One of the most difficult issues in global health is how to increase access to medicines, vaccines and technologies. But achieving access is not everything – once access is obtained, the challenge is how to sustain it. These issues are the focus of research we are conducting in collaboration between the Chatham House Centre on Global Health Security and the London School Hygiene & Tropical Medicine.
Improving access to vaccines in developing countries is essential for achieving the Millennium Development Goal of reducing the number of deaths among children under five. The GAVI Alliance (Global Alliance on Vaccines and Immunisation), a global partnership of governments, donors, global institutions and the private sector, plays a key role in co-ordinating these efforts. The Alliance sets global priorities in immunisation, co-ordinates efforts to raise and distribute funds, and seeks to use its influence to lower vaccine prices.
At its recent conference in London, GAVI succeeded in raising $4.3 billion to continue the expansion of its programmes up to 2015. The Alliance is currently seen as a good investment for donors. DFID’s recent review of multilateral institutions ranked it near the top based on its organisational strength, value for money and contribution to the UK’s development objectives. GAVI has also been the favourite vehicle for innovative financing mechanisms funded by donors.
However, a key challenge for GAVI over the coming five years will be to make progress towards a more sustainable global system for immunisation. That means driving vaccine prices down and ensuring that countries take greater ownership and prioritise the purchase of their own vaccines.
Reducing prices is key to sustainability. GAVI needs to do more to innovate and apply pressure in addressing this challenge. GAVI has already convinced pharmaceutical companies to sell their existing vaccines at lower prices. We are looking at how donor funds can be used to ensure cheap supply lines for newer vaccines. For example, the Meningitis Vaccine Project (MVP) channeled donor funds and provided expertise to the Serum Institute of India Ltd, who in return will produce a new low-cost Meningitis A vaccine for 10 years at an initial price of $0.40 per dose, just above the cost of manufacture. This mechanism, whereby donor funds are used to support a specific set of activities towards a goal, is known as a “push” mechanism.
In contrast, a “pull” mechanism provides an incentive to companies to invest in meeting a specified goal, however they see fit. In 2007 the governments of Italy, UK, Canada, Russia and Norway, and the Bill & Melinda Gates Foundation committed $1.5 billion to incentivise manufacturers to supply pneumococcal vaccines for developing countries at a low price. The donor funds will be used to supplement the purchase price for a limited period. This initiative is known as the advance market commitment for pneumococcal vaccines. Two major pharmaceutical companies, GSK and Pfizer, have signed contracts to supply 30 million doses of new pneumococcal vaccines for 10 years at prices much lower than those paid in wealthier nations.
Both initiatives negotiated commitments from suppliers to provide new vaccines at a low price, although there is controversy as to whether the maximum price for the new pneumococcal vaccine was as low as it could have been. Also, the deal currently only involves the two biggest pharmaceutical companies in the world. More could be done to engage low cost suppliers in the developing world who have helped to push down the prices of other routine vaccinations.
GAVI is seeking to reduce the pressure on its international donors and increase commitments from recipient countries. But progress to date has been slow. While GAVI set out in 2000 with the goal of being time-limited, there is little prospect of achieving this. A recent independent evaluation was critical of GAVI’s approach to sustainability, suggesting that its choice of vaccines and its basic funding model have had a negative impact on countries’ ability to finance vaccines in the longer term. In particular, while GAVI’s decision to include new and more expensive vaccines has driven its success in saving lives, it has also driven its failure to move towards sustainability.
GAVI’s challenges have grown with its success. To maintain its alliance between donors, recipient countries and the private sector will require a complex balancing act. Over the next five years GAVI must make progress on sustainability as well as maintain its commitment to providing cheap vaccines.
Contributed by Dr. James Hargreaves, Senior Lecturer in Epidemiology at the London School Hygiene & Tropical Medicine, and Research Fellow, Centre on Global Health Security, Chatham House.