Editorial
On Jan 20, 2015, Médecins Sans Frontières published the second edition of the report The right shot: bringing down barriers to affordable and adapted vaccines. The report highlighted the lack of a rational pricing system for vaccines that serves all countries and populations, and, as a consequence, private and public health providers struggle to sustain the costs of immunisation campaigns in many settings. Several factors, such as limited information on vaccine prices, introduction of costly new vaccines, absence of competition in vaccine production, and a paucity of vaccine products suited for low-resource settings, have created a market in which children in many countries are unprotected against lifethreatening—but preventable—diseases. Vaccine pricing differs widely among countries. The world’s poorest countries benefit from the support of Gavi, the vaccine alliance, which helps to negotiate low prices and equal access to new vaccines. Eligibility for Gavi support is based on gross national income. When a nation crosses a defined income threshold, it enters a process whereby it must progressively contribute more funding to its immunisation programme, ultimately funding it completely. This transition into self-funding of a national immunisation programme can be challenging because graduating countries are charged the market rate for vaccines, not the Gavi-negotiated discount prices. Vaccine cost has been an issue for middle-income countries that were never eligible for Gavi funding and consequently cannot benefit from reduced vaccine prices. They have lagged behind Gavi-supported countries in implementing immunisation campaigns with new vaccines and have expressed concern about the long-term sustainability of vaccination. High vaccine prices are a problem even in the USA, where an increasing number of physicians are discouraging use of the new pneumococcal (PCV13) vaccination. At the regional level, an alternative strategy to control vaccine prices for countries not receiving financial support is exemplified by the Pan American Health Organization (PAHO) Revolving Funding. This fund uses the contributions of its members to negotiate the same low price for all participating countries, independently from their gross national income. PAHO also introduced a controversial clause into its agreement www.thelancet.com/infection Vol 15 March 2015
with manufacturers, requiring that if a company offers a lower price for vaccines to a nation outside the group, this new price must be applied for PAHO members as well. This clause is considered an obstacle to negotiating low vaccine prices in countries outside PAHO. The difficulties that many countries have in sustaining funding of immunisation campaigns call for development of a global strategy of rational vaccine pricing. Action is required on several fronts. First, increased transparency in the manufacturing cost of vaccines is necessary. Pharmaceutical companies are unwilling to declare their production cost; thus, understanding whether the price of vaccines can be lowered without detracting from an acceptable profit is impossible. Second, increased transparency on the vaccine price for both public and private buyers is needed. Governments and international organisations such as UNICEF have been reluctant to disclose the price that they pay for vaccines. Third, use of pooled procurement for buying vaccines must be encouraged. Individual nations have limited negotiating power on the market because they purchase a low number of vaccine doses. The example of PAHO shows how a concerted strategy for buying large quantities of vaccines is beneficial for both buyers and pharmaceutical companies, which can tailor their production to a reliable and stable demand. Fourth, increased competition in vaccine production is warranted. The emergence of vaccine manufacturers from low-income and middle-income countries where production costs are lower can have a pivotal role in decreasing vaccine prices. Consequently, WHO should accelerate procedures to guarantee prelicensure while certifying that production at lower cost does not affect vaccine quality. Finally, increased investment is needed to adapt existing vaccine products to resource-limited contexts. This action would require a small investment because existing vaccines could be tested in conditions outside the strict cold-chain, which is a major limitation for low-income and middle-income settings. In order to guarantee that all children are vaccinated against preventable diseases, it is time to move towards a global approach to vaccine prices; infectious diseases do not recognise borders, nor should preventive measures. ■ The Lancet Infectious Diseases
Ton Koene/Visuals Unlimited, Inc. /Science Photo Library
Global harmonisation in vaccine price
For the MSF Report see http:// www.msf.org.uk/article/msfcalls-on-gsk-and-pfizer-to-slashpneumo-vaccine-price-to-5-perchild-for-poor-countries For Gavi Alliance see http:// www.gavi.org/pledging2015 For PAHO Revolving Fund see http://www.paho.org/hq/index. php?option=com_content&view =article&id=1864&Itemid=4071 3&lang=en
