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Special Representative to GAVI-eligible Countries
Credit: GAVI/2014/Mercy Ahun
I was happy to be in Sokoto, northern Nigeria last month to see how the introduction of the latest batch of pentavalent vaccines funded by the GAVI Alliance was progressing.
I was encouraged by the words of mothers who had brought their young babies to be immunised at Ringin Sambo Urban Clinic. They welcomed the pentavalent vaccine because it means one injection instead of two for their children – a key message when Nigeria introduces two more injectable vaccines in the near future, inactivated polio vaccine and pneumococcal vaccine against the primary cause of pneumonia.
The mothers waited patiently for health staff to collect the five-in-one vaccines from the district cold store. The clinic had been given its own fridge two years ago to protect vaccines from high temperature, but a lack of solar panels to power the unit meant it was never installed. With GAVI-funded fridges due to reach Sokoto later in 2014, I was comforted to learn that both the State and the 23 LGA chairmen had signed a Memorandum of Understanding with the federal government stating clearly roles and responsibilities for cold store maintenance.
"This is the first time that we are putting such measures in place even before the arrival of the fridges," said the Executive Secretary of the Primary Health Care Board.
Unlike previous versions, the GAVI-funded ‘solar direct drive’ fridges do not need batteries to run. This new technology avoids the risk of batteries being stolen and requires minimal maintenance.
Sokoto State began introducing GAVI Alliance-supported pentavalent vaccine in December last year as part of Nigeria’s drive to roll out the vaccine over a record 18 months instead of the three-year period initially planned. Prior to the vaccine’s introduction in 14 Nigerian states in June 2012, there had been widespread stock outs of DTP (diphtheria, tetanus and pertussis) vaccine and other routine immunisation vaccines.
Pentavalent’s three-phase introduction across Nigeria underlines the power of public-private partnership. With the National Primary Health Care Development Agency in the lead, WHO, UNICEF,the Clinton Health Access Initiative, the GAVI Alliance, the Bill & Melinda Gates Foundation and other partners have worked together to plan, provide training and oversee the national rollout of the vaccine
This included biweekly partner conference calls connecting three continents- Africa, Europe and North America- to ensure partners were fully up to speed on supply chain, logistics, data issues, etc. across the country.
Such thorough preparation brought the opportunity to identify and fix potential issues in the national introduction. For example, during work by Alliance partners to support the procurement of new equipment, train staff and link supply chain to other parts of the health system, we discovered incorrect recordings of the new vaccine. This led to an estimated loss of one third of pentavalent data for the first group of States rolling out the vaccine. We were able to act promptly to address this.
At Basansan Rural Health Clinic, the officer-in-charge pointed to planning charts for immunisation sessions pinned to walls. These showed DTP3 coverage for 2013 was 67% and more than 90% in urban and rural clinics respectively.
I asked why the 2013 Demographic & Health Survey registered Sokoto with single digit coverage. ”Ha, many reasons,” said the TSHIP volunteer (a Maternal and Newborn Child Health project funded by USAID), “The denominator is too low for example – there are more babies in our catchment area than the projected figures we receive from authorities.” This would lead to an artificially high administrative coverage misleading health workers to believe that they have covered all existing children. A coverage survey usually reflects true coverage on the ground.
The Executive Secretary was also very clear on the challenges that Nigeria still faces in rolling out new vaccines:
With all of the above in mind, we discussed next steps and how we can improve coordination in the state.
GAVI’s Special Representative to GAVI Eligible Countries
I am delighted to participate to the European Development Days (EDD), Europe’s premier forum on international affairs and development cooperation organised by the European Commission.
It is a landmark event in the development calendar and an important opportunity to share knowledge and experiences with European development practitioners and partners worldwide. It is also a major opportunity to discuss what works and what does not work on the ground without losing sight of the fact that millions of mothers, kids and families rely on our work to have a better life. Together with all stakeholders, we will examine solutions to shared problems in order to achieve a Decent Life for all by 2030, as this year's EDD sheds light on the post-2015 development agenda.
One of the next decade’s challenges will be non-communicable diseases and, more specifically, cancer. Vaccines play a critical role in preventing the infections that cause certain cancers like liver and cervical cancers. The prevention of the infectious causes of cancer through hepatitis B and human papillomavirus (HPV) vaccines can help fight the rising global burden of cancer deaths.
