Opening remarks by Daniel Berman, General Director, Médecins Sans Frontières / Doctors Without Borders (MSF) South Africa (MSF SA)
Let’s be honest: Vaccine data, pricing, and adaptability in Africa
Thank you for the introduction, and the opportunity to participate in this distinguished panel.
I’m pleased to be here today for the first international vaccinology conference to take place in Africa, and as a representative of MSF, or DoctorsWithout Borders, South Africa. Given that more than one-third of the world’s total number of unimmunised children live on the African continent, the significance of having this conference on African soil should not be under-estimated.
We at MSF believe that vaccine policy and practice have been too topdown. Its people like you—clinicians, nurses, programme managers, researchers and civil society from across the continent—that best understand the challenges to improve the reach and quality of immunisation.
We also strongly welcome the international vaccine experts and hope that this conference informs their work.
In order to tackle the challenges we face in vaccination programmes in Africa, it’s important that we are honest about the current state of affairs.
I can tell you at MSF, we are not satisfied with our own performance. Yes, we are very good at responding to outbreaks with vaccine campaigns, but we have major room for improvement in routine immunisation. Our two critical gaps are missed opportunities in vaccinating kids that come to clinics where we are working, and a lack of attention to coverage rates in our catchment areas. Since we do not have national responsibility we need to be humble about the challenges that you all are facing in terms of your national programmes.
We know that many of you are under pressure from national politicians and international funders to report better and better results. Let’s be honest coverage rates in many countries are exaggerated.
But, if we do not know our real baseline, how can we improve the situation?
If coverage rates are reduced to reflect the reality on the ground, we can then work together to see how to practically overcome barriers. We think that the current emphasis on new vaccines such as PCV, rotavirus, and HPV, need to be balanced with attention on improving routine vaccination. This may require changes to EPI approaches and new adapted tools. For example, an aerolized measles vaccine that would not require cold chain. But the first step in acknowledging EPI failures will require political will. Since political will is so important we are disappointed by the absence of a panel member tonight.
I had hoped to speak after hearing remarks from South Africa’s Minister of Health. Given his extraordinary commitment to rolling out the National HIV/AIDS Programme and his stated objective of improving primary health care as the backbone of the new National Health Insurance, his presence would have given us a sign that South Africa is serious about improving coverage rates.
I had hoped to hear about a blueprint for a stronger EPI to help South Africa reach ambitious mortality reduction goals.
When South Africa was one of only 12 countries in the world where child mortality was increasing, the Minister of Health spoke out and acknowledged how far the country needed to go. We appreciate his courage to speak the truth.
The country has taken steps to reverse this trend, but today, in the Minister’s absence, I worry that political and practical commitment to strengthen the country’s EPI may not be strong enough.
And, if we’re honest, the numbers we have on South Africa’s vaccine programme are worrying. Based on data analyzed by the World Health Organization and UNICEF, South Africa’s coverage data are significantly worse than data from countries with lower Gross National Income and less developed national health care systems.
According to WHO/UNICEF data, South Africa coverage of DTP3 in 2011 was only 72%. This is in comparison to Angola, a country with half the Gross National Income but a DTP3 coverage of 86%. And Malawi, where the GNI is a tenth of South Africa’s, but DTP3 coverage is 87%.
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 and vaccines are now one of the most expensive line items in the country’s health budget. We need to ask why this is so.
Recent government data diverges substantially from the numbers published by the WHO and UNICEF. But the accuracy of South Africa’s data is in serious question. Accurate and valid data is critically important. It tells us how many children’s lives are being saved, and how many are unnecesarily at risk. In addition, a well functioning EPI is an indicator of the health of the primary care system.
In order for South Africa to roll-out National Health Insurance effectively, and specifically to strengthen primary health care, we need good baseline indicators so that we can measure our progress. South Africa is not alone. Across the continent we see a lack of accurate data being reported. We struggle to know what the real situation is on the ground. For example, we recently looked at coverage data in one state of South Sudan: BCG coverage was 669%. We would all agree that this is a nonsense number.
We also see large differences between the recently-published 2011 coverage data from WHO/UNICEF and their 2010 estimates. For example, DRC’s DTP3 coverage estimates rose to 70% in 2011, up from 58% in 2010. But what we see on the ground in the DRC is dramatically lower coverage rates.
Across the continent we need to ensure that we’re collecting the right data, and properly assessing this data, to know where gaps lie and how to effectively strengthen EPI programmes. Without doing so, it’s like we’re playing darts in the dark, blindly hoping to get the right shot without actually seeing the target.
