Staying on trackSome of the poorest nations are moving mountains to immunize their children, while other comparatively wealthy nations seem unable or unwilling to do so. The world as a whole is not doing all it can to make vaccines available to the children who need them. That is not only a failure of leadership -- it is a moral outrage.Immunizing children is not a matter of charity, it is a matter of fulfilling a fundamental human right. Countries that ratify the Convention on the Rights of the Child, the most widely ratified human rights treaty in history, are required to "ensure to the maximum extent possible the survival and development of the child" and must take "appropriate measures ...to ensure the provision of ...health care." These rights became tangible goals at the World Summit for Children in 1990, when the leaders of over 70 countries promised to reach and sustain coverage levels of at least 90 per cent against the main vaccine-preventable diseases by the year 2000. When something becomes a right, it means that every child is entitled to it, not just those who are easy to reach. So national immunization plans must address not just the first 80 per cent but also the last 20 per cent: institutionalized children, children living on the streets, the hill tribe children in Thailand, the Romanies in Bulgaria and Romania, the isolated villagers in Nigeria. Many developing countries made spectacular progress throughout the 1980s. But some are finding it difficult to keep up the momentum, and extremely hard to go the extra mile needed to reach the remaining children. Togo, for example, managed to push its measles rate up to 65 per cent in 1995, only to see it fall to 48 per cent in 1996. Guinea-Bissau's rate fell from 65 per cent in 1994 to 53 per cent just two years later.
Such figures lie at the very core of sustainability. A country needs the enduring capacity to immunize each new generation of babies; to bolster the health infrastructure, the staff and the supply of affordable vaccines to keep up the system year after year. But, like the refrigerators and other parts of the 'cold chain' bought during the massive immunization drive of the 1980s, momentum is showing signs of wear in some quarters. The technical and political structures must be maintained or immunization rates will plummet, with disastrous results. That is why the Children's Vaccine Initiative, launched in 1990, is setting out to improve the world's supply of existing vaccines. Originally the brainchild of five sponsoring agencies -- WHO, UNICEF, UNDP, the Rockefeller Foundation and the World Bank -- the Initiative is now stimulating a global dialogue among governments, donors, vaccine manufacturers, researchers and immunization programme managers. Another way forward is the vaccine-financing strategy, which UNICEF and WHO launched in 1994, which encourages governments to assume responsibility for their own vaccine needs. The strategy establishes financing targets based on relative wealth per capita so that donor funds can be concentrated on the neediest countries. Countries are grouped in tiers, ranging from the very poorest, such as the Lao People's Democratic Republic and Mozambique, which pay only a token share of vaccine costs, to countries like Malaysia and Turkey, which received assistance only for the first year and are now self-supporting. By 1996, 25 per cent of the poorest countries were meeting their minimum targets for vaccine self-sufficiency, compared with only 2 per cent in 1990, as were 90 per cent of the countries where assistance was phased out. Many countries are paying for or producing their own vaccines, including Brazil, China, Egypt, India, Mexico, Pakistan, the Philippines and most countries in South America. Developing countries now produce more than half the vaccines used for national immunization programmes. Uganda, one of the world's poorest nations, is financing about 35 per cent of basic vaccines. Even in the midst of political and social upheaval, Burundi has managed to continue its support for vaccine funding, contributing $50,000 towards the cost of immunization in 1997. A new scheme for vaccine financing has been launched by the European Union, together with the Governments of Burkina Faso, Cape Verde, Chad, Mali, Mauritania, Niger and Senegal, to ensure that national budgets have a specific line item for vaccine purchases. To encourage this effort, the EU is providing support directly to these countries' national budgets, which now include vaccines as an integral part of overall health expenditures. This support for immunization cannot be cemented into the foundation of the worldwide immunization effort without the unshakeable political commitment of each country's leaders. These leaders must assess their priorities and examine the true value of a vaccine -- to a child, to a family, to a nation. The world needs to ask how is it possible that something so cost-effective and readily available is not reaching every child. Missing the poorest The new vaccines present great challenges as well as opportunities. At current levels, funding will be insufficient to get them to the countries that are home to the poorest 10 per cent of the world's children and that bear the heaviest burden of disease. Donors contribute around $21 million each year to these countries for the six original antigens. The addition of the vaccines for hepatitis B and yellow fever would push this bill up to $70 million. Add Hib and rotavirus vaccines, and one to tackle pneumococcal disease, and the price rises to at least $381 million. With the cost of overhauling the cold chain to keep vaccines at the right temperature, improving delivery capacity and supporting safe injection procedures, the world is looking at a total bill of $700 million each year. That $700 million may sound expensive -- but it comes to just 12 cents per person worldwide. Compare that to the $139 per person spent globally on the military machine in 1996 and the world's priorities become clear. In a $28 trillion global economy, economic resources are not the issue -- priorities are. So far, the countries of the world, developing nations and donors alike, simply are not doing all they can to get this medical miracle to the children who need it. We in the public health community have a duty to bring this outrage to the world's attention. The lives of millions of girls and boys are in our hands.
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