Since 2001, the GAVI Alliance has supported the immunisation of 360 million infants against hepatitis B in the poorest countries of the world. Ghana, my country, recently started to protect girls against cervical cancer with GAVI-supported HPV vaccines.
When I was in charge of the Expanded Program on Immunization in Ghana, I saw the urgent need to make girls and women’s health a priority. Cervical cancer now kills as many women as childbirth, claiming a life every two minutes in some countries. More than 85% of them happen in low-income countries, where infections are higher and fewer women have access to screening and treatment. Without changes in prevention and control, cervical cancer deaths are expected to increase to 430,000 each year by 2030, virtually all in developing countries.
Sweden hosted GAVI’s Mid-Term Review a few weeks ago where key results were highlighted: the Alliance is on course to reach its mission target of immunising an additional 243 million children between 2011 and 2015. By 2014, all 73 GAVI-supported countries will have introduced the 5-in-1 pentavalent vaccine, including Haiti, Myanmar, Somalia and South Sudan.
It would not have been possible without The European Union. The GAVI Alliance and the European Institutions have worked hand in hand to ensure leadership in global health issues and help achieve MDG 4. From 2003 to 2012, the European Institutions have contributed to financing vaccines introductions in GAVI-eligible African Caribbean Pacific (ACP) states with other donors. Moreover, 10 European Union member states are GAVI donors, seven of which are among the top 10 GAVI donors. Most of them provide long-term predictable funding, thereby enabling effective market-shaping and sustainable routine immunisation programmes in the ACP states and beyond.
I would like to thank the European Union at large for its major contribution and I am pleased to see the impact on the ground of taxpayers’ euros. I was recently in Nigeria for the launch of the National Routine Immunisation Strategic Plan and in Cambodia to attend the very important meeting of the GAVI Board. My visits and discussions showed the importance of country ownership in ensuring the sustainability of programmes.
Vaccines offer a giant step forward in the prevention of cancer caused by infectious agents. As research accelerates and technology evolves, new vaccines are on the horizon against other infections associated with cancer bringing the promise of a quiet revolution in cancer prevention. A new development agenda cannot be built without immunisation that leads to a healthy future for all nations.
Yesterday Bill Gates and Ali Dangote, two billionaires with a passion for immunisation, joined Nigeria's Federal Minister of Health, Prof Onyebuchi Chukwu, in the nation's capital Abuja to launch Nigeria's National Routine Immunisation Strategic Plan.
The ceremony was also attended by dignitaries including His Eminence, the Sultan of Sokoto, the spiritual head of Muslims in Nigeria, the Chairs of the Senate and House Committees on Health, as well as staff from government, faith-based groups, development partners, civil society organisations and the private sector. But amidst the VIPs, children from Bema Home, a local orphanage, were there to remind all those present why we were there and of the need to invest in immunisation - to secure the future for our children.
I was there representing GAVI's CEO, Dr Seth Berkley, and to give a short address on GAVI’s total US$ 700 million commitment to Nigeria since 2001 and the prospects for future support. GAVI has worked with Nigeria for 12 years, supporting the introduction of new and underused vaccines – pentavalent, yellow fever, Meningitis A and measles - and the strengthening of health systems.
Over this period, I have followed the twists and turns, highs and lows in its programme performance. Small peaks in coverage have been interspersed with vaccine shortages, cold chain breakdowns and outbreaks of vaccine preventable diseases. Last December the country held a ‘Get back on track’ meeting, following a prolonged vaccine shortage earlier that year and in 2011, where the bottlenecks facing the programme were outlined and seven strategies for a programme turnaround were agreed upon. By the end of 2012, I was pleased to inform my colleagues in Geneva that 2013 was looking positive for Nigeria’s routine immunisation programme.
The resolve of the leadership and commitment of the National Primary Health Care Development Agency is indeed bearing fruit. As is the use of terms like ‘100% bundling of vaccines and syringes’ and its monthly monitoring of coverage data. In terms of data quality we are not yet there, but all partners around the table agree that 2013 coverage is much better than the two previous years and GAVI-supported pentavalent introduction has contributed to the positive turnaround. Health workers who have not been trained for years have had a new lease of knowledge on injection safety and adverse events, supply chain issues have been highlighted and are being addressed, and improvement of data quality is now on everyone’s agenda.
