Background

Child mortality has decreased substantially globally—from 12.6 million in 1990 to 6.3 million in 2013—due, in large part because of governments’ and organisations’ work, to prevent pneumonia, diarrhoea and malaria, the main causes of death in the postneonatal period.

The magnitude of immunisation's contribution to the achievement of Millennium Development Goal (MDG) 4 by 2015 depends upon our ability to achieve and sustain universal vaccination coverage in all countries and districts, including those where child mortality rates are high and geographical, political, socio-economic or cultural barriers to effective provision and use of health services prevail. The key targets of this goal included reducing the under 5 mortality rate by two-thirds and increasing the proportion of 1-year-old children immunised against measles between 1990 and 2015.1

The achievement of MDG 4 depends on renewed efforts to prevent and control pneumonia, diarrhoea and under nutrition in all of the regions served by WHO, as well as malaria in the African region. In 2013, 6.3 million children died before reaching their fifth birthday; almost all of these deaths occurred in low-income and middle-income countries. Pneumonia, diarrhoea and malaria are the principal causes of child deaths from infectious diseases, causing about one-third of under 5 deaths; other causes include preterm birth complications, complications due to labour and delivery, lack of effective labour and delivery care, and lack of access to key interventions for newborns and mothers, among others.2

In 2000—the same year as the MDGs were established—the Global Alliance for Vaccines and Immunization (GAVI) was formed as a public–private global health partnership meant to address global inequities in access to and coverage of available lifesaving vaccines (figure 1).4 Vaccines are recognised as one of the most cost-effective public health interventions with the potential to significantly impact the unacceptable childhood deaths in the world. Furthermore, with the renewed emphasis on universal health coverage, immunisation has paved the way for—and continues to provide—an enabling platform for other child and maternal health services.5

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Figure 1

Causes of deaths among children under 5 years, 2013.3

From its founding, GAVI has leveraged the support of its strategic partners—including donor countries, recipient countries, industry, civil society, technical institutions, unaffiliated members and United Nations (UN) agencies—to impact public health. WHO was a founding partner of the Alliance, and together with the United Nations Children's Fund and the World Bank it currently supports the implementation of GAVI’s mission into national immunisation programmes and in monitoring the impact of GAVI’s investments in the world’s poorest countries.

WHO's work with the GAVI Alliance has several dimensions. Established in 1974, the WHO's Vaccines and Immunization Programme provides global policies using the latest scientific and technical evidence.6 The past 15 years have seen changes in the vaccine community that pertain notably to new vaccines, technology development and increased funding via new financing mechanisms, including particularly through GAVI. WHO has responded through swift reforms in its policymaking structure and regularly receives advice from the Strategic Advisory Group of Experts.7

Additionally, GAVI impacts vaccine accessibility through its use of country-directed and country-supported financing. For example, countries introducing GAVI-supported vaccines into routine schedules must co-finance these vaccines, which incentivises increased country ownership and scale-up by these countries over time towards sustained introduction by countries. By 2013, 68 countries were required to co-finance their vaccines and US$69 million or 11% of the total value of vaccine support by the Alliance was co-financed by countries.8

WHO also establishes international standards and norms for vaccines quality and safety and provides reference materials for use by vaccine manufacturers and national regulatory authorities for the manufacture and the control of vaccines.9 This programme operates in ways that allow manufacturers from developing countries to enter the market together with established manufacturers, leading to supplies of quality-assured products and competition that has brought prices down significantly, changing the dynamics of the market for public health-focused vaccines.

WHO monitors and assesses the trends and the impact of strategies and activities for reducing morbidity and mortality of vaccine-preventable diseases through collection, analysis and interpretation of reports and statistics on estimates of national immunisation coverage, surveillance data, immunisation schedules and indicators of immunisation system performance.10

In terms of GAVI governance, WHO is represented on the GAVI Alliance Board by Dr Flavia Bustreo and Dr Jean-Marie Okwo-Bele, where collectively with the other Alliance partners they are responsible for setting the strategic focus and policies of GAVI and in monitoring the impact of GAVI's investments and contribution to the global public health and development agenda.11 Dr Bustreo is a strong advocate for women's and children's health and her appointment on the GAVI Board coincided with the preparations for GAVI's first replenishment meeting in June 2011 and, subsequently, in November 2011 the Board's decision to invite countries to apply for funding for introduction of human papillomavirus (HPV) vaccines.12

GAVI's contribution to improved vaccine coverage and reducing child mortality

In May 2012, the World Health Assembly endorsed the Decade of Vaccines—Global Vaccine Action Plan (GVAP) that provides the global framework for achieving equity in coverage and expanding the benefits of vaccines to all by 2020.13 The GVAP set five targets, including the achievements of national DTP3 (three doses of diphtheria–tetanus–pertussis vaccine) immunisation coverage of 90% by 2015 with no district's coverage at <80%. The other targets are related to disease eradication and elimination to be reached at country and regional levels.

With GAVI support, low-income countries have been able to accelerate the pace of introduction of vaccines into their health systems and scale up progress towards achieving the MDGs and achieving universal health coverage. In the 73 GAVI-eligible countries, DTP3 coverage rates rose from 68% in 2000 to 83% in 2013.14

Since 2011, GAVI has contributed to 67 vaccine introductions and campaigns. The vaccines introduced in the routine programme include pentavalent (DTP3–hepatitis B–haemophilus influenza type b (Hib) vaccines), pneumococcal and rotavirus vaccines. In addition, vaccines introduced through mass campaign strategy include meningitis and measles vaccines.

By 2013, the countries supported by GAVI had immunised 440 million additional children and averted six million future deaths from vaccine-preventable diseases.8 In these countries, the milestone set for achieving the reduction of child mortality to 68 per 1000 live births by 2015 is on track.15

GAVI's broader contributions to MDGs

Continued challenges towards meeting MDG 4 targets by 2015 and beyond

GAVI has faced substantial challenges related to health systems and equity as it worked to increase immunisation and vaccine coverage in supporting eligible countries accelerate progress towards related to MDG 4. Health systems have required substantial strengthening and modernising; as they stand now, these systems’ condition often prevents programmes from scaling up to necessary levels. Additionally, governments in the developing countries face a number of competing health priorities with a limited budget within which they must work. By 2013, GAVI had committed just over US$800 million in health systems support to 56 countries.26

Supply chains are weak in many locations, creating difficulty moving temperature-sensitive vaccinations and other medications to local clinics while ensuring that these supplies are not expired. Data quality may be poor in countries that lack the infrastructure and tools to research pricing to find appropriate bids and accurately track the movement of vaccines and other medical supplies. The civil unrest and political instability observed in many eligible countries add complex and difficult-to-solve obstacles to achieving high, equitable coverage.27

The environment in which GAVI operates will look substantially different in the coming years, impacting work related to reducing child and maternal mortality. Many countries that have historically received aid are experiencing rapid economic growth and are expected to assume more responsibility for building their own social infrastructure. Fewer people now live in extreme poverty, and most of the world's poor live in middle-income countries.

In June 2014, the GAVI Alliance Board approved a strategic framework for 2016–2020 that it estimates will immunise an additional 300 million children and prevent five to six million future deaths.28 In parallel, GAVI is preparing for its second replenishment meeting in 2015 with a target of mobilising an additional US$7.5 billion to support the implementation of its next strategy. Long-term predictable funding is critical to the continued ability of GAVI in saving lives and protecting people's health.