New Bottom Billion and Vaccination, Part II

Earlier today, Bill Gates met with the Norwegian Prime Minister Jens Stoltenberg to talk about scaling-up immunization efforts in advance of GAVI’s June 13th pledging conference. I’ve blogged about GAVI and the need for greater financing for vaccinations a number of times over the past few months and want to follow up with some new ideas from readers and myself from my last post.A few weeks ago I looked at WHO figures on DTP3 by country income group and size of the cohort of one year olds. The data show that the lower middle-income countries (LMICs) are home to the largest absolute numbers of unvaccinated children. However, WHO data relies mostly on administrative reports of unknown quality, sometimes reporting number of doses purchased or shipped instead of children actually vaccinated.I’ve now looked at the gold standard source—Demographic and Health Surveys (DHS) data since 2004—to examine the situation of timely and complete vaccination for age in low-income countries (LICs) versus LMICs, adjusting for the size of each country’s population. These data are only representative of those 37 countries with a DHS and do not include the large LMIC like China and South Africa. See our spreadsheet here.The share of children with timely and complete vaccination is much larger in LICs than in LMICs.

Income Group	Child's age
	12-23 months	24-35 months	36-47 months	48-59 months	Total
Low income (20 countries; percent)	58.56	57.91	52.25	52.37	55.37
Lower middle-income(17 countries; percent)	43.86	43.11	41.06	40.48	42.16

On the one hand, this is great news. The poorest countries—with the help of GAVI and its partners—are immunizing the majority of their children on time and with the full schedule of immunizations. These results also belie the assumption that a strong health system is a pre-requisite to deliver immunizations in a timely manner.On the other hand, in the LMICs—where the largest numbers of children under five years old reside, vaccine-preventable disease burden is largest and health systems are relatively strong—on average, less than half of children are completely immunized according to age. There aren’t many upper middle-income DHS to examine, but the few that are available suggest that the situation is more similar to the LMICs than to the LICs!Further, as I mentioned in my comment to the original blog, new vaccines such as rota and pneumo—and in some cases Hib—are not yet introduced in most LMICs.What to do? Blog readers and yours truly have a number of ideas:

• LMIC governments’ own priority-setting processes need to be better understood, supported and developed. By priority-setting, I mean the process by which existing and new vaccines are considered and adopted for public funding and how population coverage decisions are taken. In most settings, this is a very ad hoc process.  (I’ll blog on this topic more in the coming months.)
• Civil society watchdogging and/or community accountability needs to be improved. Colombia has an interesting initiative where they post vaccination coverage rates on the doors of schools, churches and community centers as a way to increase awareness of the need to vaccinate. Global efforts to rank and score countries on vaccination programs may also be useful to create reputational incentives.
• The World Bank and regional development banks social and health policy lending could include conditionality and support for minimum vaccination coverage rates. Should the international community really invest in anything else until more than half of children are fully vaccinated? Can a government be expected to efficiently procure and oversee major infrastructure investments if they can’t vaccinate the majority of their young children? Some LMICs are still eligible for IDA—should a minimum vaccination rate be a condition for receipt of IDA funding (as it is for the MCC)?
• Even if some GAVI-eligible LMICs failed to take advantage of the lower GAVI price, there may be appetite for regional pooled procurement of vaccines, modeled on PAHO’s Revolving Fund for vaccine purchases (without the lowest price clause). GAVI could play a role here as the organizer of an LMIC window—consolidating purchasing without providing funding, but regional organizations could be a viable alternative.

Thanks to Juan Ignacio Zoloa for research assistance.