I’m certainly coming back in December, to see the last group of states introduce penta and follow-up on how states and Local Government Areas are translating the National Routine Immunisation Strategic Plan into work plans for 2014 and 2015.
In a previous life when I was a National Immunisation Programme Manager in Ghana, I saw firsthand the challenges that many African states face in delivering healthcare. Last week, while attending the Ministerial Forum on China-Africa Health Development, representing the GAVI Alliance, I was struck by the common legacy that China and countries across Africa share in overcoming such obstacles, and the important gains that have been made.
China and African countries also share a vision for the future: one where all citizens have a chance to lead healthy and productive lives. Our governments understand the African proverb that if you want to go fast, go alone, if you want to go far, go together.
To forge the path ahead, dozens of health ministers from across Africa and high-level Chinese government officials met at the Ministerial Forum on China-Africa Health Development in Beijing, China last week. Along with representatives of international organisations including the United Nations, they explored ways to strengthen their partnership towards greater health gains across the continent.
Ministers at the Forum also signed the Beijing Declaration of the Ministerial Forum on China-Africa Health Development, which sets a vision for a continued partnership to address a number of pressing health issues that affect Nigeria and other African countries disproportionately. Among these are HIV, malaria, schistosomiasis, reproductive health, immunisation and vaccine-preventable diseases. The declaration also highlights efforts to address the shortage of healthcare workers and increase joint research efforts. Moving forward, China-African cooperation will aim to align with African countries’ priorities as well as national and regional development plans.
These new actions at the forum build on the long-standing health partnership between China and African countries, which began when China first sent medical teams to the continent 50 years ago. Since then, China has worked with countries to establish hospitals, clinics and malaria control centers in many African countries as well as sharing technical expertise to help address health issues.
Recognising these past efforts, officials at the forum emphasised that they are entering a “new era” of Sino-African health cooperation that will meet the health needs and priorities of African countries more effectively, including Nigeria.
By working together as partners from the Global South, China and African countries can help develop sustainable, local solutions to health challenges. Addressing shortages of doctors, nurses and health technicians and improving health facilities are just some of the ways that the partnership can drive greater health impacts across the continent. Additionally, China and African countries are exploring ways to increase access to high-quality, low-cost health technologies produced in China that can make a public health impact.
China’s partnership with Africa draws on the lessons it has learned from improving the health of its own citizens, and is generating solutions to many health issues, issues which continue to affect millions of Africans.
Although many countries on the continent have made progress in increasing access to vaccines, many children still remain unimmunised. Through advances in disease surveillance, service delivery and research and development, China has reduced childhood deaths and illness from diseases such as polio, which was once widespread.
Another example is China’s partnership with the GAVI Alliance to increase access to immunisation against hepatitis B, a disease that can cause chronic liver infection and cancer. Just a decade ago hepatitis B infected one in 10 Chinese children. Today, less than one percent of children under five are chronic carriers. Such an improvement shows the dramatic gains that can be achieved by expanding access to immunisation. Through sharing best practices, technical expertise and innovations, China and Africa’s partnership can work towards addressing other health priorities across the continent.
Chinese and African leaders at the forum further pledged to develop a strategy that is responsive to the needs and priorities of African countries, and which invests in country-led development. The Nigerian government, like many of its counterparts across Africa, aims to create a health agenda that is led by African leaders and health professionals and which puts the country on a path toward sustainable progress. In May, when I joined African and Chinese officials at the International Roundtable on China-Africa Health Collaboration in Botswana, we engaged in similar consultations to help inform policies and initiatives for the partnership moving forward.
Chinese and African partners will work closely with multilateral and international organisations to help strengthen and scale-up joint efforts. The GAVI Alliance is committed to supporting China-Africa health cooperation to drive even greater impact.
Health plays a key role in reducing poverty and helping the world’s poorest communities build self-sufficiency and accelerate their own development. When people are healthy, they can reach their fullest potential. Through collaboration on health, China, Nigeria and other African countries will help advance the well-being and prosperity of all of their citizens. China and African countries have built a strong partnership over the past 50 years and, together, they can achieve even more in the decades to come.
