Vaccines need to reach the poor in middle-income countries too
Gavi’s funds should also be targeted at middle-income countries because that’s where the majority of unvaccinated children live
The world’s top aid donors met on Monday in London to replenish the Global Alliance for Vaccines and Immunisation (Gavi), netting a remarkable $4.3bn in the midst of a historic recession, to scale up immunisation programmes in the run-up to 2015 and the millennium development goal (MDG) timeline.
Gavi has increased vaccination coverage in the poorest countries of the world, known by the World Bank’s country classifications as the low-income countries (LICs, or those countries of annual income of about $1,000 or less per person), while receiving top marks for management and accountability.
Middle-income countries (MICs) are now home to the majority of the world’s unvaccinated children. Household survey data indicates that complete vaccination rates are substantially lower in MICs than LICs overall, and that the poor fare worse – a point hidden when one looks at average vaccinations data for a country.
China and India represent a chunk of the problem, with 33% of all unvaccinated children under one-year-old. Yet even excluding China and India, another 47% of unvaccinated children live in middle-income countries, with only 17% living in low-income countries. The sheer numbers of unvaccinated children might explain the frequency of outbreaks of vaccine-preventable diseases in MICs and the difficulties in eliminating polio. Without intervention, these differences may become more pronounced over time.
Gavi funds countries with a gross national income per capita of less than $1,500 so it does fund middle-income countries up to a point. Then, as countries pass the $1,500 threshold, Gavi graduates them from financial support after a three-year transition period. In 2015, 17 countries – currently Gavi’s largest recipients – will be phased out completely. As a result, some current MICs are eligible for Gavi, others are recent graduates while still others have never been Gavi-eligible.
MICs are a diverse group – some, like India, are dynamic but with large numbers of poor people; other are fragile states like Pakistan, and others are barely MICs, like Ghana.
The reasons for lagging vaccination programmes are complex. In some countries, the cost of the vaccine and fiscal capacity to increase public spending remains a challenge in spite of increases in national income. In others, the quality of governance and political will are obstacles.
While few donors like the idea of financial support for countries that can theoretically pay for themselves, there are good reasons to invest in vaccination in MICs. “Herd immunity” (the threshold for vaccination rates above which disease cases become highly infrequent) against most vaccine-preventable diseases benefits all countries by reducing the frequency of imported outbreaks.
Increasing the number and volume of vaccine purchasers can help to further reduce vaccine prices and increase the number of manufacturers in the market over time, facilitating access to vaccines for all countries. While MICs “should” invest in the health of disadvantaged populations, the reality is that it is not always happening; in these circumstances, targeted grant-making to MICs, to support civil society advocacy or to launch a new vaccine, could make more of a difference to a cohort of children and leverage scaled-up vaccination.
It’s worth remembering that working in MICs could allow for efficiency gains; MICs have most capacity to rapidly introduce a new vaccine and assume its financing over time, thus benefiting a large number of children at a lower cost, while LICs have lower-capacity health systems, will require long-term funding for new vaccines and – given their smaller populations – will benefit fewer children. Finally, where the elimination of a disease is a goal – as with polio and measles – work in MICs is essential.
Gavi is thus at somewhat of a crossroads.
In one direction, Gavi could maintain its current model, phasing out countries and working itself out of business. This sounds good for financially strapped donors, but it fails to meet the global public health objectives that were the rationale for the creation of Gavi.
In another direction, Gavi could develop targeted engagement with MICs, applying an algorithm to allocate funds based on needs, resources and capacity to deliver, while using results-based financing (like cash-on-delivery) and increasing country co-financing to create incentives for rapid and sustained increases in vaccination coverage and partner with the World Bank to generate lending for vaccination.
Finally, using its position as a public-private partnership, in countries with major governance and capacity constraints, Gavi could rethink its role as a national government counterpart to work directly with sub-national governments and non-governmental organisations to increase vaccination rates among the poor – or create new civil society accountability mechanisms that ask bigger questions about why, if a country has the financial means, its government is not (yet) delivering for the poor?