How the covid-19 pandemic exposed vulnerabilities in paediatric immunisation programmes in emerging economies.
The results, however, are anything but perfect: the absolute no. of 23 million children missing out on basic vaccinations in 2020 is alarmingly and demands urgent attention.
EIU
September 02, 2021
Gerard Dunleavy
Project Manager, The Economist Intelligence Unit
Key Messages
- In our study countries, all vaccine programmes provided sub-optimal coverage and required improvements of various kinds, even before the pandemic.
- Among our countries, those with greater health system resources are seeing declines in vaccination rates, but those with lower resources are placing a greater focus on achieving the benefits and value that childhood immunisations offer.
- The pandemic revealed the growing size of this split.
- A loss of strategic focus helps explain the decline in Latin American vaccination levels, while political commitment undergirds performance in India and Vietnam.
- Public engagement should never simply be presumed.
- The substantial progress seen against vaccine-preventable diseases is not irreversible.
- Paediatric vaccination programmes should use the assets developed for the fight against covid-19.
Key takeaways for policymakers:
- Vaccines don’t deliver themselves: they require ongoing political commitment, funding, and the application of a coherent strategy.
- Such strategies must take a broad overview of the diverse healthcare, social, economic and political factors which affect vaccination: every country has issues it needs to address, and these may differ from those of its neighbours.
- Existing strategies should be reviewed to consider how the investments, tools and lessons from the battle against covid-19 can bolster childhood immunisation programmes.
- Public engagement and interaction are fundamental to the ongoing effectiveness of vaccination programmes: hesitancy can develop quickly and the very success of immunisation in reducing incidence can undermine belief in the importance of the effort. Covid-19 has brought about greater awareness and understanding of vaccines, potentially providing a platform to improve awareness of routine childhood immunisations.
- Over-confidence can be deadly: without ongoing attention to vaccine programmes, diseases are likely to return and, with them, entirely preventable fatalities.
“Health Systems Swimming Naked? How the covid-19 pandemic exposed vulnerabilities in paediatric immunisation programmes in emerging economies” is an Economist Intelligence Unit report, sponsored by GSK.
When a highly disruptive event like the pandemic occurs, it places substantial stress on many of these programmes simultaneously, just as an economic downturn does on every company at once. The results for both finance and public health are revealing. To quote Warren Buffett, “only when the tide goes out, do you discover who’s been swimming naked”.
This report describes the methods and main findings from The Economist Intelligence Unit’s research examining the state of paediatric vaccination programmes in 5 emerging economies (Argentina, Brazil, India, Mexico and Vietnam), how they got this way, and their capacity to improve in future — as revealed by the ebbing tide created by the pandemic.
The research focuses on four diseases — measles, pertussis (or whooping cough), rotavirus-induced diarrhoea, and vaccine-preventable forms of meningitis — as well as seven vaccinations which can help control these, and which the WHO recommends for every country’s vaccine schedule.1
The findings from this research programme centred around the insights uncovered in The Vaccine-Preventable Disease Scorecard. The Scorecard is a benchmarking tool — developed following an intensive literature review and consultation with an advisory panel — which has gathered data for 19 indicators relevant to success against vaccine preventable disease, across 5 domains:
- Health System Resources;
- Drivers of Vulnerability to Disease;
- Immunisation Programme Performance;
- Surveillance and Adoption of International Recommendations;
- Supply- and Demand-Related Factors.
The point of the Scorecard is not to judge which country comes first or last: the gold medal here would be the elimination of preventable disease, not bragging rights over EIU scoring.
Our hope, instead, is to start a discussion that will help every country get closer to that goal.
Executive Summary
Childhood immunisation programmes are a fundamental foundation of effective health system performance.
The covid-19 pandemic and its accompanying disruption impeded the delivery of all elements of healthcare. Vaccine programmes were no exception. According to joint United Nations International Children’s Fund (UNICEF) and World Health Organization (WHO) figures, global coverage of doses of DTP1 and DTP3 vaccine declined by 3% in 2020 compared with 2019; for Hib3 and MCV1 the decrease was 2%; and for MCV2, it was 1%.
The declines in coverage reported in the first year of the pandemic were generally smaller than modelling studies and experts alike had predicted, as catch-up efforts valiantly recovered some ground lost during the total shutdowns experienced by numerous immunisation programmes. The results, however, are anything but perfect: the absolute number of 23 million children missing out on basic vaccinations in 2020 is alarmingly high and in need of urgent attention.