Photo credit: GAVI/2012/Olivier Asselin
I accompanied GAVI CEO, Dr Seth Berkley, on a joint country visit with Bill Gates to Ghana two weeks ago. This was Mr Gates' first visit to the Ghana Health Service.
We spent our first morning in the field, visiting the Community-based Health Planning & Services initiative’s compound, which is part of the strategy for changing primary health care from a focus on clinical care at district and sub-district levels to a new focus on high quality services at community and doorstep locations.
The Community Health Officers were working at an outreach clinic, under a shady tree providing some cover from the hot sun. They showed us their child registers and 'Well Baby Clinic' cards with records of vaccinations, weight and other relevant child health records. This particular district is also using mobile phone technology to register pregnant women. Regular messages, including vaccination appointments are sent in the local language to mothers.
The Community Health Officers use this mobile technology to generate a list of expected clients and defaulters for follow up. They also use paper systems of child health cards and registers as well as logbooks in clinics to track a child’s progress with vaccinations.
Mr Gates witnessed real progress in using the paper system and the culture of data that it supports. For example, the district holds regular monthly meetings to validate data before it is shared with higher levels.
At the end of the day, the health workers were happy with Mr Gates summary of the visit: "The system is not perfect but it works."
I was reminded of his words in subsequent conversations I had with family and friends the following week. My cousin, a dermatologist, praised the Community Health Officers for the way they keep and use immunisation data. Monthly inter-district review meetings were opportunities to share best practices and validate data on reproductive and child health including immunisation. She wished clinical services were as organised as the preventive services organised by the Community Health Officers.
At a subsequent dinner organised by some retired public health colleagues, one of them described how medical students he examined could not remember the last time they saw a case of clinical measles. He spoke eloquently about the dedication of Community Health Officers at peripheral levels of the health care system in bringing services including immunisation to communities. Countries unhampered by the scourge of vaccine preventable diseases can rise to their full developmental potential, he said.
More should be done by the Ghana Health Service and development organisations to publicise how we are contributing to national prosperity. Strong primary health care systems are the bedrock of successful immunisation programmes, which ultimately contributes to saving lives.
I was at Yar Akwa health post in Kano, Northern Nigeria last Friday. We had 2 Community Health Extension Workers (CHEW) preparing to vaccinate about 15 children who have shown up with their mothers for the vaccination session. I started a discussion with the mothers on reasons for vaccinating their children.
They believe immunisation is critical for the well-being of their children. Measles was mentioned as the most feared vaccine preventable disease. It causes blindness, deafness and pneumonia among others. I was flooded with memories from the paediatric wards in Kumasi, Ghana where I did my house job as a newly qualified doctor; 3 -4 children squeezed into a cot with the complications mentioned above from a measles outbreak. This is why I got into public health. Ghana has improved routine measles coverage since then with no recorded measles death since 2003 (measles vaccine coverage was 91% in 2011).
I first heard about GAVI in November 1999 while on a short course on Epidemiology at the CDC in Atlanta. I had gone to the offices of the Hepatitis branch to solicit support for Hepatitis B vaccine introduction in Ghana’s immunisation programme. ‘Don’t you worry’, a staff member told me. An organisation called GAVI is going to be set up soon. They will solve all your problems. They will provide support for new vaccine introduction in developing countries. I heaved a sigh of relief and waited with bated breath for the creation of the new public-private partnership.
I was not disappointed. Ghana was one of the first countries to apply for GAVI support in June 2000. We introduced the pentavalent vaccine (five-in-one shot against diphtheria, tetanus, pertussis, hepatitis B and Hib) in December 2002. Other new vaccines followed.
By the end of 2011, GAVI had contributed to the immunisation of an additional 325 million children, who might not otherwise have had access to vaccines, and averted more than five-and-a-half million future deaths.
The GAVI Alliance Board in June 2012 approved support for measles supplementary immunization activities for Nigeria to sustainably prevent measles deaths.
