The discovery of vaccines has played a central role in some of the most significant achievements in global public health. Vaccination protects children from disease, giving them the opportunity to thrive and realise their full potential. It has had an unparalleled impact on the reduction of childhood mortality.
Vaccines are one of the most successful and cost-effective ways to protect billions of people from disease. Through herd immunity, vaccines can even protect those who are not vaccinated. Vaccines have greatly reduced disease, disability, death and inequity globally, saving the lives of up to three million children each year.
Immunisation has eradicated smallpox, and international stakeholders are working to eradicate polio and eliminate measles and rubella. The world’s population stands to benefit from vaccines that do not yet exist, for diseases and pathogens such as HIV / AIDS and Group B streptococcus.
Although global immunisation coverage is increasing, nearly one in five children in 2015 did not receive basic life-saving vaccines that the World Health Organization (WHO) recommends for routine immunisation. The reasons for this are varied, including weak health systems and supply chains, insufficient vaccine supply, financing challenges, and community acceptance of vaccines. For newer vaccines, such as for pneumococcal disease (conjugate vaccines) and rotavirus, coverage is even lower: affordability and production capacity are among the key issues here. The impact of these missed immunisation opportunities is profound: almost one third of deaths of children under five years – nearly two million children – are vaccine-preventable.
Figure: Global coverage of older vaccines exceeds 80% - for newer vaccines, coverage remains relatively low
A global focus
The Global Vaccine Action Plan and Sustainable Development Goals set out clear targets to improve access to vaccines worldwide. Achieving these targets requires a coordinated framework of multiple stakeholders, including governments, multilateral organisations, purchasers, funders, vaccine developers and manufacturers. This is particularly important given the generally high level of consolidation on both the production and purchasing sides of the vaccine market (although markets for specific vaccines have different characteristics).
Balancing supply and demand
A careful balance is required between both demand and supply, and cost and value. On the demand side, vaccines for routine immunisation are generally purchased by governments or, for some low- and middle-income countries, through pooled-procurement systems aiming to lower prices. There are three main multilateral organisations involved in these systems: the United Nations Children’s Fund (UNICEF) and the Pan American Health Organization (PAHO) Revolving Fund procure vaccines on behalf of countries, while Gavi, the Vaccine Alliance, provides funding for immunisation in the world’s poorest countries and plays a market-shaping role.
An infant is vaccinated against polio following the introduction of Sanofi's inactivated polio vaccine in Nepal.
On the supply side, five large research-based multinational corporations have accounted for around 80% of global vaccine revenues in recent years. Following divestments and acquisitions, the “big four” remain: GSK (which acquired Novartis’ vaccines business in 2015), Merck & Co., Inc., a Pfizer and Sanofi. There is also a growing number of private and public vaccine manufacturers based in emerging markets. Known as developing country vaccine manufacturers, they focus on manufacturing traditional, lower-cost vaccines. While these companies’ revenues make up a smaller proportion of global sales, their combined supply volumes are significant (for example, contributing around 50% of doses supplied to UNICEF).
The nation-wide distribution of polio vaccines is carefully coordinated by government staff and volunteers in the Democratic Republic of Congo.
Vaccine market dynamics
Overall, the global vaccine market is growing: between 2000 and 2014, it expanded from USD 6 bn to USD 33 bn. Sales to high-income countries represent around 65% of the total value of this market, upper middle-income countries 23%, lower middle-income countries 8%, and low-income countries 4%. The value of UNICEF vaccine procurement doubled between 2010 and 2014 to USD 1.5 bn. As national immunisation programmes expand – both boosting coverage for older vaccines and introducing new vaccines – this presents new challenges for ensuring access. This is particularly significant for countries with growing incomes that are transitioning out of Gavi support, and that increasingly finance vaccines through national government spending.
Within this context, vaccine companies have a key contribution to improving access to vaccines. Their R&D expertise and position at the start of the innovation value chain, their role in setting vaccine prices, and their management of vaccine supply planning and production make them integral to the successful development and effective supply of vaccines in the market. Due to high failure rates, vaccine development, production and access is very demand-driven: other global health stakeholders can support mechanisms to improve access.
The Access to Vaccines Index
Given the critical role of vaccine companies in improving access to vaccines, it is necessary to clearly define expectations for the industry that can be translated into firm commitment and concrete action. It is also important to track progress against established goals and targets: data-driven performance management is essential in identifying what is working and why. Responding to this gap, the Access to Vaccines Index is the first publicly available tool for mapping the efforts major vaccine companies are engaging in to increase access to vaccines in low- and middle-income countries. Transparent information sharing about companies’ performance will help improve accountability and share good practices: this is particularly useful given the high level of consolidation of the market. It is also the first non-financial incentive for companies to improve access to their vaccines: good practice (relative to peers and/or stakeholder expectations) is reflected and recognised publically in the Index.
Companies and other stakeholders can use this information to inform priorities and strategies, and to learn where new incentives or stronger mechanisms would spur companies towards greater engagement in access issues.
"You should be commended for taking on this difficult task in the environment of a consolidated industry with many atypical manufacturers playing important roles. We feel that the ATVI has struck a good balance, recognizing the elements that are important in access to vaccines, taking a systematic approach to comparing across manufacturers, yet recognizing and appreciating the differences in this industry."
Dr. Seth Berkley
CEO, the GAVI Alliance