SIXTY-SIXTH WORLD HEALTH ASSEMBLY Provisional agenda item 16.1
A66/19 22 March 2013
Global vaccine action plan Report by the Secretariat
1. The Executive Board at its 132nd session in January 2013, considered and noted an earlier version of this report.1 The present document has been amended in response to Board members’ comments and updated to include details of recent developments. It also reports on the status of progress made towards achieving the goals of the Decade of Vaccines. 2. Four sets of activities are essential to put the plan into practice and to turn the actions into results: (1) development of guidance for putting the plan into practice; (2) completion and implementation of a mechanism for evaluation and accountability in alignment with the accountability framework for the United Nations Secretary-General’s Strategy for Women’s and Children’s Health;2 (3) securing commitments from stakeholders; and (4) publicizing the opportunities, while acknowledging the challenges, offered by the Decade of Vaccines. This report summarizes the progress made in these areas.
OPERATIONALIZING THE GLOBAL VACCINE ACTION PLAN 3. During the past few months, all regions have held technical meetings to review the strategies proposed in the action plan and the actions required at regional level. Progress in immunization activities and in implementing regional multi-year strategies and plans for immunization in alignment with the global plan will be reported to the respective regional committees in 2013. 4. WHO/UNICEF’s guidance for developing multi-year and annual national immunization plans3 is being updated in order to facilitate alignment with the global action plan’s goals and strategic objectives. The updated guidance will set out how the different elements of health systems can be used to ensure that multi-year immunization plans align better with broader national health sector plans. Guidance for Member States to develop national monitoring, evaluation and accountability processes that align with the corresponding regional and global processes will also be included in the update.
1 See document EB132/18 and the summary records of the Executive Board at its 132nd session, tenth meeting, section 3. 2 Commission on Information and Accountability for Women’s and Children’s Health. Keeping promises, measuring results. Geneva, World Health Organization, 2011 (http://www.who.int/woman_child_accountability/en/; accessed 13 December 2012).
WHO-UNICEF guidelines for developing a comprehensive multi-year plan (cMYP). Geneva, World Health Organization, 2005.
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PROPOSED FRAMEWORK ACCOUNTABILITY
FOR
MONITORING,
EVALUATION
AND
5. In resolution WHA65.17, the Health Assembly urged Member States to report every year to the regional committees on lessons learnt, progress made, remaining challenges and updated actions to reach the national immunization targets. The proposed framework for monitoring, evaluating and accountability in the implementation of the global vaccine action plan is intended to guide the content of annual progress reports submitted to the regional committees and the Health Assembly through the Executive Board. 6. Following the guidance of the Strategic Advisory Group of Experts on immunization, the proposed framework will be applied to: (1) monitoring results (defined as progress towards the action plan’s goals and strategic objectives); (2) documenting and monitoring stakeholders’ commitments to the action plan; (3) tracking resources invested in vaccines and immunization; and (4) inclusion of independent oversight and review of progress, through the Strategic Advisory Group of Experts, in the reporting to the governing bodies. 7. This proposed framework is designed to be aligned with the Accountability Framework for the United Nations Secretary-General’s Global Strategy for Women’s and Children’s Health1 and also to provide for reporting to the independent Expert Review Group2. The Accountability Framework refers to a cyclical process of monitoring, review and remedial action, in which progress is assessed, success documented, problems that need to be rectified identified, and prompt action taken as and where needed. It is structured around the 10 recommendations made by the Commission on Information and Accountability that are categorized as: (1) better information for better results; (2) better tracking of resources for women’s and children’s health; and (3) better oversight of results and resources. A similar cyclical process of monitoring, review and action is proposed for the framework for the global vaccine action plan.
