are set out in Table 1. According to ongoing work by Gakidou and Jamison (personal communication), they all show a strong excess in poor populations. Tuberculosis is 10 times more prevalent in people earning < $1 a day; maternal mortality about eight times, and childhood mortality (< 5 years) four to five times more common in children of poor families. One effect of this poverty reduction perspective is prioritizing and focusing. Thus we are faced with a limited set of predominantly infectious diseases. The question is, then, how to address them most effectively. What are the relative merits of the available tools in addressing disease burden? How cost-effective are they and what is their potential for reaching the populations in need? Clearly we need modules of different sets of interventions and need to look for synergies. From an immunization perspective we believe that with the pneumococcal vaccine soon becoming available, about 3.5 million deaths can potentially be prevented by immunization ( Table 2). Three and a half of 12.7 million (and let us add 2.3 million equivalents for family planning) would suggest that immunization could justify use of more than 20% of the resources on this basis alone, without taking into account cost effectiveness or capacity to reach the poor. In both these parameters immunization would, of course, score very high ( Miller & Hinman 1999). Based on the HIPC calculations with about $60 million per country where on average one million children are born every year, $12 would be available per child for immunization services. One of the advantages of investing in excess burden for poor people is that the investments become self-targeting, i.e. one does not need to consider specialized services for the poor, as they are notorious for becoming ‘poor’ services. While this does not exclude the possiblity of using vouchers and other mechanisms where payments are required for systems reasons, services for those conditions could be free or almost free in a poverty reduction programme. Moreover, if one focuses on outcomes, one does not necessarily have to target investments at specific disease categories. A very good example of this comes from Ghana ( Adjei 1999). Ghana has undertaken profound health sector reforms by adopting and implementing a sector-wide approach. The government agreed with international agencies and bilateral donors that resources would be pooled and and used towards an agreed strategic framework. During 1997, &, 1998, immunization coverage has increased by about 20% (from approximately 50%–70% for measles). What are the reasons? There appear to be several: Vaccine procurement was protected in a general procurement mechanism. There was a shift in resources from tertiary care to district care. District support increased from 22% in 1996 to 39% in 1998 in national health budgets. Private healthworkers including midwives have become involved in immunization activities. This has dramatically increased the number of sites at which immunizations take place. Outreach points have increased from 7 to 11 per health facility. Immunization coverage has become an outcome measure used in the negotiation between central government and districts regarding resource allocation. The impact of health reforms on immunization in other countries appears to be mixed, but hard data is difficult to come by. Decentralization appears to have had a negative effect in many countries because central functions such as procurement suffered. In Latin America at least these effects were temporary (Ciro de Quadros, personal communication). In Uganda the reform process apparently led to the cutting of all resources of outreach services, which had a dramatic effect on coverage ( Ngoma 1999). A detailed review of the impact of sector-wide reforms is in preparation by the WHO. It is important in this context to conclude that reforms do not necessarily have a negative impact. The issue is therefore not whether the investments go into one pot or not – this will depend on the stage of reform in each country. Strategies for investments in health in relation to poverty reduction may with appropriate know-how be used to promote reforms to achieve better services rather than inhibit them. We should be able to overcome vertical in favour of horizontal entrenchment. To reach out to poor populations represents a great challenge. This is where the biggest gains of poverty reduction are likely to be achieved, as illustrated by the striking differences in coverage between routine polio 3 immunization and national vaccination days ( Table 3). Similarly high coverage has been achieved with ivermectin distribution in Africa, where quantitative randomized trials showed that a community-driven approach resulted in better coverage than health centre-driven ones ( TDR 1996b). Thus it would appear that we now have several successful models: Polio national immunization days with community mobilization; Ivermectin distribution directed by communities; Health sector reforms shifting resources from tertiary to primary care; Contracting of privately practicing midwives and other health personnel; Securing resources for mobile services including transport. The optimal mix of these would of course depend on geography and other local factors. The costing of outreach services is a priority in this perspective. They may bring up the cost of services severalfold, depending on the circumstances. Over the last 1½ years, kick-started by a meeting in the World Bank, an analysis of immunization services has taken place. The analysis showed: stagnation of immunization services globally with a decline of EPI coverage for certain countries as well as marked regional discrepancies ( WHO 1999c); newly developed, efficacious vaccines against major killers are not being introduced into poorer countries, the gap between the number of vaccines used in the ‘North’vs. the ‘South’ is widening; limited investment into vaccine research for diseases that predominate in the poorest developing countries. As a result of this analysis the major partners in the field decided to strengthen their global effort in this field, leading to the formation of the Global Alliance for Vaccines and Immunization (GAVI) in July 1999 ( GAVI 1999a). GAVI has the following strategic objectives: Improve access to sustainable immunization services; Expand use of all existing, safe and cost-effective vaccines where they address a public health problem; Accelerate development and introduction of new vaccines and technologies; Accelerate R & D efforts for vaccines needed primarily in developing countries; Make immunization coverage a centrepiece of international development efforts. The main instruments created for GAVI to advance these objectives ( GAVI 1999a) are; A Global Fund for Children's Vaccines (GFCV) with the aims of purchasing vaccines and safe injection materials, financing access, infrastructure and R & D. The fund's first priority is to secure availability of newer vaccines (Hepatitis B, Haemophilus influenza b, yellow fever) ( Figure 2); A Governing Board comprising 11 members from partner constituencies. Dr Gro Harlem Brundtland, Director General of WHO, will chair for the first two years followed by Ms Carol Belamy, Executive Director of UNICEF, for the following two years; A small secretariat to implement the directions of the Board and ensure the involvement and representation of the broader immunization community; A Partners' Working Group to