I was in Ghana last week, following up on preparations to introduce two new vaccines against diarrhoea and pneumonia. I had visited Akwapim North district, some 50km from the hustle and bustle of Accra. The view from the hills was serene and the air felt fresh after a light rain. Dr Joseph Opare, the District Director of Health Services (DDHS) and Rachel, the District Disease Control Officer took me round the district, visiting health facilities and outreach centres.
As we chatted between visits to villages I probed deeper to get a better understanding of why immunisation coverage is increasing in his district, (DTP3 >90%). I had attended the 2011 performance review meeting of senior health managers in Accra the previous day. The national DTP3 coverage is stagnating around 88% and there was general agreement that it was mainly due to late release of funds for service delivery.
He described how his team strategized to increase coverage:
What struck me was how the DDHS focused on his area of influence to improve service delivery and coverage without pointing fingers at others. He had other issues to deal with as we went round: suspected measles outbreak (5 cases), industrial action by some health workers, a cholera case, plus the fact that I had taken him away from other duties he had to perform that morning…
Much discussion has gone into the importance of country ownership in ensuring sustainability of programmes. District ownership is critical to increasing and maintaining high coverage. Districts like Akwapim North need to be encouraged to continue innovating to save lives.
Mercy AhunDr Mercy Ahun, GAVI’s Special Representative to GAVI Eligible Countries
I landed at 4.30 am in Trivandrum, Kerala State, and I could hardly contain my excitement. We have been working with India’s Ministry of Health and Family Welfare for the past two years after they were approved by the GAVI Board for pentavalent vaccine introduction; and finally it’s happening, with Kerala and Tamil Nadu, two states with high immunisation coverage, taking the lead.
At the Women and Children’s Hospital, Thycaud, Trivandrum, the media were out in force to report on the first launch of pentavalent vaccine in the public sector in India.
Speaking in Malayalam, The Minister of State of Health told the crowd of 150 why the state was introducing pentavalent vaccine. He said they had put together a group of experts and determined they could further reduce by half their relatively low infant mortality of 16 per 1000 live births by 2015.
I said a few words on behalf of GAVI, expressing our support for Kerala’s achievement. The first baby was vaccinated and by the end of the first day about 6,000 infants had been vaccinated. The target is 530,000 infants for the year.
The pentavalent vaccine has been used in private clinics for a decade already. Introduction in the public sector is a matter of equity and fairness for all. Babies from low-income families also have rights!
The Director of Immunisation of an adjacent district I visited asked “Where do you come from?”, “Ghana,” I responded. “Have you introduced Penta in your country?”, “Yes, we introduced in 2002”. “You mean you introduced almost 10 years ago!?”. This was followed by a reflective silence.
On my traffic jammed way back to Trivandrum, I reflected about my experiences of seeing countries introduce new vaccines -- the excitement, the involvement of politicians and other key stakeholders and how the profile of the immunisation programme has increased after the doldrums of the post-Universal Childhood Immunisation years. We still have a long way to go in improving the programme.
My next stop is Tamil Nadu.
After arriving in Chennai, I called Dr Jameela , the state director of health services in Kerala, to thank her for the warm reception. She told me about the upsetting news of an adverse event following the previous day’s immunisation. Together with the state government, our partners from WHO and UNICEF immediately started investigating.
The venue for the launch of pentavalent vaccine in Tamil Nadu is the Alamelrangapuram Primary Health Care centre in Vellore.
We met a bigger crowd; twice the size of Trivandrum, the dais was decorated with flowers and had big banners to mark the occasion. The state was organising a double launch for pentavalent and a campaign against smoking. I met the PHC director and her staff who showed me round the centre. The mothers with their babies to be vaccinated were seated and wore their numbered badges. It was clear which baby was to be vaccinated first. A very orderly arrangement!
The press with their cameras were also there in numbers. I was introduced to WHO and UNICEF staff and also met Dr Jacob John, the former chair of the National Technical Advisory Group on Immunisation (NTAGI). He was clearly excited about the introduction of pentavalent vaccine into the public health system after it has been used in private clinics for some eight years.
The State Minister of Health arrived at 11am with his retinue. Among the speakers at the ceremony were the Minister for Development, Mayor, Local Assembly representative. The State Minister of Health who is a doctor gave the first shot. I jostled with the cameramen to get a good view and a photograph.