Monitoring results 8. Progress towards the goals and strategic objectives of the action plan as measured by the respective indicators will serve as the basis for monitoring results throughout the decade. 9. Following the endorsement of the action plan by the Health Assembly, its monitoring indicators were reviewed, with consideration being given to the comments made by Member States during the Sixty-fifth World Health Assembly.3 Relevant disease-control programmes and technical experts were consulted in order to review and refine the existing indicators, develop operational definitions for each indicator, define the source(s) of data if they exist or how data may be collected, and to establish baselines, milestones and targets, as appropriate. Additional consultations were held by in person, by telephone or online, and feedback on the draft indicators was elicited from more than 600 people, representing different stakeholders, including representatives of civil society organizations and vaccine manufacturers. The indicators revised through this process were in turn reviewed and approved by the
1 Commission on Information and Accountability for Women’s and Children’s Health. Keeping Promises, Measuring Results. World Health Organization 2011 (http://www.who.int/woman_child_accountability/en/; accessed 13 December 2012). 2 3
http://www.everywomaneverychild.org/resources/independent-expert-review-group (accessed 28 November 2012).
Document WHA65/2012/REC/3, summary record of the third meeting (section 6) and fourth meeting (section 2) of Committee B.
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Strategic Advisory Group of Experts on immunization at its most recent meeting (Geneva, 6–8 November 2012). The updated list of indicators is annexed to this report. 10. In addition to the indicators for the action plan, a report on trends in vaccine prices, classified according to the procurement mechanisms used, will be presented for review by the Strategic Advisory Group of Experts. The Advisory Group will also be requested to advise on an appropriate indicator for monitoring such price trends. 11. Progress, as measured by the indicators, except those for research and development, will be reported annually to the Health Assembly through the Board. Progress towards the research and development goals and strategic objectives will be reported biennially.
Documenting and monitoring commitments for immunization 12. For monitoring commitments made to immunization activities, it is proposed to take advantage of the process used for the commitments to the Global Strategy for Women’s and Children’s Health. However, to enable the commitments earmarked for immunization to be tracked, they have to be explicit. Following the guidelines used for making commitments towards the Global Strategy for Women’s and Children’s Health, the Secretariat has formulated specific guidelines for making commitments related to immunization; these exemplify the types of commitment that could be made towards the Decade of Vaccines. 13. The types of commitment could include financial pledges, policy and service delivery. Efforts will be made to secure commitments from a broad range of stakeholders, including national governments, development partners, global agencies, civil society organizations, academia and professional societies, vaccine manufacturers and the private sector.
Monitoring resources invested in immunization 14. Resources invested in immunization will be tracked and monitored on a yearly basis throughout the decade, using the framework of the OECD/EUROSTAT/WHO System of Health Accounts 2011,1 the global standard for reporting spending in the health sector. The development process for the monitoring of resources invested in immunization will involve an emphasis on strengthening country capacity and creating a single platform for collecting and analysing all health expenditures, including those on priority diseases or programmes like immunization, and for preparing an annual report. This effort is intended to unify under a single platform other resource-tracking initiatives, such as those being undertaken on national health accounts, and those for (i) the Commission on Information and Accountability for Women’s and Children’s Health and (ii) the Global Fund to Fight AIDS, Tuberculosis and Malaria. This exercise will not only ensure regular and efficient reporting of good-quality data as part of the monitoring process, but will also promote accountability and sustainability for immunization financing. 15. Activities to track resources will focus on evaluating funding flows to support immunization programmes from national governments, development partners and, to the extent possible, civil society organizations at the global, regional and country levels. Findings will be reported for the 94 countries, territories and areas identified in the costing and financing analysis of the global vaccine
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Available at http://www.who.int/nha/sha_revision/en/ (accessed 26 February 2013).
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action plan.1 These countries, territories and areas include those classified as low-income or lower-middle-income at the time of the analysis and those that will continue receiving support from the GAVI Alliance for part of the Decade of Vaccines. Annual reporting by countries will be phased in, with an increasing number of countries reporting annually as national capacity is enhanced. Sources of data for the resource-tracking exercise include government reports, and records of expenditures incurred by development partner agencies and civil society organizations engaged in immunization activities, insurance providers, private entities and households. Funding flows will be evaluated both in total and, to the extent possible, with disaggregated data on expenditures for vaccines and delivery. Other possible disaggregation will be explored as the quality and breadth of data are examined more fully.
