Miloud Kaddar

Indigence and access to health care in sub‐Saharan Africa

Access to health care services for the poor and indigent is hampered by current policies of health care financing in sub-Saharan Africa. This paper reviews the issue as it is discussed in the international literature. No real strategies seem to exist for covering the health care of the indigent. Frequently, definitions of poverty and indigence are imprecise, the assessment of indigence is difficult for conceptual and technical reasons, and, therefore, the actual extent of indigence in Africa is not well known. Explicit policies rarely exist, and systematic evaluation of experiences is scarce. Results in terms of adequately identifying the indigent, and of mechanisms to improve indigents access to health care, are rather deceiving. Policies to reduce poverty, and improve indigents access to health care, seem to pursue strategies of depoliticizing the issue of social injustice and inequities. The problem is treated in a technical manner, identifying and implementing operational measures of social assistance. This approach, however, cannot resolve the problem of social exclusion, and, consequently, the problem of excluding large parts of African populations from modern health care. Therefore, this approach has to be integrated into a more political approach which is interested in the process of impoverishment, and which addresses the macro-economic and social causes of poverty and inequity.

Role of the private sector in the provision of immunization services in low- and middle-income countries.

The authors conducted a literature review on the role of the private sector in low- and middle-income countries. The review indicated that relatively few studies have researched the role of the private sector in immunization service delivery in these countries. The studies suggest that the private sector is playing different roles and functions according to economic development levels, the governance structure and the general presence of the private sector in the health sector. In some countries, generally low-income countries, the private for-profit sector is contributing to immunization service delivery and helping to improve access to traditional EPI vaccines. In other countries, particularly middle-income countries, the private for-profit sector often acts to facilitate early adoption of new vaccines and technologies before introduction and generalization by the public sector. The not-for-profit sector plays an important role in extending access to traditional EPI vaccines, particularly in low-income countries. Not-for-profit facilities are situated in rural as well as urban areas and are more likely to be coordinated with public services than the private for-profit sector. Although numerous studies on non-governmental organizations (NGOs) suggest that the extent of NGO provision of immunization services in low- and middle-income countries is substantial, the contribution of this sector is poorly documented, leading to a lack of recognition of its role at national and global levels. Studies on quality of immunization service provision at private health facilities suggest that it is sometimes inadequate and needs to be monitored. Although some articles on public-private collaboration exist, little was found on the extent to which governments are effectively interacting with and regulating the private sector. The review revealed many geographical and thematic gaps in the literature on the role and regulation of the private sector in the delivery of immunization services in low- and middle-income countries.

Affordability, cost-effectiveness and efficiency of primary health care: the Bamako Initiative experience in Benin and Guinea

Since 1986 two West African countries, Benin and Guinea, have been actively reorganizing their peripheral health systems according to strategies subsequently called the Bamako Initiative. Two preceding articles described the strategies implemented and the increased effectiveness of primary health care (PHC) witnessed over a period of six years. This article presents an analysis of cost and coverage data from biannual monitoring sessions between 1988 and 1993 in approximately 200 health centres in Benin and 214 in Guinea. In order to assess affordability, the total and per capita recurrent costs for operational health centres are analysed and then compared. The cost analysis reveals a mean total cost per health centre per year of slightly over US+11,000 in Benin and nearly US+9,000 in Guinea. The median cost per capita per year is approximately US+1.0 in Benin and between US+0.60 and US+0.80 in Guinea. Comparisons of these costs between regions, health centres and over time (as coverage levels evolved) show very little variation in either country. Cost-effectiveness is estimated by allocating these costs to immunization, antenatal and curative care and comparing them to the coverage achieved with these interventions. First, the cost-effectiveness of the Bamako Initiative (BI) system as a whole is analysed. The cost per fully vaccinated child is calculated at US+10.9 in Benin and US+8.8 in Guinea. The cost per woman receiving at least three antenatal visits is US+7 in Benin and US+4.7 in Guinea. For curative care, cost per full treatment is US+1.6 in Benin and half this amount in Guinea. Cost-effectiveness is variable between regions, health centres reveals that these differences in cost-effectiveness are mainly caused by the coverage levels achieved, since total costs are relatively stable. Finally the efficiency of drug management and prescriptions as well as of outreach for the expanded programme of immunizations (EPI) is estimated by relating specific drug and outreach activities costs to the number of beneficiaries. The average cost of drugs per treatment is around US+0.5 in Benin and around US+0.3 in Guinea. Cost analysis of outreach activities undertaken for EPI in Guinea revealed a similar average cost per child completely vaccinated for health centres with different intensities of outreach (approximately US+10) and an additional cost per child vaccinated attributable to outreach of US+1-2.

Financial challenges of immunization: a look at GAVI

Securing reliable and adequate public funding for prevention services, even those that are considered highly cost effective, often presents a challenge. This has certainly been the case with childhood immunizations in developing countries. Although the traditional childhood vaccines cost relatively little, funding in poor countries is often at risk and subject to the political whims of donors and national governments. With the introduction of newer and more costly vaccines made possible under the Global Alliance for Vaccines and Immunization (GAVI), the future financial challenges have become even greater. Experience so far suggests that choosing to introduce new combination vaccines can significantly increase the costs of national immunization programmes. With this experience comes a growing concern about their affordability in the medium term and long term and a realization that, for many countries, shared financial responsibility between national governments and international donors may initially be required. This article focuses on how GAVI is addressing the challenge of sustaining adequate and reliable funding for immunizations in the poorest countries.

