Title of Section (TK)

Global Vaccine
Action Plan
2011–2020

page 1

WHO Library Cataloguing-in-Publication Data
Global vaccine action plan 2011-2020.
1.Immunization programs. 2.Vaccines – supply and distribution. 3.Health Promotion.
4.Research. 5.National health programs. I.World Health Organization.
ISBN 978 92 4 150498 0 			(NLM classification: WA 115)© World Health Organization 2013

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Printed in the USA

Credits // Photography (photographer, courtesy of) / Cover photo: Saiful Huq Omi, GAVI
Alliance / p. 12: PAHO/WHO / p. 13: Olivier Asselin, GAVI Alliance / p. 15: Amy McIver, PATH /p. 16: Anna Grove, National School of Tropical Medicine / p. 18: PAHO/WHO / p. 19: Olivier
Asselin, Sabin Vaccine Institute / p. 20: PAHO/WHO / p. 21: Gabe Bienczycki, PATH /p. 22, left: Gabe Bienczycki, PATH / p. 22, middle: PAHO/WHO / p. 22, right: Lesley Reed,
PATH / p. 23, left: PAHO/WHO / p. 23, middle: Amy McIver, PATH / p. 23, right: Esther Havens,
Sabin Vaccine Institute / p. 25: PAHO/WHO/ p. 26: Gabe Biencyzcki, PATH / p. 27: Gabe
Bienczycki, PATH / p. 29: Lesley Reed, PATH / p. 31: Olivier Asselin, Sabin Vaccine Institute /p. 33: Esther Havens, Sabin Vaccine Institute / p. 36: Amy McIver, PATH / p. 40: Olivier Asselin,
GAVI Alliance / p. 41: PAHO/WHO / p. 43: GAVI Alliance / p. 47: Jessica Stuart, Sabin Vaccine
Institute / p. 48: Esther Havens, Sabin Vaccine Institute/ p. 52: Esther Havens, Sabin Vaccine
Institute / p. 54: Amira Al-Shairf, GAVI Alliance / p. 55: Shirley Villadiego, PATH / p. 56: Olivier
Asselin, GAVI Alliance / p. 60: Patrick McKern, PATH / p. 61: Jessica Stuart, Sabin Vaccine
Institute / p. 66: Esther Havens, Sabin Vaccine Institute / p. 67: Esther Havens, Sabin Vaccine
Institute / p. 68: Olivier Asselin, Sabin Vaccine Institute p. 69: Jessica Stuart, Sabin Vaccine
Institute / p. 71: Lesley Reed, PATH / p. 73: Photomorphic, iStock / p. 77: Olivier Asselin,
Sabin Vaccine Institute / p. 78: Olivier Asselin, Sabin Vaccine Institute / p. 81: Esther Havens,
Sabin Vaccine Institute / p. 83: Olivier Asselin, Sabin Vaccine Institute p. 89: Josef Muellek ,iStock / p. 91: Olivier Asselin, Sabin Vaccine Institute / p. 95: Saiful Huq Omi, GAVI Alliance /p. 101: Olivier Asselin, Sabin Vaccine Institute / p. 108: Gabe Bienczycki, PATH / p. 115: Bartosz
Hadyniak, iStock / p. 125: Olivier Asselin, Sabin Vaccine Institute // Design: büro svenja

Global Vaccine
Action Plan
2011–2020

page 2

Table of Contents

Global Vaccine Action Plan

page 3

Table of Contents

1.
4 Foreword2.
8 T he Global Vaccine
Action Plan
10	Introduction
14

The Immunization Landscape Today

22

Six Guiding Principles

24

Measures of Success

28

Goals of the GVAP

32

Actions to Achieve Strategic Objectives

34	Strategic objective 1: All countries
commit to immunization as a priority
38	Strategic objective 2: Individuals andcommunities understand the valueof vaccines and demand immunization
as both their right and responsibility44	Strategic objective 3: The benefits ofimmunization are equitably extended
to all people3.
50	Strategic objective 4: Strong
immunization systems are an
integral part of a well-functioning
health system
58	Strategic objective 5: Immunization
programmes have sustainable
access to predictable funding, quality
supply and innovative technologies
64	Strategic objective 6: Country, regionaland global research and development
innovations maximize the benefitsof immunization72	Health Returns on Investment
in Immunization
80	Continuing Momentum for the Decadeof Vaccines (2011-2020)

84 Global Vaccine
Action Plan 2012
World Health
Assembly Resolution

4.
88 Annexes
90	Annex 1: Recommended Indicators
94	Annex 2: Stakeholder Responsibilities100	Annex 3: Costing and Funding
Methodology and Assumptions
114	Annex 4: Health Impacts andMethodology Assumptions
120	Annex 5: Countries and Organizations
that Contributed to the Elaborationof the GVAP
124	Annex 6: The Monitoring and
Evaluation/Accountability Framework5.
144 Acknowledgements& Contact

page 41.

Global Vaccine Action Plan

Foreword

Foreword
The Global Vaccine Action Plan (GVAP) is aframework approved by the World Health Assemblyin May 2012 to achieve the Decade of Vaccines visionby delivering universal access to immunization. The
mission outlined in the GVAP is straightforward:
improve health by extending by 2020 and beyond thefull benefits of immunization to all people, regardlessof where they are born, who they are, or where they live.
Overwhelming evidence demonstrates the benefitsof immunization as one of the most successful andcost-effective health interventions known. Over the
past several decades, immunization has achieved
many things, including the eradication of smallpox,
an accomplishment that has been called one ofhumanity’s greatest triumphs. Vaccines have saved
countless lives, lowered the global incidence of polioby 99 percent and reduced illness, disability and deathfrom diphtheria, tetanus, whooping cough, measles,
Haemophilus influenzae type b disease, and epidemic
meningococcal A meningitis.

page 5

page 6Foreword

Global Vaccine Action Plan

Further progress has been made in introducing vaccines against pneumococcal
disease and rotavirus diarrhoea as well as vaccines which prevent chronic diseases
such as liver and cervical cancer.
We are facing a pivotal moment in history. Right now, the global health community
has an unprecedented opportunity to coordinate with governments to develop
and implement plans and strategies that will improve the lives of millions of people
around the world through universal access to appropriate vaccines.
Together, we can overcome the hurdles that remain in delivering vaccines toevery corner of the planet. These powerful tools are already available to most, but
not yet all, people. To extend immunization to everyone, the GVAP seeks to ensure
adequate resources, develop supportive health systems and infrastructure, andwork with countries to train health workers needed to reach remote and marginalized
populations. The plan also articulates the need for a concerted effort to develop
new and improved vaccines and technologies that will help maximize the benefitsof immunization around the world for years to come.
This ambitious action plan to reach all people with the vaccines they need is the
product of the Decade of Vaccines Collaboration, an unprecedented effort thatbrought together development, health and immunization experts and stakeholders.
The powerful idea that vaccines work and save lives must now be shared with amuch broader audience, using such vehicles as World Immunization Week andothers to promote universal vaccination and help focus on current challenges
related to immunization. While dedicated health workers immunize people daily
in all countries, World Immunization Week gives countries and organizations
additional, focused opportunities to raise public awareness of how immunization
saves lives—during the same week, every year, in every country.
When they endorsed the GVAP, health officials of 194 countries also declared thatthe completion of polio eradication is a programmatic emergency for global health,asking for sufficient funding to complete the initiative. Polio eradication is an early,
major milestone in the implementation of the GVAP.
Our aim is to build on past achievements and use our know-how and experience tosave more lives. This plan, that builds on the WHO-UNICEF Global Immunization
Vision and Strategy, and the GAVI Alliance Strategy, provides the guiding

principles and strategic objectives that will enable immunization of more
people against more diseases; introduce newly available life-saving vaccines andtechnologies; and coordinate immunization and other critical health interventions.
The plan also suggests key targets for further research and development.
The Decade of Vaccines Leadership Council, along with all partners—governments
and elected officials, health professionals, academia, manufacturers, global
agencies, development partners, civil society, media and the private sector—are
committed to achieving the ambitious goals of the GVAP.
Together we will track and measure progress through the GVAP and the UN
Secretary General Global Strategy for Women’s and Children’s Health
Accountability Frameworks.
Many more are expected to add their support in the future as the plan is translated
and implemented at the country and regional levels. The success of this ambitious
global plan will be one of the most enduring legacies for today’s children and thegenerations who follow them.

Dr. Seth Berkley
Chief Executive Officer
GAVI Alliance

Dr. Margaret Chan
Director General
World Health Organization

Dr. Christopher Elias
President
Global Development Program
Bill & Melinda Gates Foundation

Dr. Anthony Fauci
Director
US National Institute of Allergies
and Infectious Diseases

Mr. Anthony Lake
Executive Director
United Nations Children’s Fund (UNICEF)

Ms. Joy Phumaphi
Executive Secretary
African Leaders Malaria Alliancepage 7

page 82.

