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We Must Correct Imbalanced Global Investments Within the World of Immunization

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In recent years, the world of immunization has been dominated by a focus on life-saving vaccines and the prevention of individual diseases. The global community has launched what is being called the "Decade of Vaccines." Not a week goes by without a major medical journal publishing articles with exciting news on the development, efficacy, value, supply, and financing of new vaccines.

Last month, the World Health Assembly (WHA) meeting in Geneva roundly endorsed a new Global Vaccine Action Plan. The WHA also declared a public health emergency to complete the eradication of polio, now 12 years past its original target date of 2000. Elimination of measles is a goal in five of six World Health Organization (WHO) regions and global measles eradication is being increasingly proposed.

Relatively lost in all the excitement is recognition that vaccines do not deliver themselves. A robust vaccination program functioning within the health system is required to achieve and sustain our ambitious goals. If we want to eliminate and eradicate disease, smoothly introduce new vaccines across an expanded life cycle, increase vaccination coverage among all target groups to close the equity gap, reduce mortality to achieve the Millennium Development Goals by 2015, and sustain those gains beyond 2015, the global community must recognize that the fundamental platform -- the vaccination program itself -- must be better supported and reinforced.

The vaccination program must routinely reach people of all ages with potent vaccines in a safe, effective, affordable, and timely way before exposure to disease. To accomplish this in many countries with weak health systems is a developmental challenge as much as it is a disease control challenge.

And yet routine vaccination services receive very little financial support from the best-known of the global initiatives. Approximately 85 percent of GAVI Alliance investment goes to the procurement of vaccine. For the past 10 years, about 90 percent of the vaccination budget of the WHO Regional Office for Africa has gone just to the eradication of polio. What little fat there might have been in routine vaccination programs has long disappeared, and we are now burning muscle.

Health staff must have the knowledge and skills to translate global policies at national and sub-national levels into customized solutions that will work within the local context. Health staff and commodities must be available and services conveniently offered. Supply chain systems and transport must function so that the right amount of supply is continually present at the right place at the right time. And political and social will at all levels must be mobilized to meet recurring operational costs day in and day out -- not just for the next event on the horizon. None of this can be taken for granted. As long as children are born, they must be vaccinated.

At the local level, families and communities must receive counseling to be made aware of and value vaccination services, so that they perceive them to be of sufficient quality and will want to return to complete all of their doses. They must know where and when to come for services. They must be treated affably and with respect by health workers. To retain the continued trust and involvement of individuals and the community is an old challenge that requires a systematic focus on improving the quality and predictability of services.

In most developing countries, strengthening the performance of routine vaccination services, as part of a functioning health system, is still required to achieve and sustain uniformly high and equitable vaccination coverage, reach disease and mortality reduction targets, integrate new vaccines, and realize the vaccination program's potential to serve as a platform for other population-based health interventions.

This week's Call to Action for Child Survival in Washington, D.C. provides a rare opportunity for world leaders, Ministries of Health, global agencies, bilateral partners, and civil society as a whole to direct urgent attention not just to increase but also to re-balance current and future investments so as to overcome the long-standing, identified weaknesses in routine vaccination programs. This will be critical to protect the investment in both "traditional" and expensive new vaccines, preserve the gains of the past, realize the potential to meet the Millennium Development Goals by 2015, and sustain those achievements beyond the midway point of the Decade of Vaccines. Let's seize this opportunity.