Improvement first requires seeing the true nature of the problem. The pandemic has certainly exacerbated it, but it is not the underlying cause. Declining coverage is a multifactorial issue resulting from a highly complex set of medical, political, economic and social interactions.
Although global data are important, vaccine delivery is largely a concern of national health systems. Some country programmes have been strengthened in recent years, others have been allowed to decline. When a highly disruptive event like the pandemic occurs, it places substantial stress on many of these programmes simultaneously, just as an economic downturn does on every company at once. The results for both finance and public health are revealing. To quote Warren Buffett, “only when the tide goes out, do you discover who’s been swimming naked.”
This Economist Intelligence Unit study, sponsored by GSK, examines the state of paediatric vaccination programmes, how they got this way, and their capacity to improve in future — as revealed by the ebbing tide created by the pandemic.
It draws on substantial desk research and consultation with 17 experts which occurred either in discussions within an advisory board early in the project or through detailed interviews later. To organise and assess some of the more pertinent evidence, this project also developed, and introduces here, the Economist Intelligence Unit’s Vaccine-Preventable Disease Scorecard. This tool can assess the strengths and weaknesses of immunisation programmes in Emerging Economies, in particular in the wake of the pandemic.
The Scorecard encompasses five domains:
- Health system resources: assesses investment in and access to healthcare
- Vulnerability to disease transmission: focusing on social determinants of health
- Programme performance: appraising vaccine coverage, its maintenance of coverage over time and equity of coverage
- Surveillance, preparedness and adopting recommendations: reviewing the adoption of latest recommendations, the status of surveillance and preparedness for outbreaks
- Supply and demand: examining stockouts, storage monitoring, school policies and vaccine hesitancy
For this study, we have used the Scorecard to assess five countries chosen for their intrinsic importance and their diverse levels of economic and healthcare development: Argentina, Brazil, India, Mexico and Vietnam.
To provide a consistent overview, we have focussed on four diseases — measles, pertussis (or whooping cough), rotavirus-induced diarrhoea, and vaccine-preventable forms of meningitis — as well as seven vaccinations which can help control these, and which the WHO recommends for every country’s vaccine schedule.1
The point of the Scorecard is not to judge which country comes first or last: the gold medal here would be the elimination of preventable disease, not bragging rights over EIU scoring. Our hope, instead, is to start a discussion that will help every country get closer to that goal.
The key findings from our Scorecard and overall research programme include:
- In our study countries, all vaccine programmes provided sub-optimal coverage and required improvements of various kinds, even before the pandemic.
In 2019, for the seven vaccination doses that this study covers, no country reached 90% coverage of the target population (the minimum goal in the WHO’s Global Vaccine Action Plan). By the end of 2020, our Latin American countries did not reach this coverage level for any of our vaccines, and India for only three. Vietnam went from four to five vaccines with 90% coverage in 2020, but the country also faced much less disruption from the pandemic. The inability of all of our study countries to provide comprehensive vaccination coverage at internationally recommended rates arises from a range of issues. An overview of the Scorecard shows that strong national scores in given domains are rare. More often, the results are middling or weak in most fields. - Among our countries, those with greater health system resources are seeing declines in vaccination rates, but those with lower resources are placing a greater focus on achieving the benefits and value that childhood immunisations offer.
An attractive attribute of vaccination for health systems is the value for money which it provides. A recent analysis found that investment in childhood vaccination programmes led to a 16-fold return. These gains arose from lower overall health system costs and improved economic productivity for carers. A consequence of this low cost is that health systems in low-income states are able, if they choose, to out-perform ones in middleincome countries in this field. By any measure, our Latin American states have more highly resourced healthcare systems than our Asian study countries. In general, this also leads to better health outcomes in the better-resourced countries. In recent years, the picture for vaccinations is the reverse. Since 2015, coverage rates in Argentina, Brazil and Mexico have generally declined — albeit unevenly and at different speeds — while those in India have grown, and Vietnam’s generally high figures have remained largely stable. - The pandemic revealed the growing size of this split.