Global Vaccine Action Plan

Global Vaccine Action Plan

Global Vaccine
Action Plan
In May 2011, a report by the Secretariat on the global
immunization vision and strategy was noted by
the Sixty-fourth World Health Assembly.1 During thediscussions the vision for the Decade of Vaccines(2011–2020) and the development of a Global Vaccine
Action Plan were welcomed. Subsequently, theExecutive Board at its 130th session in January 2012
considered the Global Vaccine Action Plan andprovided guidance.2 The Board also adopted resolution
EB130.R12 on World Immunization Week.3 The
final plan was endorsed at the 65th World Health
Assembly in May 2012.

1	See WHO documents A64/14 and WHA64/2011/REC/2, summary records of the sixth meeting, section 2, the seventh meetingand the eighth meeting, section 2.
2 	See WHO documents EB130/21 and EB130/2012/REC/2, summary record of the eleventh meeting.
3 	See WHO document EB130/2012/REC/1 for the resolution, and for the financial and administrative implications for the
Secretariat of the adoption of the resolution.

page 9

page 10Global Vaccine Action PlanTitle of Section (TK)Introduction
The Global Vaccine Action Plan builds on the successof the Global Immunization Vision and Strategy,
2006–2015, which was launched in 2005 as the first
10-year strategic framework to realize the potentialof immunization. Developing the plan has brought
together multiple stakeholders involved in immunization, including governments and elected officials,
health professionals, academia, manufacturers,
global agencies, development partners, civil society,media and the private sector, to define collectively
what the immunization community wants to achieve
over the next decade. In total, the global consultation
process reached over 1100 individuals representing
more than 140 countries and 290 organizations, andincluded two special sessions to brief representativesof the Permanent Missions of the United Nations
Offices and other Intergovernmental Organizationsin Geneva and New York.

i
Developing the planbrought together morethan 1100 individuals
in 140 countries,
representing 290
distinct organizations

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page 12Introduction

Global Vaccine Action Plan

Immunization is, and should be recognized as, a core component of the humanright to health and an individual, community and governmental responsibility.
Vaccination prevents an estimated 2.5 million deaths each year. Protectedfrom the threat of vaccine-preventable diseases, immunized children have theopportunity to thrive and a better chance of realizing their full potential. Theseadvantages are further increased by vaccination in adolescence and adulthood.
As part of a comprehensive package of interventions for disease prevention andcontrol, vaccines and immunization are an essential investment in a country’s—
indeed, in the world’s—future.
Now is the time for showing commitment to achieving the full potential of
immunization. The collective recognition of this opportunity has led the global
health community to call for a Decade of Vaccines, in line with the requests
made in resolution WHA61.15 on the global immunization strategy. The vision
for the Decade of Vaccines (2011–2020) is of a world in which all individuals andcommunities enjoy lives free from vaccine-preventable diseases. The missionof the Decade of Vaccines is to extend, by 2020 and beyond, the full benefit
of immunization to all people, regardless of where they are born, who they areor where they live.
The Global Vaccine Action Plan reiterates existing goals and sets new goals forthe decade, proposes six strategic objectives and the actions that will support
their achievement, and provides an initial estimate of resource requirements
and return on investment. Annex 1 summarizes recommended indicators tomonitor and evaluate progress. Beyond the action plan, country, regional andglobal stakeholders need to take responsibility for specific actions, translate
the action plan into detailed operational plans (updating both the action planand the operational plans as new information becomes available), complete
the development of an accountability framework for the Decade of Vaccines(2011–2020) and mobilize resources to ensure that the vision for the Decade of
Vaccines becomes a reality. Accomplishing this will require global and national
institutions to innovate and to change the way they work. Annex 2 provides asummary of stakeholder responsibilities.

The last century was, in many respects, the century of treatment, resulting indramatic reductions in morbidity and mortality, with the discovery and useof antibiotics as one of the biggest agents of change in health. This century
promises to be the century of vaccines, with the potential to eradicate, eliminate
or control a number of serious, life-threatening or debilitating infectious
diseases, and with immunization at the core of preventive strategies. Ensuringthat the vision for the Decade of Vaccines becomes a reality is a powerful stepin that direction.

This century promises tobe the century of vaccines

The vision

for the Decade of Vaccines (2011–2020) is of a world in which all individuals
and communities enjoy lives free from vaccine-preventable diseases.

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page 14

Global Vaccine Action PlanTitle of Section (TK)page 15The Immunization
Landscape Today
Important progress in the last decade
In the last 10 years, great advances have been madein developing and introducing new vaccines andexpanding the reach of immunization programmes.
More people than ever before are being vaccinatedand access and use of vaccines by age groups otherthan infants is expanding. As a result of immunization
combined with other health care and development
interventions—including improved access to cleanwater and sanitation, better hygiene and education—
the annual number of deaths among children underfive years of age fell from an estimated 9.6 million
in 2000 to 7.6 million in 2010, despite an increase in
the number of children born each year.

i
The annual number ofdeaths among children
under five years of age fell
an estimated 2 million from2000 to 2010

page 16

The Immunization Landscape Today

Global Vaccine Action Plan

Table 1:
Table 1: Vaccine-preventable infectious agents or diseases

Immunization has helped drive this reduction in child mortality: coverage ofvaccines that have been in use since the inception of the Expanded Programmeon Immunization has expanded, and new vaccines have been introduced.
Vaccines against hepatitis B and Haemophilus influenzae type b have become
part of national immunization schedules in 179 and 173 countries, respectively;
poliomyelitis is nearing eradication; and a large number of deaths from measles
are being averted every year. The number of deaths caused by traditional
vaccine-preventable diseases (diphtheria, measles, neonatal tetanus, pertussis
and poliomyelitis) has fallen from an estimated 0.9 million in 2000 to 0.4
million in 2010.4
New and increasingly sophisticated vaccines that have become available in thelast decade, including pneumococcal conjugate vaccine and vaccines against
infection with rotavirus and human papillomavirus, are currently being rolled
out globally. Efforts are being made to shorten the time lag that has historicallyexisted in the introduction of new vaccines between high- and low-income
countries. For example, pneumococcal conjugate vaccines were introduced
in low-income countries approximately a year after being introduced in highincome countries.
Through an innovative international collaboration, an affordable conjugate
vaccine against Neisseria meningitidis serogroup A was developed and is now
in use in the African meningitis belt.

Efforts are being made toshorten the time lag that hashistorically existed in the
introduction of new vaccines
between high- and lowincome countries

45

Anthrax

Measles

RubellaCholeraMeningococcal
DiseaseInfluenza

Diphtheria

Mumps

Tetanus

Hepatitis A

Pertussis

Tuberculosis

Hepatitis B

Pneumococcal
diseaseTyphoid fever

Hepatitis E

Poliomyelitis

Tick-borne
encephalitis

Haemophilus
influenzae type b

RabiesVaricella andherpes zoster(shingles)

Humanpapilloma-virus

Rotavirus
gastroenteritis

Yellow fever

Japanese
encephalitis

There are now licensed vaccines being used to prevent, or contribute to theprevention and control of, 25 vaccine-preventable infections (Table 1).
The strengthening by countries of national programmes, aided by improved
support from and coordination among local, national, regional and international
stakeholders, has succeeded in improving immunization coverage rates.
Financing from domestic budgets allocated to immunization programmes has
risen over the past decade, as has the flow of international resources dedicatedto immunization. According to the immunization programme data for 2010,5
154 of the 193 Member States report having a specific budget line item for
immunization, and 147 have developed multi-year national plans to sustain thegains achieved, further enhance performance to reach desired goals andintroduce appropriate new vaccines.

4 Sources for estimates: measles and neonatal tetanus, in World Health Statistics 2012, Geneva, World Health Organization,
2012; diphtheria and poliomyelitis, for 2000: http://www.who.int/healthinfo/global_burden_disease/estimates_regional_
2000_v3/en/index.html (accessed 5 April 2012), for 2008: http://apps.who.int/ghodata/ (accessed 5 April 2012); pertussis,
WHO Secretariat provisional data.
5 http://www.who.int/immunization_monitoring/data/en/ (accessed 13 April 2012).

page 17

page 18

The Immunization Landscape Today

Global Vaccine Action Plan

page 19

Significant unmet needs remain

Global and regional immunization initiatives have supported countries inbuilding up their systems and introducing new vaccines. Global goals andmilestones established through the Global Immunization Vision and Strategy
2006–2015, the United Nations Millennium Declaration, the United Nations
World Summit for Children, the United Nations General Assembly Special
Session on Children, and, more recently, the United Nations Secretary-General’sGlobal Strategy for Women’s and Children’s Health have stimulated expansionof national immunization programmes. In low- and middle-income countries
these have been supported by initiatives such as the GAVI Alliance, the Global
Polio Eradication Initiative, the Measles Initiative, the vaccine procurement
services of UNICEF, and PAHO’s Revolving Fund for Vaccine Procurement.

