A shot in the arm

No pain, no gain

GLOBAL-HEALTH experts are often a glum lot, but a few billion dollars should be enough to perk anybody up. Over the past decade the Global Alliance for Vaccines and Immunisation (GAVI), founded with the help of the Bill and Melinda Gates Foundation, has become the world's main advocate of immunisation. Last year Mr Gates announced a new “decade of vaccines”. But it seemed unclear whether the vast sums needed to pay for it would really be available; GAVI said it needed $3.7 billion between now and 2015 for new vaccines, mainly to prevent pneumonia and diarrhoea, the biggest killers of young children. On June 13th, at a conference in London, the group got its wish, and more, with donors pledging $4.3 billion to help immunise 250m children.

If they come through with the money, the world may be indeed on the verge of a vaccine boom. Drug firms have been researching vaccines for everything from addiction to cancer. As important, the past decade has seen changes in how vaccines are developed, financed and delivered—solving, at least partially, the conundrum of the vaccine market: poor regions have ample demand for vaccines but little ability to pay for them. As a result, immunisation rates in the poor world have soared.

One reason for this success is increased competition among manufacturers, largely thanks to vaccine-makers in emerging markets. The Serum Institute of India, for instance, says that its vaccines now immunise half the world's children. Another is GAVI itself. Before its creation, UNICEF offered short-term tenders for vaccines. By contrast, GAVI has insisted on higher volumes and long-term contracts to attract manufacturers and drive down prices. The alliance has had particular success with the hepatitis B vaccine. From 2000 to 2010 GAVI's support led to the immunisation of 267m children, according to the World Health Organisation (WHO).

Yet introducing other vaccines has proved harder. Take the pentavalent vaccine, which combines immunisation against five diseases, such as whooping cough and diphtheria, into one. Its price has remained high, because it was expensive to develop. “You can't rely on competition alone to bring down price,” says Nina Schwalbe, GAVI's policy director.

Hence the effort to find new financing models. The Gates Foundation has experimented with “push” financing, to develop a cheap vaccine against meningitis A. Thanks to cash for production facilities and technology from America's Food and Drug Administration, the Serum Institute now makes the vaccine for around 50 cents a dose. GAVI is testing “pull” financing, promising cash to any firm that comes up with an effective pneumonia vaccine. It will pay Pfizer and GlaxoSmithKline (GSK) $3.50 a dose for this, with a guarantee of 30m doses each year for a decade. Donors will pitch in extra cash. Neither mechanism, however, is perfect. The price for the meningitis vaccine is now so low that other suppliers are reluctant to enter the market. And price and purchase guarantees may fail to encourage innovation.

Different vaccines will require different models. Some may be pushed by grants while still in the early stages of development. In other cases, high prices in the rich world can subsidise low ones in poor countries. For example, on June 6th Merck and GSK said they would offer developing countries a lower price for their vaccines to fend off diarrhoeal disease.

Other solutions may yet emerge. The WHO is studying the issue. Mr Duncan Learmouth of GSK suggests that donors invest in a portfolio of basic research to reduce the risk of betting on one technology. And innovative manufacturers from the developing world will continue to help, argues Mickey Chopra, UNICEF's chief of health. In March the WHO said that Chinese firms could begin submitting vaccines for approval.

Progress depends on the continued support of rich countries and on new activity from poor ones. Developing countries must play a greater role in setting clear priorities, argues Princeton University's Adel Mahmoud. The past decade saw a surge in innovation in the financing and development of vaccines. The next ten years will require even more.