Managing the effect of TRIPS on availability of priority vaccines

The stated purpose of intellectual property protection is to stimulate innovation. The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) requires all Members of the World Trade Organization (WTO) to enact national laws conferring minimum standards of intellectual property protection by certain deadlines. Critics of the Agreement fear that such action is inconsistent with ensuring access to medicines in the developing world. A WHO convened meeting on intellectual property rights and vaccines in developing countries, on which this paper is based, found no evidence that TRIPS has stimulated innovation in developing market vaccine development (where markets are weak) or that protection of intellectual property rights has had a negative effect on access to vaccines. However, access to future vaccines in the developing world could be threatened by compliance with TRIPS. The management of such threats requires adherence of all countries to the Doha Declaration on TRIPS, and the protections guaranteed by the Agreement itself, vigilance on TRIPS-plus elements of free trade agreements, developing frameworks for licensing and technology transfer, and promoting innovative vaccine development in developing countries. The role of international organizations in defining best practices, dissemination of information, and monitoring TRIPS impact will be crucial to ensuring optimal access to priority new vaccines for the developing world.

Global support for new vaccine implementation in middle-income countries

Middle-income countries (MICs) as a group are not only characterized by a wide range of gross national income (GNI) per capita (US

The role of emerging manufacturers in access to innovative vaccines of public health importance

1026 to

Impact of BRICS? investment in vaccine development on the global vaccine market

12,475), but also by diversity in size, geography, governance, and infrastructure. They include the largest and smallest countries of the world-including 16 landlocked developing countries, 27 small island developing states, and 17 least developed countries-and have a significant diversity in burden of vaccine-preventable diseases. Given the growth in the number of MICs and their considerable domestic income disparities, they are now home to the greatest proportion of the worlds poor, having more inhabitants below the poverty line than low-income countries (LICs). However, they have little or no access to external funding for the implementation of new vaccines, nor are they benefiting from an enabling global environment. The MICs are thus not sustainably introducing new life-saving vaccines at the same rate as donor-funded LICs or wealthier countries. The global community, through World Health Assembly resolutions and the inclusion of MIC issues in several recent studies and important documents-including the Global Vaccine Action Plan (GVAP) for the Decade of Vaccines-has acknowledged the sub-optimal situations in some MICs and is actively seeking to enhance the situation by expanding support to these countries. This report documents some of the activities already going on in a subset of MICs, including strengthening of national regulatory authorities and national immunization technical advisory groups, and development of comprehensive multi-year plans. However, some additional tools developed for LICs could prove useful to MICs and thus should be adapted for use by them. In addition, new approaches need to be developed to support MIC-specific needs. It is clear that no one solution will address the needs of this diverse group. We suggest tailored interventions in the four categories of evidence and capacity-building, policy and advocacy, financing, and procurement and supply chain. For MICs to have comparable rates of introduction as other wealthier countries and to contribute to the global fight against vaccine-preventable diseases, global partners must implement a coordinated and pragmatic intervention strategy in accord with their competitive advantage. This will require political will, joint planning, and additional modest funding.

Sustaining GAVI-supported vaccine introductions in resource-poor countries

The role of developing country manufacturers in assuring global access to innovative vaccines was compared to the situation in 2005. These producers now supply over 60% of traditional vaccines doses globally and an increasing value (up to 15% in 2007) of innovative products. More suppliers are now strong players in global market, and an even larger group has potential to do so. These manufacturers are not a homogeneous group and most of them are now at a crossroads. Decisions made by their management and governments as well as by the international community will have a large impact on their existence and future and their ability to manufacture innovative vaccines at affordable prices.

Are current debt relief initiatives an option for scaling up health financing in beneficiary countries

Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--have made considerable progress in vaccine production, regulation and development over the past 20 years. In 1993, all five countries were producing vaccines but the processes used were outdated and non-standardized, there was little relevant research and there was negligible international recognition of the products. By 2014, all five countries had strong initiatives for the development of vaccine technology and had greatly improved their national regulatory capacity. South Africa was then the only BRICS country that was not completely producing vaccines. South Africa is now in the process of re-establishing its own vaccine production and passing beyond the stage of simply importing, formulating and filling vaccine bulks. Changes in the public sectors price per dose of selected vaccines, the global market share represented by products from specific manufacturers, and the attractiveness, for multinational companies, of partnership and investment opportunities in BRICS companies have all been analysed. The results indicate that the BRICS countries have had a major impact on vaccine price and availability, with much of that impact attributable to the output of Indian vaccine manufacturers. China is expected to have a greater impact soon, given the anticipated development of Chinese vaccine manufacturers in the near future. BRICS accomplishments in the field of vaccine development are expected to reshape the global vaccine market and accelerate access to vaccines in the developing world. The challenge is to turn these expectations into strategic actions and practical outcomes.