The impact of covid-19 on childhood vaccination rates exacerbated existing trends. As noted above, Vietnam continued to reach most children. India, although its routine immunisation programme was greatly disrupted with the arrival of its first wave of the pandemic in early 2020, showed an impressive ability to claw back lost ground by December. This was consistent with its steady improvement in performance in recent years. The Latin American study countries, however, generally saw ongoing declines in coverage. The few exceptions involved at most modest recoveries in coverage of specific vaccines that had all seen very poor performances in 2019. In 2020, these states provided only around three-quarters of their target populations the vaccines covered in this study. Seven or eight years earlier, such coverage had been nearly universal. - A loss of strategic focus helps explain the decline in Latin American vaccination levels, while political commitment undergirds performance in India and Vietnam.
One key explanation of the varying immunisation coverage in our countries is the extent of political commitment. In India, vaccination is a key governmental priority: planning, financial and human resources follow accordingly. It is also an important issue for the Vietnamese government. Argentina, Brazil and Mexico, in contrast, have all faced general economic austerity in the last five to six years. The result has been diminished health budgets with vaccination programmes seeing more substantial cuts than other areas of care. This decline in attention has had important knock-on effects. In Brazil and Mexico, institutions which helped direct vaccine efforts have been dissolved. Gaps in governance and a lack of resources have also led to practical problems such as increased stockouts. As experts from the region report, turning the decline around requires not just more resources, but also coherent strategies on how to use them effectively.
Although these specific problems are currently facing our Latin American countries, the lesson should apply to all, including India and Vietnam as the international funding for their vaccination programmes tapers off. Argentina, Brazil, and Mexico have shown over the years that they can deliver high levels of vaccine coverage. They have also shown how quickly that can diminish when focus is not maintained. - Public engagement should never simply be presumed.
Vaccine hesitancy, at least related to paediatric vaccination, is not currently a significant problem in any of our study countries outside of Brazil. Events there, however, show how quickly the issue can crystalise. Brazilian expert interviewees point to an inflection point around 2016, when rumours about dangers arising from certain inoculations began to spread rapidly, sparking concern in a growing proportion of the population. Even where hesitancy is low, however, eagerness by patients — or their parents and guardians — for vaccination to take place can wane, especially where the relevant diseases seem to be rare. Effective immunisation programmes need to be aware of how public opinion maybe evolving on vaccines and engage in public education efforts. The latter must respect those who raise issues as members of society with legitimate questions, rather than dismissing them as troublesome impediments to greater vaccination coverage. - The substantial progress seen against vaccine-preventable diseases is not irreversible.
Progress in our five countries against the vaccine-preventable diseases on which this study focuses has been notable in recent decades. In terms of incidence, measures against the pandemic, particularly public health-driven restrictions, have further dampened case numbers for these paediatric illnesses in much of the world. This breathing space should not fool policymakers into over-confidence. As lockdowns and behavioural mandates lift around the globe, communicable diseases will come roaring back. Without better vaccination coverage to support herd immunity, such resurgent conditions will include entirely preventable diseases. Measles’s high contagiousness makes it a useful bellwether. Even prior to the pandemic, at a global level, the incidence of measles was rising rapidly — by 556% between 2015 and 2019. This jump was not even, but driven by outbreaks in specific countries where vaccination programmes were weak. The situation is not yet this ominous in Latin America, but it is worrying that measles, once eliminated from the region, has reappeared in Argentina, Brazil and Mexico. These countries have so far addressed the problem with focussed, local vaccination campaigns in affected areas. Ultimately, though, without better routine vaccination across the population as a whole, the number of outbreaks will only grow. Ad hoc strategies alone will not suffice. - Paediatric vaccination programmes should use the assets developed for the fight against covid-19. Even as covid-19 has complicated efforts to continue routine childhood immunisation, investments to deal with the pandemic can provide tools for better paediatric vaccination programmes in the years ahead. These include: harnessing the value of public education about the role of vaccination and its public health benefits; integrating the improved and expanded health workforce skills related to delivering immunisations rather than letting them atrophy once no longer needed for covid-19 vaccination efforts; and repurposing information technology (IT) tools, such as India’s CoWIN, to improve capacity to monitor and deliver a range of vaccines to the entire target population.
Key takeaways for policymakers
- Vaccines don’t deliver themselves: they require ongoing political commitment, funding, and the application of a coherent strategy.
- Such strategies must take a broad overview of the diverse healthcare, social, economic and political factors which affect vaccination: every country has issues it needs to address, and these may differ from those of its neighbours.