Despite this progress, vaccine-preventable diseases remain a major cause ofmorbidity and mortality. Adoption of new vaccines by low- and middle-income
countries (where disease burdens are often the highest) has been slower thanin high-income countries. In 2010, for example, only 13% of the total highincome country birth cohort lived in countries that did not have pneumococcal
conjugate vaccines in their immunization schedules. Of the total low-income
country birth cohort, 98% lived in countries that did not have pneumococcal
conjugate vaccines in their schedules.

Reaching underserved
populations will be especiallychallenging, but inequities
need to be tackled because
these populations often
carry a heavier disease burden

Coverage gaps persist between countries, as well as within countries. The
average coverage with three doses of diphtheria-tetanus-pertussis-containing
vaccine and with measles-containing vaccine in low-income countries was 16%
and 15% below that of high-income countries in 2010, respectively. However,this represents a positive trend in comparison with the coverage gap of 30%
for both vaccines in the year 2000.
In some countries, coverage of measles-containing vaccine in rural areas is
33% lower than in urban areas. Similarly, the measles vaccine coverage rate
for the richest fifth of the population in some countries is up to 58% higher
than for the poorest fifth. Coverage can also be very low in settlements of theurban poor, especially in cities with transitory migrant populations, and inindigenous communities.
Geographical distance from health centres is not the only determinant of
low coverage; inequities are also associated with other socioeconomic
determinants, such as income levels and the educational status of the mother.
A special geographic focus is needed on lower-middle-income countries withlarge populations, where the majority of the unvaccinated live. Reachingunderserved populations will be especially challenging, but inequities need tobe tackled because these populations often carry a heavier disease burden andmay lack access to medical care and basic services, with the fragile economies
of individuals and their families suffering a severe disease-related impact asa consequence.

16%

lower DTP3 coverage in
low-income countries thanin high-income countries
in 2010

page 20The Immunization Landscape Today

Global Vaccine Action Plan

New opportunities and challenges for the Decadeof Vaccines (2011–2020)

Immunization funding needs in the areas of research and development,
procurement and delivery are expected to more than double in the coming
decade. New and more complex vaccines will bring new funding
requirements and countries will be confronted with difficult decisions indealing with competing health priorities. Resources will need to be allocatedmore efficiently, with the relevant decisions guided by national priorities,
capacity, clear information on the costs and benefits of choices, and improved
financial management. Expenditures must be linked to outputs and impacts,
showing a clear investment case for immunization.

Individuals and communities, governments and health professionals haveprimary responsibility for exploiting the opportunities and confronting thechallenges that this decade will bring. New and improved vaccines are expected
to become available, based on a robust pipeline that includes several vaccines
for diseases that are not currently preventable through vaccination. The
introduction of new vaccines targeted against several important causes of major
killer diseases, such as pneumonia, diarrhoea and cervical cancer can be used
as a catalyst to scale up complementary interventions. In addition to reducing
mortality, these new vaccines will prevent morbidity with resulting economic
returns even in countries that have already succeeded in improving mortality
rates. Innovations in existing vaccines will bring additional benefits, suchas greater effectiveness, thermostability, easier administration and lower cost.
At the same time, the development of vaccines and other immunization
innovations is facing increasingly complex manufacturing and regulatory
processes, as well as rising research, development and production costs. As
new vaccines (for example, against dengue and malaria) become available
and underutilized vaccines (for example, those against cholera, humanpapillomavirus, rabies, rotavirus, rubella and typhoid) are administered more
widely, supply and logistics systems—already burdened—will face an evengreater need for innovations. Finally, the number of health workers, as well as
their knowledge and skills, will need to be enhanced, better coordinated andbetter supervised. While the challenges are many, the introduction of new
vaccines also represents an opportunity to strengthen immunization systems
and to act as a catalyst to implement many of the required reforms. As
national immunization investments increase, so must government oversightand accountability.

page 21

The number of healthworkers, as well as theirknowledge and skills,
will need to be enhanced

As the economies of many low- and middle-income countries continue togrow, so will their potential to fund immunization. Countries that have reliedon development assistance will be able to fund an increasing proportion of theirimmunization programmes, and may even, eventually, be able to fully sustain
them. Some will be able to extend new financial and technical support to global
immunization projects. At the same time, vaccine manufacturers in some ofthese countries will be expected to make an even more significant contribution
to the supply of high-quality, affordable vaccines, spreading the sources of
production more widely and increasing competition.
The growing availability of information and penetration of mobile telephoneand social networks can boost public demand for immunization, and ensurethat people are made aware of both the benefits derived from vaccines and theirpotential risks. The immunization community can take advantage of social
networks and electronic media to more effectively allay fears, increase awarenessand build trust.
The lessons learnt from past decades, the unmet needs, and the opportunities
and challenges that this decade presents have been carefully considered in theformulation of the guiding principles, measures of success and recommended
actions articulated in the following sections.

As the economies of many
low- and middle-income
countries continue togrow, so will their potential
to fund immunization

page 22

Six Guiding Principles

Global Vaccine Action Plan

page 23

Six Guiding Principles
Six principles have guided the elaboration of
the Global Vaccine Action Plan.

1

2

3

4

5

6

Country ownership

Shared responsibility
and partnership

EquityIntegration

Sustainability

Innovation

equitable access to immunization
is a core component of the rightto health.

strong immunization systems, as partof broader health systems and closely
coordinated with other primary healthcare delivery programmes, are essential
for achieving immunization goals.

informed decisions and implementation
strategies, appropriate levels offinancial investment, and improved
financial management and oversightare critical to ensuring the sustainabilityof immunization programmes.

the full potential of immunization can
only be realized through learning,
continuous improvement and innovationin research and development, as wellas innovation and quality improvement
across all aspects of immunization.

countries have primary ownershipand responsibility for establishinggood governance and for providing
effective and quality immunization
services for all.

immunization against vaccinepreventable diseases is an individual,
community and governmental
responsibility that transcends
borders and sectors.

These six fundamental principles can realistically and effectively guide thefull spectrum of immunization activities throughout the Decade of Vaccines(2011–2020). Although the Global Vaccine Action Plan will need to be translated
into specific regional, country and community contexts, these guiding principles
are universally applicable and relevant to each of the Decade of Vaccines’ goals
and strategic objectives described below.

page 24

Global Vaccine Action PlanTitle of Section (TK)i

Measures of Success
The Decade of Vaccines is about taking action toachieve ambitious goals. Early in the decade,this means achieving already established eliminationand eradication goals. It means dealing with the
public health emergency constituted by wild
poliovirus transmission in order to secure a world
free of poliomyelitis. It also means assuring the
global or regional elimination of measles, rubella
and neonatal tetanus. Completing this agenda
has never been more critical. Success will encourage
the achievement of additional ambitious goals.
Failure will mean millions of preventable cases of
disease and death will continue to occur.
66 	By 2015, achieve maternal and neonatal tetanus elimination (defined as less than one case of neonatal tetanus per 1000
live births) in every district, measles elimination in at least four WHO regions and rubella elimination in at least two WHO
regions. By 2020, achieve measles and rubella elimination in at least five WHO regions.

By 2020, coverage of target
populations should reach atleast 90% national vaccination
coverage and at least 80%
vaccination coverage inevery district or equivalentadministrative unit for
all vaccines in national
immunization programmes

page 25

page 26

Measures of Success

Global Vaccine Action Plan

page 27

Later in the decade, success will be recorded in terms of the expansion of
immunization services to meet vaccination coverage targets in every
region, country and community. In 2015, the coverage of target populations
should reach the goal of the Global Immunization Vision and Strategy, 2006–
2015 of at least 90% national vaccination coverage and at least 80% vaccination
coverage in every district or equivalent administrative unit (the marker forthis being coverage for diphtheria-tetanus-pertussis-containing vaccines). By
2020, coverage of target populations should reach these levels for all vaccines
in national immunization programmes unless alternative targets exist.
Vaccine introductions should also be monitored, with the goal of at least 80
low- or middle-income countries introducing one or more appropriate new orunderutilized vaccines by 2015. These technical accomplishments will not besustained unless countries take full ownership of their routine immunization
programmes (see strategic objective 1 below).
During this decade millions of additional deaths and cases of disease should
become preventable as a result of the development, licensure and introductionof new and improved vaccines and technologies for high-burden diseases.
Specifically, progress towards the licensure and launch of vaccines should betracked against one or more major pathogens not currently vaccine preventable(such as, cytomegalovirus, dengue virus, group A streptococcus, hepatitis C
virus, hookworm, leishmania and respiratory syncytial virus) and at least one
new platform delivery technology.

Meet vaccination targets
in every region, country,
and community

page 28

Goals of the Decade of Vaccines

Global Vaccine Action Plan

Goals of the Decade of
Vaccines (2011–2020)
Achieve a world freeof poliomyelitis

Meet global and regionalelimination targets

Meet vaccination coveragetargets in every region,
country and community

Develop and introduce
new and improved vaccines
and technologies

Exceed the Millennium
Development Goal 4 target
for reducing child mortality

MDG4

If these immunization-specific goals are achieved,
hundreds of millions of cases and millions of future
deaths will be averted by the end of the decade,billions of dollars of productivity will be gained, andimmunization will contribute to exceeding theMillennium Development Goal 4 target for reducing
child mortality (and the target that succeeds it post-2015).

