Daniel Berman, Deputy Director at MÃ©decins Sans FrontiÃ¨res Access Campaign has given a great presentation about vaccine pricing and adaptation in developing countries at the World Vaccine Congress last week.
MSF annually vaccinates over 10 million people around the world. Mr. Berman said that MSF considers the provision of specific prices for specific products by UNICEF, rather than just average prices, as a landmark improvement in price reporting and transparency. This helps improve understanding of the dynamics of vaccine pricing in the global marketplace. MSF looks at the potential role of vaccine adaptation in increasing the reach of immunization services to difficult-to-reach populations. They are also interested in making the vaccines easier to use in field settings.
Over time, there is a rising cost of immunizing each child. Some recent additions to the WHO recommended routine immunization schedule (Hep B in 2004, Hib in 2006, Pneumo in 2010, Rotavirus and Rubella in 2011), have brought the cost to just under $40 per child. When comparing this price with the average cost today in countries like the US (~$1000), this price looks good, but these increases are a major reason for concern over the sustainability of childhood vaccinations globally.
GAVI has made very good progress, but in Mr. Berman’s opinion, they have not brought down prices enough. In fact, according to their own commissioned independent review, reduction of prices is one of GAVI’s continuing major challenges. Unless prices decrease, GAVI will be facing a deficit. From the country perspective, Honduras has $1,801 per capita income. They have introduced both rotavirus and PCV vaccines. They currently pay $1.05 per child for these two vaccines. When they ‘graduate’ from GAVI’s program, their post-GAVI cost per child will be $25.50. For the whole birth cohort, this is a $5.1 million per year increase. For even poorer countries, there is vaccine rationing, and they are forced to target vaccines to high risk groups. The Kenyan Ministry of Health equated cost of vaccinations as "taking out multiple mortgages."
Relative to other health care products, Mr. Berman asked why there hasn’t been more talk about vaccine prices. Ten years ago, there was a very fragile vaccine market out of which GAVI was begun. Now it is clear that the crises in pricing are more than the donors can handle. MSF’s objective in in engaging in vaccine pricing analyses is to stimulate debate over the numerous issues countries are facing, especially with respect to the 16 countries that will be exiting GAVI’s eligibility.
MSF has undertaken massive responses to meningitis outbreaks, and is appreciative that the Gates Foundation, the Serum Institute, and PAHO worked together to create a useful product, though there may have been ways to have the technology available earlier for developing countries in need.
Vaccine adaptation is necessary to increase the reach of immunization services in places with weak health care systems. Mr. Berman described a "wall" that workers in the field have come up against, where there are certain products that require a cold chain and require needles. MSF has been able to overcome those barriers in different ways, but it is not practical for health governments in the DRC or Chad for instance, to provide reliable infrastructure to support vaccinations. For polio, the use of community workers has helped. GAVI has been quoting that DPT3 coverage is 79%, but there is much variability over time and between different countries, with Chad’s coverage between 19-59%, Bihar, India, 40%, and Nigeria, 44%. The wish list from the perspective of MSF field workers include elimination of cold chain, reducing difficult injections, generating dosing schedules that fit the developing market reality, and production of products that can enable task-shifting to help increase coverage in places with weak health systems.
Despite the apparent success of measles vaccinations in prior decades, in 2010, twenty-eight African countries faced measles outbreaks. There were more than 100,000 cases in the DRC. MSF vaccinated 4 million people. Low coverage and lack of natural immunity contribute to the need. A measles dry powder is being pioneered in Denver through a Gates Foundation Grand Challenge, while partnering with the Serum Institute. The dry powder can be applied through a surgical mask. Mr. Berman also described the rotavirus vaccine as a "game-changer", but expressed worry that the current products are not practical for use in some developing countries. Studies on rotavirus show that there is reduced efficacy in Kenya, and that in Brazil the dosing schedule has not worked well. There is an important question about who will pay for the additional clinical research necessary to make these products practical for the developing world, especially in the context of tiered pricing.
From his experience working in industry prior to his time at MSF, Mr. Berman recognized that management is not often very responsive to these sorts of concerns. In Uganda, MSF is partnering with the WHO to do a clinical trial for PCV, with some of the original investigators.
Mr. Berman urged the need to harness the power of greater price transparency and competition. The issues regarding vaccine prices in South Africa give a prime example of problems that arise when there is not pooled procurement in place. The PAHO model has worked quite well, even though industry has been resistant to give good prices to all of the PAHO countries.
Ongoing concerns for vaccine pricing and utility in the developing world include the WHO pre-qualification of the rotavirus vaccine despite concerns regarding practicability of use is a particular concern. Also, there are concerns regarding recommending PCV vaccination despite differences in targeted pathogen strains and the vaccine strains.
Check back here in a couple of days for the presentation.