Global immunization for the 21st century.

Abstract

M illennial winds are blowing through the field of global vaccinology. Fifteen years after the Bellagio Conference, which unlocked a new $100 million per year to bring the six most common infant vaccines to 80% of the world's children, the Villa Serbelloni (the Rockefeller Foundation's study center in Bellagio, Italy) was once again the site of a historic meeting. On 15 to 17 March 1999, the key United Nations (UN) agencies met with leaders of the vaccine industry, representatives of bilateral aid agencies and major foundations, and a few independent academics. The agenda: a new global partnership designed to save 40 million lives over the next 10 years at a cost that could approach $3 billion per year. Not surprisingly, such an ambitious agenda has created some curiosity and not a little controversy. The rumor mill has been working overtime, suggesting that the meeting failed to deliver. As chair of the meeting, I welcome this chance to set the record straight. As would be expected with 35 strong personalities in the room, the discussion was sometimes robust, and consensus could not be reached on every point. Nevertheless, real progress was made toward forging a global coalition and, in particular, industry was embraced as an active and equal partner. Each party made new pledges. The World Health Organization (WHO) has put extra staff and resources into its restructured immunization programs. Indeed, global immunization is by far the biggest technical program within WHO at headquarters, regional, and country levels. The UN Children's Fund (UNICEF) reasserted that it would invest more in immunization than in any other field: 56% of its discretionary health funds. The World Bank acknowledged that its total effort in immunization had not matched the promise of the field and vowed to do more. In the bank's “comprehensive development framework,” countries will be asked to outline their development plans in conjunction with bank professionals. Immunization outcomes could be incorporated as targets in resulting loan agreements. The bank lends about $1 billion per year for health programs, half of it essentially at zero interest, so if a substantial proportion of this went to immunization, it would make a big difference. The bank also offered to work with manufacturers to explore mechanisms that might reduce the risks of investing in global capacity. Industry pledged to be a full and active partner within an appropriate structure and offered to invest in adequate volumes of production of the newer vaccines. These would be made available to the poorest countries at the lowest possible price, provided efforts were made to prevent leakage of vaccine supplies to richer countries. Industry was also prepared to target more of its research effort to vaccines of predominantly Third World interest if the global coalition succeeds in creating a true, worldwide, public-sector market. Although the bilateral aid agencies and the foundations (particularly the new Bill and Melinda Gates Children's Vaccine Program) spoke encouragingly, no one came to Bellagio waving a magic wand. So it was agreed that the World Bank would convene and lead a working party on financing to consider a multifaceted approach, including the possibility of a large Global Vaccine Fund. Obviously, advocacy at the highest level will be required, and UNICEF will lead a working party on advocacy, including a strategy for a launch of the new global coalition by the heads of agencies and of industry in September/October 1999. Definite targets for introduction rates of new vaccines will be refined, and a new, small coordinating secretariat will be set up in Geneva, with the transition from the present Children's Vaccine Initiative still to be negotiated. The governing body of the partnership would be a small group of 8 to 10 members, representing developing countries as well as the partners. How one views the Bellagio meeting depends on whether one prefers to regard a glass as half empty or half full. It is clear that a huge task remains in building vaccine infrastructure in the poorest countries, motivating health authorities there, and raising funds to purchase the newer vaccines. It is also evident that a revitalized partnership with full UN commitment and industry participation has at least a sporting chance of bringing off the greatest public health achievement of the 21st century.