For example, it is estimated that if the coverage targets for introduction and/or sustained use of 10 vaccines alone (those against hepatitis
B, Haemophilus influenzae type b, human papillomavirus, Japanese
encephalitis, measles, meningococcus A, pneumococcus, rotavirus,
rubella and yellow fever) in 94 countries during the decade aremet, between 24 and 26 million future deaths could be averted
compared with a hypothetical scenario under which these vaccines
have zero coverage (see also Annex 4).

24-26
million future deaths
could be averted

page 29

page 30

Six Strategic Objectives

Global Vaccine Action Plan

page 31

Six Strategic Objectives
Continuous progress towards the following Six
Strategic Objectives will enable the achievement of
the goals of the Decade of Vaccines (2011–2020).

1

2

3

4

5

6

All countries commit
to immunization as a priority.

Individuals and communities
understand the value of vaccinesand demand immunization as boththeir right and responsibility.

The benefits of immunization are
equitably extended to all people.

Strong immunization systems
are an integral part of awell-functioning health system.

Immunization programmes havesustainable access to predictable
funding, quality supply andinnovative technologies.

Country, regional and global
research and development
innovations maximize the benefitsof immunization.

Key indicators to monitor progress
towards this strategic objective will be
the percentage of routine immunization
costs financed through government
budgets and globally installed capacity
for production of universally recommended
vaccines within five years of licensure/potential demand.

Key indicators of progress towards thisstrategic objective include proof of concept
for a vaccine that shows greater or equal to
75% efficacy for HIV/AIDS, tuberculosis or
malaria and the initiation of phase III trials
for a first generation universal influenza
vaccine. In addition, country research anddevelopment capacity can be measured
by the institutional and technical capacity
to manufacture vaccines and/or carry out
related clinical trials and operational andorganizational research.

Key indicators to monitor progress towards
this strategic objective at the country
level are the presence of a legal frameworkor legislation that guarantees financing
for immunization and the presence of an
independent technical advisory group thatmeets defined criteria.

Progress towards increased understanding and demand can be evaluatedby monitoring the level of public trustin immunization, measured by surveys
on knowledge, attitudes, beliefs
and practices.

Progress towards greater equity can beevaluated by monitoring the percentage
of districts with less than 80% coveragewith three doses of diphtheria-tetanuspertussis-containing vaccine and coverage
gaps between lowest and highest
wealth quintile (or another appropriate
equity indicator).

The strength of health systems can beevaluated based on dropout rates
between the first dose of diphtheria-tetanuspertussis-containing vaccine and thefirst dose of measles-containing vaccine.
The quality of data is important formonitoring the functioning of a healthsystem. Data quality can be evaluated bymonitoring whether immunization
coverage data is assessed as high quality
by WHO and UNICEF.

page 32

Global Vaccine Action PlanTitle of Section (TK)

Actions to Achieve
Strategic Objectives
Achieving the vision and goals of the Decade of
Vaccines (2011–2020) will only be possible if all
stakeholders involved in immunization commit
themselves to, and take action to achieve, the six
strategic objectives; uphold the Decade of Vaccines
guiding principles when implementing all theactions; and regularly monitor and evaluate progress
towards both strategic objectives and goals using
the indicators described above (see also Annex 1).

i
An accountability framework is neededthat defines the methodology and sourceof data for these indicators, identifies
which stakeholders will be responsible forwhat actions, and articulates the process
and responsibilities for monitoring andevaluating progress over the course of theDecade. The Global Vaccine Action Planlays the groundwork for each of theseelements. Further development andimplementation of the accountability
framework at country, regional and global
levels could take place over the course of2012 by leveraging the findings of

the Commission on Information andAccountability for Women’s and Children’s
Health and aligning work, wherever
possible, with other accountability
efforts and initiatives by all stakeholders
at the country level to deliver andmonitor progress.

All stakeholders involved
in immunization commit
themselves to, and takeaction to achieve, the six
strategic objectives

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page 34

Strategic Objective 1

Global Vaccine Action Plan

Strategic
objective1

All countries commit to immunization as a priority.
Committing to immunization as a priority first and foremost means recognizing
the importance of immunization as a critical public health intervention andthe value that immunization represents in terms of health and economic returns.
Countries demonstrate a commitment to immunization by setting ambitious
but attainable national targets and allocating adequate financial and humanresources to programmes to achieve these targets; ensuring that their national
immunization plans are fully integrated into national health plans, with appropriate budgets and formulated with the participation of all major stakeholders;and demonstrating good stewardship and implementation of their national healthplans. Country commitment to immunization does not, however, imply that
immunization programmes will be prioritized or funded at the expense of othervital health programmes.
National legislation, policies and resource allocation decisions should be
informed by credible and current evidence regarding the direct and indirect
impact of immunization. Much of the evidence base exists but does not reachpolicy-makers, as those who generate the evidence are not always those whointeract with these decision-makers. Collaboration between, on the one hand,
technical experts who generate the evidence and, on the other, the championsof immunization who construct context-specific messages that highlight theimportance of immunization within health and social services, canunequivocally articulate the value of immunization and how immunization
supports equity and economic development.

All countries: Establish and sustain commitment to immunization;
Inform and engage opinion leaders on the value of immunization;
Strengthen national capacity to formulate evidence-based policies.

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Strategic Objective 1

Global Vaccine Action Plan

Independent bodies, such as regional or national immunization technicaladvisory groups, that can guide country policies and strategies based on local
epidemiology and cost effectiveness should be established or strengthened,thus reducing dependency on external bodies for policy guidance. Thesebodies can readily be supported by institutions or individuals charged withcollating and synthesizing information required for informed decisionmaking. Regional support systems and initiatives, such as the PAHO ProVac
initiative,7 can be expanded to support countries in strengthening theirdecision-making. It is important that national immunization technical advisorygroups or their regional equivalents, engage with academia, professionalsocieties, and other national agencies and committees, such as the vaccine
regulatory agencies, national health sector coordination committees, and interagency coordination committees, in order to ensure a cohesive and coordinatedapproach to achieving national health priorities. Strong links between
ministries of health, education8 and finance, as well as human resources andlegislators are also essential for sustainable programme implementation.
Support and formal endorsement of national policies and plans at the highest
political and administrative levels, nationally and subnationally, is consideredessential for ensuring commitment and sustainability. Governments andelected officials are responsible for putting in place necessary legislation andbudget allocations. As immunization is a strong indicator of the overall
ability of the health system to deliver services, legislators should be encouraged
to scrutinize, defend and closely follow immunization budgets, disbursements
and immunization programme activities, both at the national level and within
their respective constituencies. Civil society organizations can effectively
advocate for greater commitment and hold governments accountable forcommitments once they are made. Immunization programmes need to havemanagement structures for programme implementation to be effective. Officials
at the national and subnational levels responsible for implementation of theimmunization plans can be held accountable for programme performance when
they are sufficiently empowered to provide effective leadership and have therequired management and programme monitoring skills.

For high- and middle-income countries, commitment to immunization should
cover the same areas, but may also include maintaining or assuming therole of development partners. Together with global agencies, development
partner countries can coordinate the sharing of information and best practices
among countries, help bridge temporary funding gaps, and support capacity
strengthening by working with stakeholders in different country settings.

Table 2: Summary of recommended actions for strategic objective 1
All countries commit to immunization as a priority.

Ensuring that national
immunization plans
are fully integrated into
national health plans

Establish and sustain
commitment to immunization.

Inform and engage opinion leaderson the value of immunization.

Strengthen national capacity toformulate evidence-based policies.

Ensure legislation or legal framework
in all countries, including provisions
for a budget line for immunization,and for monitoring and reporting.

Explore models to promote collaboration between the stakeholders thatgenerate evidence on immunizationand those who use it in order to set
priorities and formulate policies.

Create, or strengthen existing,independent bodies that formulate
national immunization policies(for example, national immunization
technical advisory groups or regional
technical advisory groups).

Develop comprehensive national
immunization plans that are part ofoverall national health plans througha bottom-up process that includes
all stakeholders.
Set ambitious but attainable countryspecific targets within the context ofmorbidity and mortality reduction goals.
Scrutinize, defend and follow moreclosely immunization budgets,
disbursements and immunization
programme activities.
Support local civil society organizations
and professional associations tocontribute to national discussions on
immunization and health.

7	ProVac is a package of tools to support: (i) the estimation of cost-effectiveness and epidemiological and economic impact of new
vaccines; (ii) training; and (iii) the strengthening of national infrastructure for decision-making.
8	Especially important for delivering immunization to older children and adolescents through school health programmes and formonitoring school entry requirements with immunization.

page 37

Develop and disseminate the evidencebase on the public health value ofvaccines and immunization and theadded value of achieving equity inaccess and use of immunization.
Develop and disseminate the evidencebase for the broad economic benefitsof immunization for individuals, households, communities, and countries.
Include immunization in the agendas
of governing body meetings at alllevels and in other social, health andeconomic forums.

