A dangerous game of darts in the dark

By Daniel Berman and Gregory Hussey

South Africa claims with pride its status as a middle-income country and economic powerhouse but when it comes to saving the lives of children through routine immunisations, we are far behind neighbouring countries. By 2010, South Africa was already spending R1.2 billion on vaccine procurement every year but child vaccination rates remained low – lower than those of Malawi, a country with 8% of South Africa’s per capita income.

Recently, Médecins Sans Frontières/Doctors Without Borders (MSF) South Africa questioned the current system in South Africa at the inaugural International African Vaccinology Conference in Cape Town.

For MSF South Africa and others concerned about immunisation, the facts are clear: young South African children are not receiving basic immunisations. Meanwhile, South Africa is overpaying for these vaccines while under-spending on programme support.

Discrepancies between department of health-issued vaccination coverage data and official estimates by the World Health Organisation and UNICEF are alarming. The Department of health claims 96% of South African children have received the three-in-one vaccination against diphtheria, whooping cough and tetanus, but international organisations are reporting immunisations rates of about 20% less. This discrepancy requires urgent attention.

Estimates for Malawi’s tetanus vaccination (DTP3) coverage are at 97% while Angola, with half of South Africa’s gross national income per capita, has vaccinated 86% of all children.

It is time for an honest appraisal of the current state of affairs. Accurate and valid data is critically important to determining the baseline indicators needed to measure progress. We are encouraged by the department of health’s proposed national vaccine coverage surveys to improve data collection, but these discussions need to be backed by solid action plans and adequate budget.

Without collecting the right data and analysis, it’s impossible to identify gaps and strengthen the country’s Expanded Programme on Immunisation (EPI). Presently, we are playing a dangerous game of darts in the dark, blindingly hoping to get the right shot without seeing the target.

Too high a cost?
These disappointing results are not because of a lack of spending.

South Africa pays the highest prices for vaccines of any country in the developing world, up to three times those paid by African countries supported by donor-funded Global Alliance for Vaccines and Immunisation (GAVI).

Imported vaccine prices are inflated because they are exclusively handled by a public-private partnership that levies a handling fee of up to 15%. That fee is meant to help fuel local vaccine development and production, but has done little to stimulate South African production in this sector.

To its credit the department of health has called for a stop to subsidising “local” production through high prices and has rightly urged the department of trade and industry to offer direct support for product development instead. Internationally, such support has played a large part in the development of a new affordable meningitis vaccine being rolled out in West Africa at only R4.30 a dose.

But there’s more the department can do.

Recently there has been a focus on the introduction of new, more expensive vaccines such as those designed to prevent pneumonia and life-threatening diarrhoea. While new vaccines give us opportunities to save more lives, they only reach children when vaccine programmes are working. A R483 anti-pneumonia vaccine is no more likely to reach those in need than a measles vaccine that costs just a few rand.

Simply adding a new vaccine without strengthening EPI’s weaknesses is a grave mistake and is indeed a false economy. It doesn’t make sense to import expensive vaccines if we are not going to invest in bolstering capacity at all levels, including improving human-resource management and training, data collection and expanding our clinic’s cold chain capacity with additional fridges.

These flaws can be remedied with honesty about our shortcomings and strong political will to implement the right decisions.

It is vital that the department of health conduct a national EPI coverage survey to determine accurate vaccination rates. Clinic staff and community healthcare workers should also be empowered to monitor coverage in their areas – responsibilities that fit into the department of health’s current revitalisation of primary healthcare strategy.

But we cannot expand access to vaccines if we don’t have a ground-up approach. Communities must understand the importance of immunising their children and demand these services.

In the fight against HIV we learned that those affected had to know about the science and policy behind the virus and the policies to know and demand their rights.

We need the same groundswell on immunisation. Vaccines are vital to saving the lives of children and an effective immunisation delivery system is essential to achieving this.

* Daniel Berman is the general director of Médecins Sans Frontières / Doctors Without Borders (MSF). MSF works in 68 countries worldwide and vaccinated more than 6 million people in 2011.
* Gregory Hussey is an infectious diseases specialist and is currently the director of The Vaccines for Africa Initiative at the University of Cape Town.