Injecting reality into immunisation
Claiming blanket protection of children without accurate data is playing it fast and loose with lives, writes Daniel Berman and Gregory Hussey.
South Africa claims with pride its status as a middle-income country and an economic powerhouse leading the way in Africa. But it seems that when it comes to saving the lives of young children through routine immunisation we are far behind neighbouring countries. By 2010, South Africa was already spending R1.2-billion a year in vaccine procurement, but its child immunisation coverage rates still remain surprisingly low – lower than Malawi, which has 8% of South Africa's per capita income.
Last week, Médecins Sans Frontières South Africa questioned whether the South African system was working at the first International African Vaccinology Conference hosted in Cape Town.
For Médecins Sans Frontières and others concerned about immunisation the facts are clear: young South African children are not receiving basic immunisation and the costs are too high. South Africa is also overpaying for vaccines while underspending on programme support.
Discrepancies between department of health-issued vaccination-coverage data and official estimates by the World Health Organisation and the United Nations Children's Fund are alarming. The department claims that 96% of South African children have been reached by benchmark triple vaccinations against diphtheria, whooping cough and tetanus, but the international organisations are reporting a rate of 72%. The reasons for this discrepancy require urgent attention.
The estimate for Malawi's coverage is 97%, whereas Angola, with half of South Africa's gross national income per capita, has 86% coverage. Compared with other middle-income countries such as Brazil, which has a vaccination rate of 96%, South Africa also fares poorly.
It is time for an honest appraisal of the state of affairs. Accurate and valid data is critically important to determine good baseline indicators so that we can measure progress. We are strongly encouraged to hear the health department talk of doing national vaccine-coverage surveys to see which children are really receiving which vaccines. But these discussions need to be backed up with a solid action plan and budget.
Without collecting the data from the right sources and properly assessing it to know where the gaps are, it is near impossible to strengthen the country's expanded programme on immunisation. At present, it is as though we are playing a dangerous game of darts in the dark, blindly hoping to get the right shot without actually seeing the target.
However, these disappointing results are not because of a lack of spending. South Africa is paying the highest prices for vaccines anywhere in the developing world. The country pays R161 a dose for the new anti-pneumonia vaccine, three times the price paid by most other donor-supported African countries through the Global Alliance for Vaccines and Immunisation. Because this vaccine requires three doses, the cost of vaccinating each child is R483.
Imported vaccine prices are inflated because they are exclusively handled by a public-private partnership that levies a 10% to 15% handling fee. The fee is meant to fuel the local development and production of vaccines, but it has so far had little impact on stimulating specific vaccine development and production in South Africa. To its credit, the health department has called for an end to the subsidy of "local" production through high prices and has rightly urged the trade and industry minister to offer direct support for product development instead.
Direct support has been successfully used by other countries and institutions and played a large part in the development of a new affordable meningitis vaccine (MenAfriVac), which is now being rolled out in West Africa at only R4.30 a dose. But the department can do more.
Human resource capacity
In recent years there has been a focus on the introduction of new vaccines, such as those designed to prevent pneumonia and life-threatening diarrhoea, which has created an imbalance in immunisation strategy. Although new vaccines create an unprecedented opportunity to save more lives, they reach vulnerable children only when the vaccine programme is working. An anti-pneumonia vaccine that costs R483 a child is no more likely to reach those who need it than a measles vaccine that costs just a few rands. Simply adding new vaccines without ensuring that the weaknesses of the immunisation programme are addressed is a mistake and a false economy. It just does not make sense to import expensive vaccines if we are not going to invest in bolstering human resource capacity at all levels: improving the management, training, data collection and collation, surveillance and monitoring, and evaluation of the immunisation programme and expanding the cold-chain capacity with additional fridges in clinics.
It is vital that the health department conducts a national survey on the coverage of its expanded programme on immunisation to determine the true coverage at national, provincial and district levels. Clinic workers should also be empowered to monitor coverage in their own catchment areas.
But we cannot expand access to vaccines if we do not have a ground-up approach in which people in communities have a voice and understand the importance of immunising their children. Effective communication between providers and recipients (in this case, the caregivers of children) is essential to ensure success. In the fight against HIV/Aids, we learned that those affected had to know about the science and policy behind the virus and know and demand their rights. We need the same groundswell on immunisation because it affects everyone sooner or later. Vaccines are vital to saving the lives of children and an effective immunisation delivery system is essential to achieve this goal.
Daniel Berman is the general director of Médecins Sans Frontières. It works in 68 countries worldwide and vaccinated more than six million people in 2011.
Professor Gregory Hussey is an infectious diseases specialist and is the director of the Vaccines for Africa Initiative at the University of Cape Town