Develop more effective ways fornational regulatory agencies, healthsector coordination committees, andinteragency coordination committees
to support immunization programmes
as part of disease control programmes
and preventive health care.
Create regional forums and peer-topeer exchange of information, bestpractices and tools.
Create expanded and more transparent
mechanisms for aggregating,sharing and using information tomonitor commitments.

page 38

Strategic Objective 2

Global Vaccine Action Plan

Strategic
objective

2

Individuals and communities understand thevalue of vaccines and demand immunization as
both their right and responsibility.
Significant improvements in coverage and programme sustainability are possible
if individuals and communities understand the benefits and risks of immunization; are encouraged to seek services; are empowered to make demands on
the health system; and have ownership of the planning and implementation ofprogrammes within their local communities. Although there has generally beena high demand for vaccination services, accessing hard-to-reach populations,attaining higher coverage levels and achieving equity objectives may require
additional approaches to stimulate demand for vaccination.
Generating individual, household and community demand will require
using traditional platforms more effectively as well as new strategies to convey
the benefits of immunization, emphasize immunization as a core componentof the right to health and encourage greater use of services. New efforts
could take advantage of social media and approaches used by commercial andsocial marketing efforts to promote immunization and address concerns.
New mobile and Internet technologies should also be utilized, drawing on theexperiences and successes of other innovative public health campaigns.
Communications and social research to identify the barriers to and drivers ofvaccination should inform the development of context-specific messages.
Lessons on vaccines and immunization should be included in the primaryschool education curriculum. Multisectoral approaches that promote efforts,such as female education and empowerment, will help improve utilizationof immunization and health services in general.

Significant improvements in coverage and programme
sustainability are possible if individuals and communities
understand the benefits and risks of immunization

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Strategic Objective 2

Global Vaccine Action Plan

Where appropriate, programme strategies could also include measures toprovide an incentive both to households to seek immunization services andto health care providers to improve their performance in vaccinating children,
particularly those that have not been reached previously. At the household
level, conditional cash transfer programmes often include vaccination ofchildren as a requirement for receiving household income transfers. There isevidence that such programmes may have a positive impact on immunization
coverage rates, even in countries with high coverage rates, and particularly formore marginalized populations. Because conditional cash transfer programmes
are often administered in countries as part of a broad package of social protection
or poverty alleviation measures, these programmes provide an opportunity
to link immunization programmes and health ministries with other broader
development initiatives, including those administered by other ministries.
At the health facility level, both households and health care providers can befurther motivated by in-kind gifts at the time of vaccination, or by giving
performance-based financing bonuses to providers. There is some early evidence
to suggest that performance-based financing of immunization services leads
to increasing numbers of children being vaccinated, although more rigorous
analysis of the impact of performance-based financing on immunization is still
being carried out.
Providing incentives to health care workers and households through monetary
and in-kind gifts has implementation challenges that need to be carefully
addressed. These schemes need to respect the autonomy of beneficiaries.
Social research is also needed to determine the conditions under which incentives
contribute to improved coverage and the types and levels of incentives that areappropriate for a given context. Demand-generation activities must be coupledwith mechanisms to ensure reliability of vaccine supply.
Some reasons for hesitancy are undoubtedly amenable to improved communications and advocacy initiatives designed to counteract growing anti-vaccination
lobby groups and to increase understanding of the value of vaccines or of thedanger of diseases. However, others are best addressed by ensuring the qualityof the services provided. Individuals will be less hesitant to use services if they

Demand-generation
activities must be coupledwith mechanisms to ensure
reliability of vaccine supply

page 41

perceive the quality of those services to be acceptable. They are more likely tocome to vaccination sessions when scheduled services are convenient andpredictably available; when practical counselling is offered about where andwhen to come for vaccination and why, and about what to expect following
vaccination; when the health workers have a welcoming attitude; when waitingtimes are reasonable; and when services are offered without charge. Healthcare workers should receive training in effective communication to enable themto deal with the media and with local communities when there are reports ofserious adverse events following immunization, in order to allay fears and tackle
vaccine hesitancy.
Bringing about change will require the participation of individuals, households
and communities in the development and implementation of all demandgeneration strategies. It will also require new and stronger community-based
advocates with local knowledge, credibility and the front-line experience necessary
to drive change. The participation of in-country civil society organizations
will be crucial to develop strong advocacy efforts and should be supported bycapacity building. Here again, an effort that promotes collaboration between
evidence generators and evidence users could provide training for champions
and link with local social and professional networks, which are an importantsource of grass-roots immunization champions. This will especially be required
as country programmes embrace a life-course approach to immunization.
Current advocates must recruit new voices—potentially including educators,
religious leaders, traditional and social media personalities, family physicians,
community health workers and immunization champions. Researchers andtechnical experts will also have an important role in creating greatercommunity awareness and providing credible responses to misinformation
regarding immunization.
Generating individual and community demand will reinforce country
commitment to vaccines and immunization (strategic objective 1). Activities
to generate demand for vaccines and immunization should build on the broader
movement in order to help people to hold their governments accountable foraccess to health services.

There is some early
evidence to suggest that
performance-based
financing of immunization
services leads toincreasing numbers ofchildren being vaccinatedpage 42

Strategic Objective 2

Global Vaccine Action Plan

Table 3: Summary of recommended actions for strategic objective 2
Individual and communities understand the value of vaccines anddemand immunization as both their right and responsibility.
Engage individuals and communities
on the benefits of immunization andhear their concerns.
Engage in a dialogue which bothtransmits information and responds
to people’s concerns and fears.
Utilize social media tools andlessons learnt from commercial andsocial marketing efforts.
Leverage new mobile andInternet-based technologies.

Create incentives to stimulate demand.

Create incentives for households
and health workers in favour of
immunization, where appropriate,while respecting the autonomy ofbeneficiaries (for example, cash or
in-kind transfers, bundling of services,media recognition).
Conduct social research to improve thedelivery of immunization services andthe ability to meet the needs of diverse
communities.

Include immunization in the basic
education curriculum.

Train health-care workers in
effective communication techniques,
especially to address vaccine
hesitancy and to respond to reportsof serious adverse events following
immunization in order to maintain
trust and allay fears.
Engage, enable and support
in-country civil society organizations
to advocate the value of vaccines tolocal communities and policy-makers
and local and global media.
Create national or regional
advocacy plans that involve incountry civil society organizations.

Build advocacy capacity.
Conduct communications research.
Recruit new voices, including those of
educators, religious leaders, traditionaland social media personalities, family
physicians, community health workers,
and trained immunization champions(among others).

Link global, national and community
advocacy efforts with professional
and academic networks.

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Strategic Objective 3

Global Vaccine Action Plan

Strategic
objective

3

The benefits of immunization are equitably
extended to all people.
Today, four out of every five children receive at least a basic set of vaccinations
during infancy and are therefore able to lead healthier, more productive
lives. Unfortunately, this means one child in every five is not being reached. In
this decade, the benefits of immunization should also be more equitably
extended to all children, adolescents and adults. Achieving this strategic objective
will mean that every eligible individual is immunized with all appropriate
vaccines—irrespective of geographic location, age, gender, disability, educational
level, socioeconomic level, ethnic group or work condition—thereby reachingunderserved populations and reducing disparities in immunization both within
and between countries. Because disease burdens tend to be disproportionately
concentrated in more marginalized populations, reaching more people will
not only achieve a greater degree of equity, but will also achieve a greater healthimpact and contribute to economic development. Furthermore, diseaseeradication and elimination goals cannot be met without achieving and sustaining
high and equitable coverage.
In 2002, WHO, UNICEF and other partners introduced the concept of“Reaching Every District”, a first step toward achieving more equitable coverage.
Through its various operational components, which include re-establishingoutreach services, providing supportive supervision, engaging with communities,
monitoring and use of data and district planning and resource management,
the Reaching Every District strategy was able to expand the provision of
immunization services. Similarly, initiatives aimed at disease eradication andelimination or rapid mortality reduction have used strategies, such as nationalor subnational immunization days (for poliomyelitis eradication) andsupplementary immunization activities (for measles and rubella elimination,

Achieving this strategic objective will mean that every
eligible individual is immunized with all appropriate
vaccines—irrespective of geographic location, age,gender, disability, educational level, socioeconomic level,
ethnic group or work condition

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Strategic Objective 3

Global Vaccine Action Plan

measles mortality reduction and neonatal tetanus elimination). More recently,
strategies collectively referred to as periodic intensification of routine
immunization have been used to extend immunization to the unreached,packaged together with other primary health care interventions.
Even these strategies continue to miss populations, for example those that resideoutside traditional social and governmental structures. To sustain the gainsof these historical efforts and to achieve and sustain disease control goals, theReaching Every District strategic approach should be recast as “Reaching Every
Community”. To attain more equitable coverage, the definition of community
should be expanded beyond geographically defined communities. Reaching
every community will mean aiming to encompass every eligible individual, eventhose beyond typical government outreach.
Reaching every community will call for an understanding of the barriers toaccess and use of immunization; it will also require the underserved to be
identified, and micro-plans at the district and community levels to be reviewed
and revised in order to ensure that these barriers can be overcome. The
rapid expansion of information technology should be leveraged to establish
immunization registries and electronic databases that will allow eachindividual’s immunization status to be tracked, timely reminders to be sent
when immunization is due and data to be accessed easily to inform actions.
The introduction of unique identification numbers could be a catalyst for theestablishment of such systems.
Drawing on the experiences of successful poliomyelitis vaccination campaigns,
decentralized planning and outreach should be used to reach populations
that are remote or nomadic or that have been historically marginalized. New
strategies for reaching the urban poor and urban migrants will also be necessary.
Given the tenuous and evolving community structures and the inadequate
security involved, new approaches to community outreach will be especiallycritical for reaching these groups. This is all the more true in view of the factthat sometimes the most unifying force in these urban and peri-urban areas isa shared and deep-seated mistrust of outsiders, especially governments.