Oversight, review of progress and next steps 16. The regional and global level review will use WHO’s existing processes. At the global level the review process will be through the Strategic Advisory Group of Experts on immunization and to the Health Assembly through the Board. The proposed mechanism for the review and reporting at the global level is through the constitution of a working group on the Decade of Vaccines by the Strategic Advisory Group of Experts on immunization. The working group would consist of eight individuals with the technical expertise to review each component of the framework for monitoring, evaluation and accountability and would have the appropriate geographical and gender representation. 17. It is proposed that the Secretariat prepare and transmit annual reports on the Decade of Vaccines to the working group for detailed review, and that the assessment report and any draft recommendations for corrective actions from this working group be submitted to the Strategic Advisory Group for further review, on the basis of which the progress report for the Board and Health Assembly will be prepared. 18. At the regional level, WHO’s regional offices are considering the mechanisms for review and reporting to the regional committees. Member States would need to consider the review and reporting modalities at the country level. It is envisaged that countries will develop a national-level framework to monitor performance of immunization programmes as well as a review process to document best practices, identify problems and make recommendations for corrective action. At the country level, the National Immunization Technical Advisory Groups and the Interagency Coordination Committees may have important roles to play in this regard. 19. The process for collecting and synthesizing data based on the proposed framework has been initiated, with the first substantive report to the Strategic Advisory Group of Experts for immunization due in 2013. Following that, a report based on the assessment of progress by the Advisory Group will be provided to the governing bodies in 2014. The reports, once considered by the Health Assembly,
Afghanistan, Angola, Armenia, Azerbaijan, Bangladesh, Belize, Benin, Bhutan, Bolivia (Plurinational State of), Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Côte d’Ivoire, Cuba, Democratic People’s Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, El Salvador, Eritrea, Ethiopia, Fiji, Gambia, Georgia, Ghana, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iraq, Kenya, Kiribati, Kyrgyzstan, Lao People’s Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Marshall Islands, Mauritania, Micronesia (Federated States of), Mongolia, Morocco, Mozambique, Myanmar, Nepal, Nicaragua, Niger, Nigeria, Pakistan, Papua New Guinea, Paraguay, Philippines, Republic of Moldova, Rwanda, Samoa, Sao Tome and Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Sudan, Sri Lanka, Sudan, Swaziland, Syrian Arab Republic, Tajikistan, Timor-Leste, Togo, Tonga, Turkmenistan, Tuvalu, Uganda, Ukraine, United Republic of Tanzania, Uzbekistan, Vanuatu, Viet Nam, Yemen, Zambia, Zimbabwe, and Kosovo (in accordance with Security Council resolution 1244(1999)) and the West Bank and Gaza Strip.
