British Medical Journal
1 October 2011 Volume 343, Issue 7825
http://www.bmj.com/content/current

Editor’s Choice
Why don’t we know how much vaccines cost?
Fiona Godlee, editor, BMJ
[Free full-text]

The Global Alliance on Vaccines and Immunisation can be proud of what it has achieved. As Sophie Arie reports, it has prevented more than five million premature deaths since it started in 2000 (doi:10.1136/bmj.d5182). It has also attracted huge amounts of funding, reflecting the confidence of major donors, so it’s well set to meet its target of saving a further four million lives by 2015.

But GAVI has prominent critics, raising challenges for its incoming chief executive officer, Seth Berkley, who is interviewed this week by Rebecca Coombes (bmj.com/podcasts). At issue is GAVI’s current strategy. Could it use its vast resources more effectively? Is it right to focus on access to new vaccines against rotavirus and pneumonia for children in countries that can afford to contribute financially? Or should it help the very poorest countries building health systems so their children can get basic vaccines against diphtheria, tetanus, and pertussis? Most vexed of all, is GAVI paying too much for vaccines? Could it vaccinate even more children with the funds it has been given if it negotiated a better deal from the industry?

Most of the vaccines acquired by GAVI and then bought by Unicef and other agencies come from the major vaccine manufacturers; GSK, Pfizer, and Merck. But as Arie explains, there is growing competition from emerging markets, notably India and China, where manufacturers can in some cases produce vaccines for less than half the standard price. This is in spite of GAVI getting vaccine manufacturers to agree to charge substantially less if they are paid in advance.

The major manufacturers have the important advantage of being able to provide rapid and reliable supplies. GAVI is clear that delays in supply cost lives. But one thing has introduced more competitive edge. Against fierce resistance from the major manufacturers, Unicef started publishing the prices for the drugs and vaccines it buys. This revealed substantial profits, in one case of around 180%.

So what about western governments’ decisions to buy vaccines? The UK must shortly decide which vaccine to buy if it is to continue its vaccination programme against human papilloma virus. The programme has been a success, according to René Verheijen (doi:10.1136/bmj.d5720). Coverage is on target at around 80% and the evidence on efficacy and safety is strong. But which is the most cost effective vaccine? In 2008 the UK chose the bivalent vaccine Cervarix. Compared with the quadrivalent vaccine Gardasil it provides greater protection against cervical cancer, but no protection against anogenital warts. As Mark Jit and colleagues reported in their modelling study in 2008 (BMJ 2008;337:a769) and again in an updated study this week (doi:10.1136/bmj.d5775), the bivalent vaccine is only cost effective if it is substantially cheaper. However, as Verhiejen says, because the price of the vaccines is confidential we don’t know whether the right decision has been made. “In the end then, the key determinant of cost effectiveness is the only factor that cannot be evaluated.”

Unicef’s brave decision to publish the price of the drugs and vaccines it buys has changed the conversation on global health. Why don’t governments, purchasing drugs and vaccines on our behalf, show equal courage

International Health : How should GAVI build on its success?
Sophie Arie
BMJ 2011;343:doi:10.1136/bmj.d5182 (Published 8 September 2011)

Extract
Immunisation programmes supported by GAVI have prevented more than five million deaths in a decade, but critics argue that the alliance could do more to bring prices down and help the most vulnerable countries. Sophie Arie reports

There are not many development organisations these days that can say they have raised the full amount of funding they need to meet their goals. But GAVI, the Global Alliance for Vaccines and Immunisation, is in that happy position only 10 years after it was created.

At GAVI’s first pledging conference in June this year, public and private donors pledged $4.3bn (£2.7bn; €3bn), bringing the alliance’s funds for 2011-15 to a total of $7.6bn. With that, the organisation says, it can achieve its aim of immunising more than 250 million of the world’s poorest children against life threatening diseases, thus preventing more than four million premature deaths by 2015. 1

Geneva based GAVI, which brings together governments of developing and donor countries, UN agencies, the World Bank, major philanthropists, and the drug industry, has prevented more than five million deaths since it began work in 2000, according to its 2011 progress report. 2

But can donors be sure that the money pledged will be spent in the best possible way? Could GAVI be vaccinating more children and saving even more lives if it did things differently?

Price concerns

Everyone agrees GAVI has made huge achievements and that vaccination is a highly efficient form of development aid. The knock on effects on the economies of recipient countries are huge in terms of children being able to attend school and become productive adults and their parents being able to work rather than care for sick and dying children.

The UK Department for International Development’s assessment of multilateral development organisations showed that GAVI was the best value in …