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On Jan 20, 2015, Médecins Sans Frontières published the second edition of the report The right shot: bringing down barriers to affordable and adapted vaccines. The report highlighted the lack of a rational pricing system for vaccines that serves all countries and populations, and, as a consequence, private and public health providers struggle to sustain the costs of immunisation campaigns in many settings. Several factors, such as limited information on vaccine prices, introduction of costly new vaccines, absence of competition in vaccine production, and a paucity of vaccine products suited for low-resource settings, have created a market in which children in many countries are unprotected against lifethreatening—but preventable—diseases. Vaccine pricing differs widely among countries. The world’s poorest countries benefit from the support of Gavi, the vaccine alliance, which helps to negotiate low prices and equal access to new vaccines. Eligibility for Gavi support is based on gross national income. When a nation crosses a defined income threshold, it enters a process whereby it must progressively contribute more funding to its immunisation programme, ultimately funding it completely. This transition into self-funding of a national immunisation programme can be challenging because graduating countries are charged the market rate for vaccines, not the Gavi-negotiated discount prices. Vaccine cost has been an issue for middle-income countries that were never eligible for Gavi funding and consequently cannot benefit from reduced vaccine prices. They have lagged behind Gavi-supported countries in implementing immunisation campaigns with new vaccines and have expressed concern about the long-term sustainability of vaccination. High vaccine prices are a problem even in the USA, where an increasing number of physicians are discouraging use of the new pneumococcal (PCV13) vaccination. At the regional level, an alternative strategy to control vaccine prices for countries not receiving financial support is exemplified by the Pan American Health Organization (PAHO) Revolving Funding. This fund uses the contributions of its members to negotiate the same low price for all participating countries, independently from their gross national income. PAHO also introduced a controversial clause into its agreement www.thelancet.com/infection Vol 15 March 2015
with manufacturers, requiring that if a company offers a lower price for vaccines to a nation outside the group, this new price must be applied for PAHO members as well. This clause is considered an obstacle to negotiating low vaccine prices in countries outside PAHO. The difficulties that many countries have in sustaining funding of immunisation campaigns call for development of a global strategy of rational vaccine pricing. Action is required on several fronts. First, increased transparency in the manufacturing cost of vaccines is necessary. Pharmaceutical companies are unwilling to declare their production cost; thus, understanding whether the price of vaccines can be lowered without detracting from an acceptable profit is impossible. Second, increased transparency on the vaccine price for both public and private buyers is needed. Governments and international organisations such as UNICEF have been reluctant to disclose the price that they pay for vaccines. Third, use of pooled procurement for buying vaccines must be encouraged. Individual nations have limited negotiating power on the market because they purchase a low number of vaccine doses. The example of PAHO shows how a concerted strategy for buying large quantities of vaccines is beneficial for both buyers and pharmaceutical companies, which can tailor their production to a reliable and stable demand. Fourth, increased competition in vaccine production is warranted. The emergence of vaccine manufacturers from low-income and middle-income countries where production costs are lower can have a pivotal role in decreasing vaccine prices. Consequently, WHO should accelerate procedures to guarantee prelicensure while certifying that production at lower cost does not affect vaccine quality. Finally, increased investment is needed to adapt existing vaccine products to resource-limited contexts. This action would require a small investment because existing vaccines could be tested in conditions outside the strict cold-chain, which is a major limitation for low-income and middle-income settings. In order to guarantee that all children are vaccinated against preventable diseases, it is time to move towards a global approach to vaccine prices; infectious diseases do not recognise borders, nor should preventive measures. ■ The Lancet Infectious Diseases
Ton Koene/Visuals Unlimited, Inc. /Science Photo Library
Global harmonisation in vaccine price
For the MSF Report see http:// www.msf.org.uk/article/msfcalls-on-gsk-and-pfizer-to-slashpneumo-vaccine-price-to-5-perchild-for-poor-countries For Gavi Alliance see http:// www.gavi.org/pledging2015 For PAHO Revolving Fund see http://www.paho.org/hq/index. php?option=com_content&view =article&id=1864&Itemid=4071 3&lang=en
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