Finally, an hour and a half later, the launch had gone smoothly, all the babies have been vaccinated.
Mission accomplished. Pentavalent vaccine is finally launched in the public sector in India.
At a point in time it looked like it wasn’t going to happen this year, but the GAVI Alliance has “country-driven” as one of our core principles and India determined when it was ready to introduce and informed us. All I did was rely on my colleagues in India to make it happen. And they did. Additional states have indicated their interest to introduce penta in the near future.
Thanks to all who made this possible.
Mercy AhunManaging Director, Programme Delivery, GAVI Alliance
Immunising children against polio in remote Ghanaian villages a decade or so ago, I came across a case of pneumonia that has haunted me to this day.
After riding pillion on a motorbike for hours through cornfields, we arrived in a small hamlet of three mud huts. The men were eating lunch and the women were on the periphery, attending to their ‘household chores’. We extended traditional greetings and asked to see any children under the age of five.
From the corner of my eye, I noticed a young child, about 18 months old, lying on a mat and I took a closer look. She was an ill looking toddler with fast and shallow breaths. I touched her. She was feverish. I did not need my stethoscope to diagnose pneumonia.
We did not have antibiotics with us, the only effective treatment. So I told the father he must take her to the nearest clinic.
You must not be serious, his body language said. He could only get to the nearest clinic, more than 20 miles away by borrowing a neighbour’s tractor. But he would still have to find fuel and his daughter would be dead on arrival.
He turned away, pain in his eyes. This was clearly not the first time he had faced a similar situation. I stood there riveted. How could I leave this child to die?
A couple of decades later, I still wonder what happened to this child. My mind refuses to accept the obvious. But this is my motivation for working at the GAVI Alliance.
GAVI now supports developing countries to introduce the pneumococcal vaccine that protects against pneumonia, the biggest killer of children. With sufficient donor support, this vaccine could save 7 million lives by 2030.
And then maybe, I’ll never see such a tragic scene again.
This blog post is also featured on the Bill & Melinda Gates Foundation website.
Growing up in a Ghanaian coastal village, the dry and dusty trade winds that blew in from the Sahara were associated with Advent, Christmas, and happiness.
But as I moved inland with my work, they also became linked with meningococcal meningitis A, Ghana’s most common form of meningitis, which brought major epidemics every 8 to 12 years.
Meningitis A strikes children and young adults suddenly, causing severe headaches, fever, and a stiff neck. Patients can die within 48 hours.
I still remember the hospital wards, where I used to work. Meningitis patients were usually on the floor because their seizures made them fall off the bed. As a medical student, I often had to bend the rigid patients into a foetal position so that I could extract the cloudy fluid from their spinal cord and confirm the suspected diagnosis. Year after year, we gave intravenous antibiotics every four hours and prayed the patient would survive without major complications.
MenAfriVac, a new vaccine against Meningococcal Meningitis seroptype Nm A, is expected to prevent meningitis epidemics in Africa's "meningitis belt" of 25 countries that stretch from Senegal in the west to Ethiopia in the east.
In 1989, I became the district medical officer responsible for preventive health of a city of one million people. On one memorable occasion, with an epidemic threatening, a terrified crowd of people nearly broke down the vaccine cold store door in an attempt to get the vaccine. The fear on their faces was palpable.
Then, in 1997, the biggest ever meningitis A epidemic struck, not just in the four northern regions as usual - but throughout the country - hitting about 20,000 people.
And just a few years later, in 2001, a close relative of mine - a healthy 20 year old - began complaining of a headache. He later collapsed and was given intravenous antibiotics. Within 48 hours he was dead.
His death devastated my family, with rumours amok about the role of evil spirits. A decade later, my extended African family is still coming to terms with the loss.
I’m proud to say the GAVI Alliance has just committed another US$100 million to support the roll-out of a new conjugate vaccine, MenAfriVac™, to rid the region of these meningitis A epidemics. If our pledging conference is successful on 13 June, GAVI will be able to roll this vaccine out to all African countries at risk.
This Christmas, I am taking my children back to Ghana. The new MenAfriVac™ vaccine gives us the opportunity to celebrate without fear of this ancient scourge. It provides us hope for the future.
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