ensure Board decisions are translated into operational actions appropriate to each lead agency; Task forces of limited duration to address specific issues; A biannual meeting to bring together the broader immunization community. Structure of the Global Fund for Children's Vaccines. The intention of GAVI's modus operandi is to ensure that the partners do the work and that the secretariat remains small to avoid duplication of efforts. The working group with its weekly teleconferences appears to be an important mechanism for coordination with strongly dedicated people of the main partners. The Fund became reality before the end of the year 1999 with a contribution of $150 million per year for five years from the Bill and Melinda Gates Foundation. This needs to be matched by a 30% contribution from other sources to become a charity with tax-free status. The UNICEF national committee of the US has taken on that challenge. Initially the Fund will be used to supply HEP B, HIB and yellow fever vaccines to the poorest countries with a per capita GNP < $1000. China, Indonesia and India are considered special cases because of their purchasing power and vaccine production capacity. Thus GAVI will discuss with these countries how best to support them through mechanisms other than external purchase. Countries are invited to submit proposals which will be reviewed on the basis of clearly defined eligibility criteria ( Unicef 1999b), giving considerable scope for synergy with HIPC-based investments. With an estimated $1 billion potentially available over the next five years, Figure 3 illustrates the possible disbursement of funds to sets of countries in $50 million increments. These countries would receive fully funded vaccines for three years; support would then be tapered off by 25% per year with the last 25% continuing for three years, giving a total support period of eight years. $1 Billion distributed in 4 separate $250 million trunches each starting with $50 million for 3 years. Different shaded areas relate to different cohorts of countries with different implementation rates. The cost of vaccines and safe injection material for a fully immunized child is approximtely $10. Thus $200 million will cover 20 million children, i.e. about half of the total child cohort in eligible countries. Assuming that many countries would need to strengthen their immunization services first, both in terms of infrastructure and access to qualify, the programme is being phased in to reach maximum capacity in the third year. With the Fund, GAVI has extraordinary new opportunities in relation to immunization, but if they are to materialize fully, some problems need to be resolved. Many countries targeted for this programme have low coverage of DPT3, often < 60%. Their infrastructure was eroded in the 1990s and coverage capability is limited. A substantial proportion of children may not receive a full immunization schedule. However, the polio eradication initiative greatly strengthened infrastructure in recent years. As outlined above, clear successes have been achieved in sector and community-based research. Strengthening current services is a challenge to GAVI partners already involved in supporting health and immunization services, notably the countries themselves, UNICEF, WHO, bilateral agencies and the development banks. We do not consider it likely that the GFCV will play an instrumental role here initially. GAVI will support the strengthening of existing mechanisms. HEP B and HIB vaccines will be required for newborns every year in the poorest countries. Thus their continued financing must be secured. While the costs of the vaccines is likely to continue to fall, substantial investments will be required on a continuing basis, necessitating collaboration of all parties concerned. The governments of eligible countries have a particularly important role to play: Only if it is a priority to them can bilateral agencies provide assistance and development banks concessionary loans. New vaccines, such as one agains pneumococcal pneumonia, are in the pipeline. This vaccine alone could save more than a million children from dying of acute respiratory infection. Unless we can secure the funding of currently available vaccines, we cannot ensure funding of new ones. On the other hand, if we are successful with the former, we will have a good chance to raise the resources required to introduce new vaccines. This is illustrated in Figure 4. The need to secure sustainable financing to secure funding for new vaccines. Since the last biotechnological revolution, we have seen a continuos trend towards a sharper distinction between public and private sector, which has accelerated after the collapse of the communist system. Within R & D the roles have also become more distinct: The public sector plays a key role in supporting basic, clinical, epidemiological and operational research while the private sector tends to be responsible for product development. Product development is, in part due to rules and regulations imposed by the public sector, a complex operation spanning intellectual rights related to discovery, preclinical and clinical development, production, marketing and post marketing surveillance. The driving force for the private sector is profit. Through a century of competitive development, the R & D industry has become the most effective actor in this field, and continues to undergo change to retain that competitive edge especially in a globalized market. A problem arises for unprofitable products; so far, the public sector has had to take a responsibility for these. Most who have been involved in public sector product development realize that it is difficult to match the range of expertise and competence required. Thus, if the public sector could guarantee a market that would engage the private sector, many obstacles would be overcome. This is what is called the ‘pull’ mechanism. For some products, such as the pneumoccocal vaccine which has a market in the industrialized countries, the pull mechanism does not need to be very substantial. Potential availability of $100–200 million for the poorest countries is expected to be sufficient. On the other hand, vaccines that are of greater use to poor populations and countries, such as vaccines against malaria, HIV/AIDS or tuberculosis, would require a stronger pull, on the order of magnitude of a billion dollars or more per year for at least five years. We are awaiting private sector assessments. There is considerable interest in pursuing this mechanism by the World Bank, by Jeffrey Sachs and colleagues at Harvard, and the US government. If the GFCV were to become a vehicle for such a pull mechanism, it would need to be substantially strengthened. If increased investments in vaccine R & D can be achieved, many resent discoveries and tools provided by basic science would become part of a development effort. These include identification of protective antigens selectively synthesized in vivo where tissue damage occurs; functional and structural characterization of antigens derived from genomics efforts; rationalization of the immunization process itself through improved methods for introduction and expression of vaccine DNA and selective targeting to the presentation mechanisms of the immune system ( Hoffman & Liu 1999); and simpler The most important challenge for GAVI is to that all whether in the or in the field, will as part of this effort to and health, through the use of safe