Calling on the GAVI Board to Enable Introduction of Lifesaving Pneumonia Vaccine for Children in Fragile Settings

Originally posted June 9, 2022 on

“We appeal to all of the donors to respond to this issue of the Gavi co-financing barrier. We are ready to act…I hope the donors will be with us and support us and all of the fragile countries. Don!t leave us alone. Be with us.”

George Legge, Director, Expanded Program on Immunization, Ministry of Health, South Sudan, 2021

Board members of Gavi, the Vaccine Alliance, have an opportunity at their June meeting to accelerate the introduction of a lifesaving vaccine to protect children living in fragile, conflict, and displaced populations against one of the leading threats to their survival – pneumonia.

The pneumococcal conjugate vaccine (PCV) is a highly effective vaccine that targets the leading bacterial cause of pneumonia. Following introduction, the vaccine’s impacts are felt quickly. For example, studies have shown that following PCV introduction in Kenya in 2011, vaccine-type pneumococcal cases dropped by 92%1 and pneumonia hospitalizations by 27%.2 The PCV has contributed to the impressive 40% decline in childhood pneumonia deaths across Kenya in the last decade.

But despite the power of the PCV, many of the world’s most vulnerable children are not protected because they live in fragile countries. Although eligible for financial support from Gavi, their governments cannot afford the cofinancing required to introduce the vaccine.

This includes children living in Somalia, Guinea, South Sudan, and Chad – all Gavi-eligible – who are among the last countries in Africa to introduce the PCV. Across these four countries, pneumonia is killing more than 40,000 children under five each year.

By introducing the PCV, these countries could prevent the deaths of more than 92,000 children over the next decade and take a major leap forward to achieving the child survival Sustainable Development Goal. Currently, all four countries are off-track to meet this goal. In the last twelve months, Health Ministers in the four African countries have made it clear they want to introduce the PCV but will need external financing support to meet the Gavi co-financing requirement.

Most recently at the World Health Assembly (WHA) event, Protecting all children with the Pneumococcal Conjugate Vaccine, the Undersecretary for Health from South Sudan, Dr. Victoria Anil Majur, said that South Sudan is still seeking financial support from Gavi and other donors to be able to meet the co-financing obligation, which she described as one of the “stumbling blocks” to PCV introduction.

The four countries each need to source between $US173,000 and $US375,000 per year to introduce the PCV, according to estimates published in the Every Breath Counts report, Introducing the Pneumococcal Conjugate Vaccine (PCV) in Somalia, Guinea, South Sudan, and Chad.

It is a tragedy that currently all that is standing in the way of protecting the estimated 10 million children under five in these four countries is $1 million per year in Gavi co-financing.

There are innovative models of PCV co-financing relief in most regions. For example in 2018, the Asian Development Bank (ADB) partnered with four Pacific Island countries who are not Gavi-eligible – Tonga, Samoa, Vanuatu, Tuvalu – to co-finance three vaccines at once including PCV, rotavirus, and Human papillomavirus (HPV).

The ADB helped the four governments finance the introduction of these three vaccines by covering 100% of the costs in the first year and scaling back each year to 80%, 60%, 40%, and so on, until the government took over the costs. Other examples of creative solutions to PCV co-financing for both Gavi- and non-Gavi-eligible countries are included in the Every Breath Counts report, Co-financing the Pneumococcal Conjugate Vaccine (PCV): Country Case Studies.

If these solutions are possible for the children of Tonga, Samoa, Vanuatu, Tuvalu and also Gavi-eligible countries, why not the children of Somalia, Guinea, South Sudan, and Chad? Why do the world’s most vulnerable children continue to miss out on lifesaving vaccines?

The Gavi Board has identified equity as the “organizing principle” for Gavi’s Strategy 5.0 and prioritized the urgency of reaching “zero-dose” children – children that have not received any routine vaccine. As many of these children live in fragile settings delivering on this objective will require innovative approaches, including addressing the co-financing requirement in creative and sustainable ways. Such approaches will also be relevant for middle-income countries.

Gavi has signaled that it understands the challenge. The revision of the Gavi Fragility, Emergencies and Displaced Populations Policy is an opportunity to introduce a new suite of Gavi support options with a greater level of flexibility and tailoring for countries experiencing severe economic distress, widespread conflict, and/or disasters that are severely undermining the functioning of government.

We urge the Board to resource Gavi with effective tools to reach children living in these settings, including a range of co-financing flexibility options that enable Somalia, Guinea, South Sudan, and Chad to introduce the PCV in the next 12 months. Gavi should also have a role and the support needed to help countries (including middle-income) finance new vaccine introduction with grants and/or loans from multilateral and regional development banks and private philanthropies.

And not just for the PCV. If fragile countries can also introduce the rotavirus vaccine it could double the number of child deaths prevented. This was highlighted at the WHA Child Survival Action Roundtable by Dr Ubah Farah Ahmed, Director of Family Health at the Somali Ministry of Health, when she argued that Somalia needed to introduce both the pneumococcal and rotavirus vaccines as, “more than 25% of our child deaths are due to pneumonia and diarrhea.”

The challenges and urgency of vaccinating children in fragile settings are not going away. The economic costs of the pandemic, the impact of the war in Ukraine on food supplies, and the ongoing effects of climate change are simultaneously increasing the number of children at risk of vaccine-preventable death and reducing the ability of their governments to respond.

As Gavi enters these headwinds, it must be equipped with co-financing flexibility tools to deliver on its “high ambition” to reach the unreached. Lifting the $US 1 million “stumbling block” that is preventing the children of Somalia, Guinea, South Sudan, and Chad from being protected against pneumonia is a critical first step that the Gavi Board should take this month.