The Reaching Every
District strategic
approach should berecast as “Reaching
Every Community”

Implementing strategies to reach all underserved populations will require
engagement with the nongovernmental sector, including civil society
organizations and private sector organizations, and will need to involve all
aspects of immunization including advocacy, social mobilization, service delivery
and monitoring programme performance. To support such collaboration,
governments should allocate increased resources to underserved communities
and ensure that programmes have sufficient, well-trained personnel to executestrategies effectively. Partnerships across government sectors (for example,
with educational institutions) and coordination with programmes that focus onvulnerable populations will be essential. In addition, efforts to provide highquality immunization services to all children will need to continue unabated inorder to protect gains already recorded.

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Strategic Objective 3

Global Vaccine Action Plan

page 49

Likewise, targeted plans are needed to ensure access to immunization during
humanitarian crises, outbreaks and in conflict zones. These plans should
include a focus on communication and provision for the development ofvaccine stockpiles.

Creating strategies
for reaching
individuals throughout
their life course
There are other dimensions of equity that merit consideration during the Decadeof Vaccines (2011–2020), including disparities between countries, adolescent andadult immunization, and immunization during emergencies.
Historically, it took decades before new vaccines used in high-income countries
became available in low- and middle-income countries. Steps are being taken
to address this inequity, including the introduction of new vaccines, with thesupport of the GAVI Alliance. However, much more needs to be done to sustain
and extend these gains, particularly to middle-income countries.
A “life-course” approach must also be taken in order to make the benefits ofimmunization available to all those at risk in every age group. As diseases arebeing successfully controlled through infant immunization, the need to boost
immunity to sustain and extend these gains is increasingly being recognized.
In addition, new and existing vaccines that are beneficial for school children,
adolescents and adults at special risk—such as health workers, immunocompromised individuals, animal handlers, and the elderly—(for example, vaccines
against human papillomavirus, influenza and rabies) are now available and being
increasingly used. The success of efforts to eliminate maternal and neonatal
tetanus and the benefits to both women and infants of influenza vaccination
during pregnancy have increased interest in exploring the development of othervaccines that could be used during pregnancy (for example, group B streptococcus
or respiratory syncytial virus vaccines). This will mean creating strategies forreaching individuals throughout their life course, and developing plans for thesystems that will monitor and track progress.

Social and operational research is needed to inform the design and test theeffectiveness of the delivery strategies mentioned above. Key areas of focus forthis research could include identifying the main causes of low coverage inparticular areas and communities, assessing economic barriers to immunization,
understanding the best approaches for reaching individuals of various
ages, and assessing the most effective incentives for reaching different groups.

Table 4: Summary of recommended actions for strategic objective 3
The benefits of immunization are equitably extended to all people.
Develop and implement new strategies
to tackle inequities.
Recast “Reaching Every District” to“Reaching Every Community” in order todeal with inequities within districts.
Engage underserved and marginalizedgroups to develop locally tailored,targeted strategies for reducing inequities.
Introduce appropriate new vaccines
into national immunization programmes(see also objective 5).
Establish a life-course approach to
immunization planning and implementation, including new strategies to ensure
equity across the life span.

Prevent and respond to vaccinepreventable diseases during disease
outbreaks and humanitarian crises,
and in conflict zones.
Build knowledge base and capacity
for enabling equitable delivery.
Track each individual’s immunization
status, leveraging immunization
registries, electronic databases andnational identification number systems.
Take advantage of community structures
to enhance communication and deliver
services (for example, traditional birthattendants, birth registries).
Involve civil society organizations incommunity outreach and planning.

Develop new approaches tocommunity engagement for urban
and peri-urban areas.
Train health workers and civil society
organizations in engaging communities,
in identifying influential people who
can assist in planning, organizing andmonitoring health and immunization
programmes, as well as community
needs, and in working with communities
to meet those needs.
Conduct operational and social
science research to identify successful
strategies to reduce inequities andimprove the quality and delivery of
immunization services.

page 50

Strategic Objective 4

Global Vaccine Action Plan

Strategic
objective

4¥

R

Strong immunization systems are an integral
part of a well functioning health system.
The success of national immunization programmes in introducing new vaccines,
attaining goals for quality, equity and coverage, and becoming financiallysustainable depends upon a well functioning health system. The many interconnected components of an immunization system require multi-disciplinary
attention in order to build a cohesive, non-fragmented and well-functioning
programme that coordinates and works in synergy with other primary healthcare programmes.
Health systems encompass a range of functions from policy and regulation to
information and supply chain systems, human resources, overall programmemanagement and financing. Health systems include both the public andprivate sectors, and in some countries the private sector can play a valuable rolein educating households about the need for and benefits of vaccination, as
well as providing health care. Some of these functions have been dealt with inother sections of this document. This section discusses the actions required
to foster greater coordination between immunization and other programmes
within health systems and to strengthen the information, human resources,
supply chain and logistics components of health systems.
Immunization service delivery should continue to serve as a platform forproviding other priority public health interventions, such as those for vitamin
A supplementation, deworming, and insecticide-treated bednets. Other priority
programmes should also serve as a platform for delivering immunization.
Every contact with the health sector should be used as an opportunity to verify
immunization status and provide immunization where indicated. Furthermore,

Immunization service delivery should continue toserve as a platform for providing other priority publichealth interventions

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Strategic Objective 4

Global Vaccine Action Plan

Access to timely high-quality information is essential for effective immunization.
Critical information includes process indicators that allow programmes tomonitor their performance and take corrective action, and outcome indicatorsthat measure the impact of programmes. Output and impact indicatorsneed to be analysed along with expenditures in order to identify bottlenecks
and best practices and to gauge overall programme efficiency (value for money).
Immunization information systems need to be linked to broader healthinformation systems, while remaining readily accessible and meeting
immunization programme needs.

Coordinating immunization
with integrated primary
health-care programmes
may also facilitate social
mobilization efforts
as new vaccines become available that target some but not all pathogens thatcause particular syndromes, such as pneumonia, diarrhoea and cervicalcancer, it is important that their introduction be an opportunity to scale up thedelivery of complementary interventions. For example, the vaccines against
pneumococcus and rotavirus should be complemented with other actions toprotect, prevent and treat related respiratory and diarrhoeal diseases.
New vaccine deployment should therefore be accompanied by comprehensive
disease-control plans both within countries and globally. Coordination of
immunization with other services should take place at all levels of a country’s
programmes, involve outreach efforts and participation by health centres, and bea part of programme management. Coordinating immunization with integrated
primary health-care programmes may also facilitate social mobilization efforts,
helping to generate community demand for services (strategic objective 2) andaddress inequity (strategic objective 3). Additionally, efforts should be made toensure that global vaccine programmes focused on eradication and elimination
goals (for example, poliomyelitis and measles campaigns) do not operate insilos. The choice of mechanisms to promote greater interaction and coordination
between different programmes should be made by countries according to theirlocal context. The synergies and efficiencies as a result of integration andcoordination will be particularly beneficial in countries with fragile health systems.

Monitoring of immunization coverage and dropout rates has been in placesince the launch of the Expanded Programme on Immunization to ensure
programme effectiveness. Although the quality and timeliness of data reporting
have improved steadily over the years, the quality of administrative coverage datais still inadequate in many countries. Furthermore, the use of data in order totake corrective action at district and community levels is still unsatisfactory. New
approaches to immunization tracking through unique identification numbers(discussed in strategic objective 3) can improve the quality of immunization
coverage data and facilitate the development of comprehensive immunization
registries. New technologies, including hand-held communication devices andmobile phones, can support this effort and facilitate data sharing. Armed withhigher-quality data and new data-analysis tools, programme managers at alladministrative levels can use information to improve programme performance,
allocate funding appropriately, and track progress more effectively.
Disease surveillance is critical for informing decision-making on the adoptionof new vaccines and on the strategies for their use in their respective national
programmes. Such surveillance is also essential for monitoring the impact of
immunization and changes in disease epidemiology, and for supporting
sustained use. Robust epidemiological data will also be crucial for understanding
vaccine effectiveness and guiding priorities in the research and development
community, and will help to identify the areas where research and development
is most needed (strategic objective 6). Disease surveillance platforms need
to be strengthened to improve the quality and sharing of information. This
will include strengthening laboratory capacity for microbiological confirmationof diagnosis and for tracking the spread of diseases using moleculartyping techniques.