- Existing strategies should be reviewed to consider how the investments, tools and lessons from the battle against covid-19 can bolster childhood immunisation programmes.
- Public engagement and interaction are fundamental to the ongoing effectiveness of vaccination programmes: hesitancy can develop quickly and the very success of immunisation in reducing incidence can undermine belief in the importance of the effort. Covid-19 has brought about greater awareness and understanding of vaccines, potentially providing a platform to improve awareness of routine childhood immunisations.
- Over-confidence can be deadly: without ongoing attention to vaccine programmes, diseases are likely to return and, with them, entirely preventable fatalities.
Acknowledgements
We would like to thank the following individuals who served as our expert panellists on the topic and provided guidance on the Scorecard:
- Dr Florencia Cahn, President of the Argentine Society of Vaccination and Epidemiology (SAVE) and member of the Advisory Committee of the Ministry of Health, Argentina
- Dr Carla Domingues, independent researcher, and former co-ordinator of Brazil’s National Immunisation Program, Brazil
- Dr Alejandra Gaiano, Paediatrician specialising in infectious disease, Hospital Materno Infantil de San Isidro, Argentina
- Dr Maria de Lourdes García García, Deputy Director of Prevention and Surveillance in Infectious Diseases, Center for Research in Infectious Diseases, National Institute of Public Health, Mexico
- Dr Karin Regina Luhm, Professor of the Graduate Program in Public Health, Universidade Federal do Parana, Brazil
- Dr Claudio Maierovitch Pessanha Henriques, Physician, Fiocruz Brasília, Brazil
- Dr Jaime Sepúlveda, Executive Director of Global Health Sciences, University of California, San Francisco, US
We would like to thank the following individuals and organisations for generously contributing their insight and expertise on paediatric immunisations for this report:
- Dr Raj Shankar Ghosh, Senior advisor, Vaccine Delivery, Bill &Melinda Gates Foundation, India
- Dr Jerome Kim, Director-General, International Vaccine Institute, South Korea
- Prof Heidi Larson, Director of The Vaccine Confidence Project, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, UK
- Dr Kayla Laserson, Deputy Director for Infectious Diseases and Vaccine Delivery, Bill & Melinda Gates Foundation, India
- Dr Gustavo Olaiz, General Co-ordinator of the Center for Research, Policies, Populations and Health (CIPPS) of the Faculty of Medicine of the National Autonomous University of Mexico, Mexico
- Prof Paul A. Offit, Director of Vaccine Education Center, Professor of Paediatrics at Division of Infectious Diseases at Children’s Hospital of Philadelphia, US
- Prof Walter A. Orenstein, Professor of Medicine, Epidemiology, Global Health, and Paediatrics, Associate Director of the Emory Vaccine Center, US
- Dr Arindam Ray, India country lead, New vaccines and immunisation systems, Bill and Melinda Gates Foundation, India
- Dr Gunjan Taneja, Program Officer, Vaccine Delivery, Bill & Melinda Gates Foundation, India
- Dr Pham Quang Thai, Vice Head of Communicable Diseases Control and Prevention, National Institute of Hygiene and Epidemiology (NIHE), Vietnam
1The vaccinations in question are doses one and three of diphtheria-tetanus-pertussis combined vaccine (DTP1 and DTP3); doses one and two of measles containing vaccine (MCV1 and MCV2); the rotavirus vaccine (RotaC); the third, and final, dose of haemophilus influenzae type B vaccine (Hib3), and the third and final dose of pneumococcal conjugate vaccine (PCV3). The last two also reduce incidence of certain forms of meningitis.
On September 30th 2021, Economist Events will be hosting a virtual panel discussion “The covid aftermath: rebuilding paediatric immunisation programmes”. Speakers include Dr Jerome Kim, Director-general, International Vaccine Institute; Dr. Raj Shankar Ghosh, Senior advisor, Vaccine delivery, Bill and Melinda Gates Foundation. The discussion will be hosted by Rohit Sahgal, Principal, Global Health (Asia), The Economist Intelligence Unit. Register to join.
About the author
Gerard is a Manager in the Health Policy and Clinical Evidence team. He holds a PhD in Public Health and Epidemiology from Maastricht University. His areas of expertise are health promotion, evidence synthesis and workplace health.
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