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will also be sent to the independent Expert Review Group1 for inclusion in its report to the United Nations Secretary-General on the Global Strategy for Women’s and Children’s Health. 20. Available data on progress made toward achieving the goals for the Decade of Vaccines as of 2011 are summarized below. Progress made on poliomyelitis eradication is described in a separate report.2 21. Between 2000 and 2011, the reported incidence of measles at global level decreased by 65% from 146 to 52 cases per million population. In 2011 reported measles incidence was lowest in the Region of the Americas (2 cases per million), followed by the Western Pacific Region (12 cases per million), the South-East Asia Region (36 cases per million), the European Region (43 cases per million), the Eastern Mediterranean Region (61 cases per million) and the African Region (227 cases per million). However, despite this progress, a careful assessment of the comprehensive reports presented indicates that based on current trends and programme performance, the 2015 targets for immunization coverage and mortality reduction will not be met. On the same basis, it is also likely that the regional elimination targets for three regions will not be met by their respective target years: the European Region (2015), the Eastern Mediterranean (2015) and the African Region (2020). 22. By the end of 2011, 23 of the 58 countries targeted had been validated as having eliminated neonatal tetanus.3 Supplemental immunization activities targeting women of reproductive age are being implemented in the remaining countries to enable them to achieve the elimination target. 23. An estimated 83% of infants worldwide received at least three doses of diphtheria-tetanuspertussis-containing vaccine (DTP3) in 2011; 130 Member States achieved national coverage of at least 90% and 113 of them had sustained this level of coverage for three or more years. However, only 50 of them achieved coverage of at least 80% in each district or equivalent administrative unit; 49 did not achieve this target and 31 did not report subnational coverage data. Five countries (Ethiopia, India, Indonesia, Nigeria and Pakistan) accounted for 62% of all unvaccinated or under-vaccinated children in the world. 24. In 2011, 33 of the 141 Member States classified as low- or middle-income countries by the World Bank added one or more new or underutilized vaccines to their national immunization schedule. 25. Under-five mortality is declining. Among the 74 so-called Countdown countries,4 24 are now on track to achieve the Millennium Development Goal 4.
The independent Expert Review Group reports regularly to the United Nations Secretary-General on the results and resources related to his Global Strategy for Women’s and Children’s Health and on progress in implementing this Commission’s recommendations (available at http://www.who.int/woman_child_accountability/about/ierg/en/index.html, accessed 26 February 2013). 2 3
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Document A66/18.
The countries validated were: Bangladesh, Benin, Burundi, Comoros, Congo, Egypt, Eritrea, Ghana, Liberia, Malawi, Mozambique, Myanmar, Namibia, Nepal, Rwanda, Senegal, South Africa, Togo, Turkey, Uganda, Viet Nam, Zambia, Zimbabwe. 4 The Countdown countries consist of the States that bear the highest burden of child and maternal mortality and whose progress towards achievement of the Millennium Development Goals is monitored by a group of United Nations agencies through the countdown process.
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COMMUNICATING THE OPPORTUNITIES OF AND CHALLENGES TO THE DECADE OF VACCINES 26. In order to ensure progress towards the achievement of the goals and objectives of the Decade of Vaccines, coordinated advocacy and communication strategies and consistent messages will be required. These efforts will need to demonstrate the value of vaccines and secure the necessary commitments from all stakeholders, including national governments and communities. The 5th GAVI Alliance Partners’ Forum ‒ which was held in Dar es Salaam, United Republic of Tanzania, from 5–7 December 2012 ‒ provided an opportunity to advocate in support of the Decade of Vaccines and to the participants with update about developments since the endorsement of the global vaccine action plan by the Health Assembly. 27. WHO is working with UNICEF, the National Institute of Allergy and Infectious Diseases in the United States of America, the GAVI Alliance and the Bill & Melinda Gates Foundation and other partners to develop a communications strategy for World Immunization Week, the designation of which was requested by the Health Assembly in resolution WHA65.18. The Secretariat will produce a new information pack for World Immunization Week, which will take place from 24 to 30 April 2013. The pack will include multimedia features, a campaign essentials toolkit for event organizers, and relevant info-graphics. 28. A Global Vaccine Summit will be held in Abu Dhabi, United Arab Emirates on 24 and 25 April to coincide with World Immunization Week. The Global Vaccine Summit will continue the momentum of the Decade of Vaccines. 29. The Global Vaccine and Immunization Research Forum, to be held approximately every 18 months, will serve as an opportunity to track progress and to stimulate debate on the research agenda of the action plan. The Forum will be co-hosted by WHO, the United States National Institute of Allergy and Infectious Diseases, and the Bill & Melinda Gates Foundation in close collaboration with other major stakeholders. The first Forum will be held in early 2014.