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page 54

Strategic Objective 4

Global Vaccine Action Plan

page 55

The increasing complexity of immunization programmes and ambitious
new goals, mean that more trained health workers are needed to manage theincreased burden of work, including programme managers at the nationaland subnational levels as well as front-line workers who deliver services andinteract directly with communities. Programme managers need to be equippedwith technical knowledge about vaccines and immunization, as well as withmanagement skills. Front-line health workers, who deliver not only vaccinations
but also primary health care interventions and health education, needcoordinated, comprehensive and very practical pre- and in-service training, with
updated, relevant curricula and post-training supervision. Health-care workers
need to be able not only to explain why immunization is important, but also togive advice to individuals and communities on nutrition, create a healthier environment and recognize the danger signs when someone falls ill. Immunization
programmes should ensure that this training and supervision is effectively
extended to community-based health workers. Civil society organizations canhelp with training and coordinating such workers.

On rare occasions, adverse reactions can affect the health of vaccine recipients.
More frequently, coincidental health events can follow immunization and may
be wrongly attributed to vaccines. In both instances, it is extremely important
to detect and analyse promptly serious adverse events following immunization.
To assist low- and middle-income countries in managing such important issues,
WHO and its partners have developed the Global Vaccine Safety Blueprint.
This strategic plan will enable the countries concerned to have at least minimal
capacity for vaccine safety activities; it will also enhance capacity for vaccine
safety assessment in countries that introduce newly developed vaccines, that
introduce vaccines in settings with novel characteristics or that both manufacture
and use prequalified vaccines; and it will establish a global vaccine safety
support structure. Implementing the Global Vaccine Safety Blueprint strategies
to build capacity for safety surveillance during the Decade of Vaccines (2011–2020)
will ensure that everyone everywhere receives the safest vaccines possible andthat safety concerns are not a cause of hesitancy in using vaccines.

Ensure that everyone
everywhere receives thesafest vaccines possible
and that safety concerns
are not a cause ofhesitancy in using vaccines

Health workers can only be effective if sufficient supplies (vaccines, supplements
and medicines) are available when they need them. The influx of new vaccines
has outstripped the capacity of the current cold-chain system in many countries.
Thus, supply chains and waste management systems urgently need to be
expanded and made more efficient and reliable. They should be streamlined tomaximize effectiveness. They should also take into account and make aneffort to minimize the environmental impact of energy, materials and processes
used for immunization both within countries and globally. The availability of
new technologies provides the opportunity to innovate, not only to improve
immunization supply chain management, but also to seek increased synergies
with other sectors and supply systems for other health interventions. Anotherpotential area of innovation concerns understanding the lessons learnt
from private-sector practices and supply chain management. In addition, tasks
that could be outsourced to private sector companies in order to create greater
efficiency should be explored.

The availability of newtechnologies provides theopportunity to innovate

page 56

Strategic Objective 4

Global Vaccine Action Plan

page 57

Table 5: Summary of recommended actions for strategic objective 4
Strong immunization systems that are an integral part of awell-functioning health system.

Front-line healthworkers need coordinated,comprehensive andvery practical pre- andin-service training
It will be essential to ensure that immunization supply systems are staffedwith adequate numbers of competent, motivated and empowered personnel at
all levels. Likewise, improvements to health information systems should also
support the management of resources, helping staff to ensure that adequate
quantities of vaccines are always available to meet demand. Efforts to strengthen
supply chains should be implemented in such a way that they benefit bothimmunization programmes and broader national health efforts.
Developing stronger, more efficient, comprehensive approaches to disease
control and immunization will require health ministries to take the lead instrengthening and coordinating immunization programmes and health systems
more broadly, including engaging civil society organizations, academia andprivate practitioners. They can draw on the expertise of academics to help develop
and deploy new tools and approaches to service delivery. Civil society organizations can contribute to the development of integrated programmes so thatthey are aligned with local realities and incorporate community-based humanresources. Communities can ultimately hold their governments accountable bydemanding integrated services. Regional and global organizations can also
help by ensuring that data and best practices are shared in and across countries
and that country programmes have access to analytical tools. Development
partners can provide supplemental financial resources if needed.

Develop comprehensive andcoordinated approaches.

Strengthen monitoring andsurveillance systems.

Ensure that global vaccine programmes focusing on eradicationand elimination goals (for example,
poliomyelitis and measles campaigns)
are incorporated into national
immunization programmes and do
not operate independently.

Improve the quality of all administrative data concerning immunizationand promote its analysis and use at alladministrative levels to improve
programme performance.

Ensure that new vaccine deployment
is accompanied by comprehensive
plans to control targeted diseases.
Ensure coordination between the
public and private sectors for new
vaccine introduction, reporting ofvaccine-preventable diseases andadministration of vaccines, andensure quality of vaccination in the
public and private sectors.
Consider the inclusion of vaccines(as appropriate to national priorities)
in health programmes across thelife-course.

Develop and promote the use of newtechnologies for collection, transmission
and analysis of immunization data.
Further strengthen and expand
disease surveillance systems to generate
information for decision-making,monitoring the impact of immunization
on morbidity and mortality and changes
in disease epidemiology.
Ensure capacity for vaccine safety
activities, including capacity tocollect and interpret safety data, withenhanced capacity in countries that
introduce newly developed vaccines.
Strengthen capacity of managers
and frontline workers.
Ensure that immunization and otherprimary health-care programmes haveadequate human resources to scheduleand deliver predictable services of
acceptable quality.

Increase levels of pre-service, inservice and post-service training forhuman resources, and develop
new, relevant curricula that approach
immunization as a componentof comprehensive disease control.
Promote coordinated training andsupervision of community-based
health workers.
Strengthen infrastructure
and logistics.
Innovate to improve cold-chain
capacity and logistics, as well as
waste management.
Minimize the environmental impact
of energy, materials and processes
used in immunization supply systems,
both within countries and globally.
Staff supply systems with adequate
numbers of competent, motivated andempowered personnel at all levels.
Establish information systems
that help staff to track the available
supply accurately.

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Strategic Objective 5

Global Vaccine Action Plan

Strategic
objective

5

Immunization programmes have sustainable
access to predictable funding, quality supply andinnovative technologies.
To meet goals of the Decade of Vaccines (2011–2020), actions must be taken
both within countries and globally to increase the total amount of available
funding for immunization from both countries and development partners.
Countries should ensure the financial sustainability of national immunization
programmes through regular evaluation of resource needs; efficiency in service
delivery; availability of adequate domestic financing; and resource mobilizationfrom development partners to meet any funding gaps. Governments alsoneed to explore alternative and innovative financing mechanisms for health andimmunization. Some countries have established trust funds or use dedicatedtax revenues, among other strategies. In addition, it is important to movebeyond budgets and into expenditures. Governments can improve vaccine
access and prevent shortages of vaccines, immunization equipment or healthworkers by assuring that budgeted funds are disbursed in an ongoing andtimely fashion that responds to programmes’ needs.
Although the financing of immunization services is first and foremost a core
responsibility of governments, development partners should support national
strategies through more predictable, longer-term financing, and should also
explore the next generation of innovative financing mechanisms. Emphasis
needs to be placed on mutual accountability between countries and theirdevelopment partners in terms of immunization financing. One possible

Actions must be taken both within countries andglobally to increase the total amount of available
funding for immunization

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Strategic Objective 5

Global Vaccine Action Plan

A crucial but often
overlooked key driverunderpinning allthese interventions is
the quality assuranceof vaccines
approach is to undertake annual resource tracking of immunization financing
from partners and governments alike. For both countries and development
partners, evidence-based advocacy and policy efforts should be focused on
obtaining a renewed commitment to past funding pledges.
There is also a need to improve the allocation, accountability and sustainabilityof funding. Coordinating funding support from development partners andother external sources to target national budget priorities will ensure that funds
are addressing the most pressing country needs. Funding allocation strategies
should be revised periodically to confirm they are achieving goals, such as
eradication and elimination of disease, as quickly and as effectively as possible.
Feedback loops should be established to enhance programme sustainability,
results and impact. One potential methodology to explore is a pay-for-performancefunding system. However, the merits of this approach must be balanced against
the importance of ensuring the predictability of funding, the risks of creating
perverse incentives, and the fact that implementation of such a scheme requires
high-quality data. This would include linking international, national, andlocal funding distribution to specific performance metrics and leveraging theresulting metrics to promote programme improvement.

