Lancet Infectious Diseases
Oct 2019 Volume 19 Number 10 p1035-1148, e337-e369
Moving towards equitable access to vaccination
The Lancet Infectious Diseases
Progress in childhood immunisations has stalled for almost a decade. According to new data from UNICEF and WHO, only 86% of children worldwide received life-saving vaccinations for diseases such as diphtheria, pertussis, and measles in 2018, with little change from 84% in 2010. The Global Vaccine Action Plan, which aims to ensure equitable access to vaccines by 2020, is not on track to meet its targets.
This stagnation hampers global health and development and is a key issue for Gavi, the Vaccine Alliance, to address in its third replenishment round from 2021–25. The Gavi investment case was launched at a meeting in Japan at the end of August, ahead of a conference in London next year where funds will be pledged by governments and other donors. The next Gavi 5-year plan calls for investment of at least US$7·4 billion (slightly down from $7·5 billion in the period 2016–20), with the objective of immunising 300 million children against 18 diseases and saving up to 8 million lives. At the same time, the governments of low-income countries that partner with Gavi will be asked to put $3·6 billion into their vaccine programmes, up from $1·6 billion in the previous period.
The Gavi plan puts a focus on immunising children who are not currently receiving adequate vaccine coverage. Almost half of under-vaccinated children live in just 16 countries, where lack of access, conflict, and displacement are important barriers to vaccination. To tackle these issues, Gavi proposes to invest $3·3 billion in strengthening immunisation systems through infrastructure development, an objective that Seth Berkley, the Chief Executive Office of Gavi, says amounts to “building out the primary health-care system”.
Another potential impediment to equitable vaccine access is the sustainability of programmes in countries that, as they become wealthier, are no longer eligible for Gavi support or low vaccine prices. Berkley has indicated that ways should be found to support countries with pricing and procurement in this post-transition period. Because of the cost of vaccines, children in middle-income countries that have never been eligible for Gavi support are now those least likely to have access to recommended vaccines—70% of the least vaccinated children will be in these countries by 2030. To help tackle this crucial coverage gap, up to 3% of Gavi’s budget will go towards vaccination programmes in transitioning and middle-income countries.
However, none of the laudable objectives of Gavi can be achieved without adequate funding. When it was last replenished in 2015, Gavi received more than the $7·5 billion it asked for. But the world of 2015 feels a long way away. The UK, Gavi’s biggest funder, was then led by Prime Minister David Cameron in a pre-Brexit era. How will Boris Johnson, freshly installed as UK prime minister, approach funding for Gavi? Johnson has questioned the budget and priorities of the Department for International Development and has mooted support for ending its existence as a cabinet-level department. The UK will host Gavi’s 2020 replenishment pledging conference—when on home soil, anything but the strongest commitment would surely be an embarrassment to the host government.
The USA provided the second largest national contribution in 2015, doubling its financial commitments, which was one of the key reasons that expectations were exceeded. President Trump’s continued commitment to the President’s Emergency Plan for AIDS Relief has been counterbalanced by a decrease in money for the Global Fund to Fight AIDS, Tuberculosis and Malaria to the USA’s lowest contribution in a decade. And then there is China, the world’s second largest economy. It committed a paltry $5 million in 2015. What prospect is there that China will embrace a more multilateral approach to global health when Gavi calls for support?
Potential donors should consider building on the great progress that has already been achieved and exploiting new opportunities. More children than ever before (116·3 million) received three doses of diphtheria-tetanus-pertussis vaccine in 2018. Global immunisation with a second dose of measles vaccine has climbed, from 39% in 2010 to 67% today. Switching to Pneumosil, a new, cheaper pneumonia vaccine could free-up $1 billion.
Achieving global equitable vaccination will boost economies, improve global health security, and help achieve the Sustainable Development Goals: not just those related to health, but also poverty, inequalities, education, and more. A well funded and strategically astute Gavi is essential to reaching this goal. It needs strong support now more than ever before.