ACTION BY THE HEALTH ASSEMBLY 30. The Health Assembly is invited to take note of the report, including the proposed framework for monitoring and evaluation and accountability.
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ANNEX SUMMARY OF PROPOSED INDICATORS Goal-level indicators and targets1 Goal Achieve a world free of poliomyelitis Meet global and regional elimination targets Target by 2015 Target by 2020
• Interrupt wild poliovirus transmission globally (by 2014)
• Certification of poliomyelitis eradication (by 2018)
• Neonatal tetanus eliminated in all WHO regions
• Measles and rubella eliminated in at least five WHO regions
• Measles eliminated in at least four WHO regions
• Rubella/congenital rubella syndrome eliminated in at least two WHO regions Meet vaccination coverage targets in every region, country and community Develop and introduce new and improved vaccines and technologies
• Reach 90% national coverage and 80% in every district or equivalent administrative unit with vaccines containing diphtheria-tetanuspertussis
• Reach 90% national coverage and 80% in every district or equivalent administrative unit with all vaccines in national programmes, unless otherwise recommended
• At least 90 low- and middle-income countries have introduced one or more new or underutilized vaccines
• All low- and middle-income countries have introduced one or more new or underutilized vaccines
• Licensure and launch of vaccine or vaccines against one or more major currently non-vaccine preventable diseases
• Licensure and launch of at least one platform delivery technology Exceed the Millennium Development Goal 4 target for reducing child mortality
• Reduce by two thirds, between 1990 • Exceed the Millennium and 2015, the under-five mortality rate (Target 4.A) Development Goal 4 Target 4.A for reducing child mortality
The working group of the Strategic Advisory Group of Experts on immunization on the Decade of Vaccines that will review the annual report of progress made in putting the global vaccine action plan into practice will also consider the development and addition of indicators that measure equity in access to vaccines between countries and an indicator to monitor integration of immunization systems into broader health systems.
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Strategic objective-level indicators Global vaccine action plan’s strategic objective All countries commit themselves to immunization as a priority Indicators
• Domestic expenditures per person targeted • Presence of an independent technical advisory group that meets defined criteria
Individuals and communities understand the value of vaccines and demand immunization both as a right and a responsibility
• Percentage of countries that have assessed (or measured) confidence in vaccination at subnational level1
• Percentage of unvaccinated and under-vaccinated people in whom lack of confidence was a factor that influenced their decision
The benefits of immunization are equitably extended to all people
• Percentage of districts with 80% or greater coverage with three doses of diphtheria-tetanus-pertussis-containing vaccine
• Reduction in coverage gaps between lowest and highest wealth quintile and another appropriate equity indicator Strong immunization systems are an integral part of a well-functioning health system
• Dropout rate between first dose and third dose of diphtheriatetanus-pertussis-containing vaccines
• Sustained coverage with diphtheria-tetanus-pertussiscontaining vaccines ≥ 90% for three or more years
• Immunization coverage data assessed as high quality by WHO and UNICEF
• Number of countries with case-based surveillance for vaccine-preventable diseases that meets quality standards Immunization programmes have sustainable access to predictable funding, quality supply and innovative technologies2 Country, regional and global research and development innovations maximize the benefits of immunization
• Percentage of doses of vaccine used worldwide that are of assured quality2
• Progress towards development of vaccines against HIV infection, tuberculosis and malaria
• Progress towards a universal influenza vaccine (protecting against drift and shift variants)
• Progress towards institutional and technical capacity for conducting vaccine clinical trials
• Number of vaccines that have either been re-licensed or licensed for use in a controlled-temperature chain at temperatures above the traditional 2–8 ºC range
• Number of vaccine-delivery technologies (devices and equipment) that have received WHO prequalification compared to 2010
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Provisional indicator to be finalized in light of the outcomes of pilot assessments in selected regions. The report on progress will also narrate advances in vaccine supply, pricing and procurement.
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