Like many people my, age I carry a small childhood scar on my left shoulder, an indication that I was once vaccinated against smallpox. In the villages of Tanzania, such scars used to act as a form of branding, a sign of an otherwise invisible gap that existed between those of us fortunate enough to have been immunized against that deadly virus and those who were tragically still at risk. As the scars now fade, so too does the memory of smallpox, thanks to vaccines. Nevertheless, today immunization gaps persist across Africa for many other diseases, and because of this we still see nearly three million children dying needlessly every year.
It is true that great progress has been made in recent years to increase the coverage of childhood immunization across the continent, and this has helped to halve childhood mortality since 1990. But it is also true that one in five children in Africa are still not fully protected against vaccine-preventable diseases. This must change. Not just because it is our moral duty to protect all children, but also because ultimately doing so can help us to bring an end to poverty.
This may sound fanciful, but there is growing evidence to support such a claim. The power of vaccines to save lives and prevent disease is already well known. What is less widely understood, however, is that immunization also offers broader economic benefits which can help boost economies. A healthy child does not need costly healthcare and medical treatment. A healthy child’s parents are in a better position to go out to work. And a healthy child is able to attend school and become a more productive member of society. The latest research suggests that in the world’s poorest countries, every dollar invested in vaccines translates into US$16 in immediate healthcare savings, and US$44 in longer-term economic returns.
It follows that we simply cannot fail to increase immunization coverage if we want to achieve our goals for the African Agenda 2063. Failing to address the inequities that prevent children from being vaccinated could help exacerbate the economic gaps which exist among individuals, communities and even nations. We saw this recently, first with Ebola and now with yellow fever, where the effects of infectious disease were amplified by weak health systems and felt not just in terms of human suffering but also long-term economic impact. By allowing immunization gaps to endure there is a real danger that individuals, communities and nations missing out on life-saving vaccines will continue to fall behind, not just in terms of their health but economically too.
The good news is that there is plenty we can do to close these gaps and plenty of progress to build upon. Since 2000, routine immunization in Africa has risen considerably, with the percentage of children receiving all three doses of the most basic vaccines – diphtheria-pertussis-tetanus (DTP3) – increasing from 57% in 2000 to 80% by 2014. The impact has been remarkable. With millions more children getting access to immunization, the number of cases of vaccine-preventable diseases, like measles and meningitis, has fallen in many countries. Indeed, Africa has now gone nearly two years without a single case of wild polio (since 24 July 2014). This is a huge milestone and a significant step towards eradicating a disease that until recently was paralyzing 1,000 children globally every day.
However, increases in national immunization rates can conceal actual decreases in coverage that exist in pockets of marginalized communities. Often the children who are still missing out are not just the last to be reached; they are also the hardest to reach, living on the very edge of societies, from remote rural regions to urban slums.
This is evident if we assess progress towards the goals of the Global Vaccine Action Plan (GVAP), the global health community’s 10-year vision, as well as the Regional Vaccine Action Plan (RVAP). By 2014, as many as 23 out of the 54 countries in Africa had already reached the GVAP 2020 target of 90% national coverage for receiving three shots of DTP. However, only nine had achieved the second target of at least 80% DTP3 coverage in every district – a clear indication of disparities within countries.
So, if we are to succeed in the task of reaching these children, then we will need to do more. One of the biggest challenges lies in the supply chain. In many parts of Africa, the entire vaccine distribution system is in great need of either improvement or extension, or both. Equipment is often faulty or non-existent, transport is less than optimal, there is a lack of staff and a lack of staff training, accountability and quality data. Currently, in low-income countries around 20% of health facilities that need cold chain equipment don’t have it; of those that do, many of the installed devices do not work. Where equipment does work, in the majority of cases it works very poorly, with 60% running the risk of damaging vaccines by exposing them to excessive freezing or unacceptably high temperatures.
Moving more doses of vaccines through existing supply chains will place an ever-greater strain on their already faltering equipment and resources. So improvements are even more urgent if we are to successfully increase access to immunization. After all, we would not just be reaching more children, but also reaching them with increased numbers of new and underused vaccines, to ensure protection against infectious diseases not already covered in national programmes.
Countries like Mozambique have already taken great strides towards this end with the introduction of new supply chain systems. Initially introduced in one province, the system proved so successful that it has now been rolled out to serve half the country. Such examples are extremely encouraging, but the sheer cost of such wide-scale improvements can nevertheless act as a deterrent to governments with struggling economies – even though modernizing the supply chain can translate into significant long-term savings through the use of more energy-efficient equipment.
Organizations like the World Health Organization, UNICEF and Gavi, the Vaccine Alliance, can help, and indeed have already played a major role in increasing immunization coverage. In my own country, Tanzania, we doubled the number of vaccines given to children in just 14 years, something that would have taken considerably longer if it wasn’t for Gavi’s catalytic support.
Besides working tirelessly to bring down the prices of existing vaccines, the Vaccine Alliance has accelerated access to new vaccines, such as pneumococcal and rotavirus, which provide protection from the biggest killers of children, pneumonia and diarrhea. The human papillomavirus (HPV) vaccine has also been made available to girls in 21 African countries, thanks to Gavi, providing protection against the biggest cause of cervical cancer. Without the Vaccine Alliance’s support, it could have taken more than a decade before the price of these vaccines came down sufficiently to become more affordable to low-income countries.
Now, Gavi is applying the same public-private partnership business model to help improve supply chains in poor countries. As part of its new supply-chain strategy, Gavi is now looking to stimulate innovation in and improve access to the latest cold chain technology by providing incentives to manufacturers.
While all of this presents African nations with a golden opportunity to close immunization gaps, it will not be successful without country ownership. African Health Ministers already understand the importance of immunization. In addition to supporting GVAP, in 2014 they committed to Universal Health Coverage in Africa. Several also signed up to the Immunize Africa 2020 Declaration.
However, it will take more than their support and more than declarations to achieve these goals; it will require action throughout government. It is only by acting together and speaking with one voice that we can truly bring about change. From heads of state and prime ministers, to ministers of finance, we all have a role to play, whether that involves becoming a champion of immunization or ensuring that vaccines are a line item in budgets. MPs, civil society, religious and community leaders must also do their part to strengthen demand for vaccines, to hold governments to account and to ensure that policies are implemented.
We already know what immunization can do in terms of saving lives and securing promising futures for children. I have seen this first-hand in my own country, Tanzania. But it is important to recognize the economic benefits too; between 2011 and 2020, the majority of countries in Africa will collectively see a net economic benefit of US$224 billion by investing in immunization programmes . Immunization is truly an investment, not just in the health of a nation’s future – its children – but also in its economic future.
Former President of Tanzania and Global Ambassador for Immunisation.
Executive Director, International Trade Centre