Throughout our next few days together, I hope we can speak honestly about the data we do have, what weaknesses these show, and our priorities for collecting additional data.
South Africa can set an example. We strongly urge the Department of Health to conduct EPI coverage surveys. This would be a first step towards understanding the true state of EPI in South Africa. These surveys would fit nicely into the Health Minister’s effort to put a renewed focus on primary health care.
We have seen significant political and financial commitment nationally and internationally in the last several years. Examples are the Decade of Vaccines and the GAVI Alliance’s multi-billion dollar investment in new vaccines. But many African countries are still struggling to ensure good coverage with the basic EPI vaccines. We think too sharp a focus on new vaccines has created an imbalance.
While some new vaccines give us an unprecedented opportunity to save more lives, we believe that adding new vaccines without simultaneously addressing the weaknesses of EPI is a mistake.
If an EPI system is not functioning, a GAVI-purchased $7 dose of pneumococcal conjugate vaccine is just as unlikely to reach a child as the .20 cent dose of measles.
Twenty-six GAVI-eligible countries in Africa have already introduced or have a plan to introduce PCV within the next year. But let’s ask the difficult questions: Does it make sense to introduce PCV in a country like Niger with only 22% of children being reached by vaccination services?
And these new vaccines are expensive. While most GAVI-supported countries have their new vaccines mostly paid by donors, non-GAVI countries such as South Africa have been left to fend for themselves. They must negotiate themselves with companies and procurement agencies. Pricing information is unacceptably difficult to get. In no other health commodity are prices so opaque and contracts so secretive.
With information that is available we see that Botswana is paying 5-10 times more for their pentavalent vaccine than the UNICEF supply division price. South Africa had been paying $30 per dose for PCV. Prices have since become more transparent. In its newest tender for PCV, South Africa was able to consider internationally available prices, and successfully reduce the PCV price per dose down to $20. This is significant progress, but the price is still nearly triple the price being paid by GAVI, and more than what WHO’s PAHO region pays.
We have demonstrated that pricing transparency helps reduce cost, and we are going to continue to push for this. We can start in South Africa.
For the past decade vaccine tenders have been handled by a public-private partnership called BioVac. They have not been handled by the Department of Health or Treasury. Biovac procures all of the country’s vaccines, and charges a 10-15% handling fee. That fee is meant to help fuel local development and production of vaccines. But so far this system has not led to vaccines being developed in South Africa.
The Department of Health has suggested that it’s time to to stop subsidysing local drug and vaccine production through high prices. A better system of encouraging local production would be direct support from the Department of Trade and Industry to high-priority vaccine delevopment projects in the Department of Health. This financing system has been used successfully, for example the development of the new Menigitis A vaccine, which is sold at an affordable price.
Prices are a problem. We now know that South Africa pays more for vaccines than other countries in the region, and more than most countries in the developing world.
This begs the question: is this system working for South Africa?
Besides keeping our eye on prices, we think we also need to use our collective buying power to push for adaptation of vaccines. One example that I have already mentioned is aerolised measles vaccines. Another example is MSF’s research arm, Epicentre, and their clinical trial to look at the impact of one dose of PCV in a wider age range.
We can no longer accept that vaccines are developed for European and American disease burdens and health care systems. Things like heat stable vaccines, schedules with less doses, and non-needle based administration are critical issues. Industry is well represented here today. Do they have product adaptation research agendas? We know Merck is adapting their rotavirus product, but are there other examples?
There is no shortage of topics for us to discuss and debate during our time together this week. Central to ensuring that these issues are addressed, and addressed properly, is the question of advocacy, and especially community-led advocacy. We can’t expand access to African-appropriate vaccines if we don’t have a ground-up approach in which people in communities have a voice.
We’re meeting together here in South Africa, which has a proud history of HIV/AIDS activism. We think we can learn from this experience. Organisations like the Treatment Action Campaign use the notion of so-called “treatment literacy” to ensure that those affected by HIV know about the science and policy behind the virus, and they also know and demand their rights.
We do not see such mobilization for vaccines. Perhaps this is because vaccines are focused on young children which of course do not have a voice. As we meet here this week, perhaps we can think about how to give mothers and care givers support so that they become immunisation advocates. We think that the money allocated so far to support community awareness and advocacy to prepare and push for rotavirus and PCV introductions is too narrowly focused and too product specific.
I look forward to robust and honest discussions over the next few days. I’m excited to learn from your experiences.
Thank you for your kind attention.