Innovative pricing and procurement mechanisms are needed to alleviate funding
pressure and to support the development and scale-up of new and existing
vaccines. Innovations will be particularly important for those lower-middleincome countries that do not have access to the PAHO, UNICEF and GAVI
Alliance pricing and procurement mechanisms. Mechanisms to explore include
differential pricing using new approaches to define price tiers and pooled
negotiation or procurement methods for lower-middle-income countries. Current
pooled procurement models exist in both the vaccines and pharmaceuticals
markets. One example is the PAHO revolving fund pooled procurement andshort-term credit mechanism. This and other models could be assessed
and modified to best suit the needs of the lower-middle-income countries andthe individual vaccine markets.
The provision of long-term sustainable funding will be an incentive tomanufacturers, thereby improving supply security. In addition, supply-side
interventions are needed. A growing proportion of affordable vaccines that areused to immunize the world’s population are manufactured in middle- andlower-middle-income countries. In the coming decade, these countries will not
only have a requirement to ensure the quality, safety and efficacy of vaccines
used domestically, but also a growing global obligation to protect and enhance
the security of the global immunization enterprise. Potential supply-side
interventions to ensure quality, safety and efficacy include identifying anddisseminating best practices in manufacturing and quality control, investingin research and development capabilities, and initiating technology transfersand co-development agreements.
A crucial but often overlooked key driver underpinning all these interventions
is the quality assurance of vaccines. Good-quality assurance relies crucially on
effective standardization, which ensures that each vaccine product can be
manufactured consistently and also enables multiple manufacturers to makesimilar products of the same quality. Normative processes to achieve globally
harmonized standards for vaccines already exist, including international biologicalreference materials, but action is needed to strengthen global standardization.

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Strategic Objective 5

Global Vaccine Action Plan

In addition, each country should develop the capacity to monitor and assure
the safe use of vaccines, in line with the strategy defined in the WHO Global
Vaccine Safety Blueprint initiative (as discussed under strategic objective 4).
Action should also be taken to strengthen national regulatory systems anddevelop globally harmonized regulations in order to ensure that the increasing
demand for regulatory reviews can be managed in an effective and timely
manner. This is an issue not just for low- and middle-income countries
involved in technology transfer, but also for regulatory agencies in high-income
countries where expertise and resources need to be maintained. These
supply-side interventions need to be based on solid business cases developed bycountries to ensure the impact of these significant and long-term investments.
Making change happen with respect to sustainable funding will requirecommitments from governments and development partners to increase
resources and improve programme efficiencies, as well as from additionalcountries joining the development partner ranks. Likewise, sustainable supply
will require the multisectoral involvement of governments (for example, thescience and technology, trade, industry and health sectors) in order to create
an environment that helps suppliers to strengthen their capabilities. Emerging
economies have a particularly important role to play in both cases, given theirhigh rate of economic growth and the rapid expansion of the supply base there.
To increase alignment, activities currently performed by the UNICEF Supply
Division and the GAVI Alliance to improve communication and coordination
among countries, vaccine manufacturers and public-sector organizations
should be further expanded. Countries need a forum where they can moreclearly communicate expected demand for new vaccines and provide guidanceon desired product profiles. This first-hand information would enable suppliers
to make more informed product development and capacity planning decisions,
thereby mitigating product development and supply risk. This information
would also help development partners and other public-sector organizations toestablish more defensible and reliable strategies and support plans. This forum
could further be utilized to enable suppliers to accurately communicate thepossible current and future range of pricing and supply to countries, and forcountries to share information on and experience with vaccine procurement.

Table 6: Summary of recommended actions for strategic objective 5
Immunization programmes have sustainable access to long-term fundingand quality supply.

page 63

R

Increase total amountof funding.

Improve allocation of funding inlow- and middle-income countries.

Secure quality supply.

Establish a commitment forgovernments to invest in immunizationaccording to their ability to pay andthe expected benefits.

Strengthen budgeting and financial
management in-country to better
integrate financial and health careplanning and priority setting.

Build and support networks ofregulators and suppliers to share
best practices and to improve
quality assurance capabilities andquality control.

Engage new potential domestic anddevelopment partners and diversify
sources of funding.

Coordinate funding support
from development partners and otherexternal sources.

Develop the next generation of
innovative financing mechanisms.

Evaluate and improve funding support
mechanisms on the basis of theireffectiveness in reaching disease goals.

Increase affordability for
middle-income countries.

Base funding on transparency andobjectivity in order to ensure thesustainability of programmes.

Explore differential pricing
approaches to define explicit criteria
for price tiers and the current andfuture prices to be made available tolower middle-income and middleincome countries.
Explore pooled negotiation or
procurement mechanisms forlower-middle-income and middleincome countries.

Promote the use of cost and costbenefit arguments in fund raising,decision-making, and in defence of
immunization funding.
Explore pay-for-performancefunding systems.

Develop tools to strengthen global
standardization of manufacturing
and regulatory processes.
Strengthen national regulatory
systems and develop globally
harmonized regulations.
Provide a forum where countries
can communicate expected demandfor vaccines and technologies andprovide guidance to manufacturers
on desired product profiles.

¥

page 64

Strategic Objective 6

Global Vaccine Action Plan

Strategic
objective

6

Country, regional and global research anddevelopment innovations maximize the benefitsof immunization.
In the coming decade, targeted and innovative research and development efforts
are needed across discovery, development and delivery. Innovative research anddevelopment efforts will lead to: (1) identification of mechanisms of protection andpathogenesis; (2) well-defined and novel antigenic targets for developmentof new vaccines; (3) development of bio-processing, formulation, manufacturing
and delivery technologies for new and improved vaccines; and (4) development
of disease-burden and cost-effectiveness data for in-country decision-making.
WHO has conducted a detailed study of disease prioritization and the Instituteof Medicine in the United States of America is in the process of developing amodel designed to assist decision-makers in prioritizing preventive vaccines
based on health, economic, demographic, programmatic and social impact
criteria, as well as scientific, technical and business opportunities. The Decadeof Vaccines collaboration has not undertaken a vaccine or disease prioritization
exercise. To complement the above efforts, a spectrum of research and development needs is presented across discovery, development and delivery, fromwhich stakeholders can choose to invest according to their own priorities andperceptions of the return on their investments.

Research is needed to accelerate development,
licensing and uptake of vaccines that are currently
in early development

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Strategic Objective 6

Global Vaccine Action Plan

Scientists from disciplines
not previously engaged in
vaccine research will need
to be recruited
Across all research and development activities, increased engagement andconsultation with end-users is needed to ensure that technologies and innovation
are prioritized according to real demand and added value. New arrangements
will also be required to facilitate the transfer of technologies and access toand sharing of associated information, while acknowledging and respecting
intellectual property rights. In order to support this work and maximize its
effectiveness of, scientists from disciplines not previously engaged in vaccine
research (systems biology, nanotechnology, structural biology and metabolomics)
will need to be recruited. Chemical and mechanical engineers, chemists andinformation technology specialists will also have key roles to play in this endeavour.
In addition, capacity building and human resource development are needed
in low- and middle-income countries to conduct research and development,
including finding better ways to conduct operational research and evaluate
immunization programmes. Research and development is being conducted ininstitutions of excellence in many low- and middle-income countries. This
capacity is producing indigenous data, as well as fostering bilateral andmultilateral collaboration in basic sciences and vaccine development. Capacity
can be further strengthened through peer-to-peer training and exchanges
between countries. Greater networking among research centres (from discovery
to clinical trials) will facilitate the exchange of ideas and the efficient buildingof partnerships among institutions in high-, middle- and low-income countries.

Discovery and basic research will lay the groundwork for impact in future
decades. Research at the interface between host and pathogen is needed to enable
the development of new vaccines. Advancing knowledge of innate and adaptive
immune responses will permit more rational vaccine design. Strengthening
the understanding of immunologic and molecular characteristics of microbes
through systems biology will permit the identification of new antigenic targets
for vaccine development and effective ways of predicting protective immune
responses and mechanisms of protection. Appropriate studies of host genetics
and biomarkers will contribute to understanding the causes of variation inhuman population responses to vaccines, or susceptibility to adverse effects.
For the development of new and improved vaccines and vaccine technologies,
the research and development community will benefit from adopting bestpractices in portfolio and partnership management, including the identificationof early indicators of success and failure to inform milestone-based investments.
The community should also consider new approaches to ensure promisingvaccine candidates are advanced from discovery to development, particularly
where market incentives are insufficient. This is especially important for vaccines
to prevent “neglected” diseases.
Research is needed to accelerate development, licensing and uptake of vaccinesthat are currently in early development, including development of technologies
for more efficacious and less expensive manufacturing of vaccines. Greater
access to the technology and associated information for adjuvants and theirformulation into vaccines is needed for advances in developing new and more
effective vaccines. Non-syringe delivery mechanisms and vaccine packaging thatbest suit the needs and constraints of countries, as well as thermostable vaccinesand new bioprocessing and manufacturing technologies, are priority researchareas for accelerating the development of next-generation vaccines that are more
effective, less expensive and easier to manufacture and deliver.

Non-syringe delivery
mechanisms as well as
thermostable vaccines arepriority research areas

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Strategic Objective 6

Global Vaccine Action Plan

Additionally, the elaboration and aggressive pursuit of a global regulatory
science agenda will improve manufacturing efficiency, better characterize
products, improve clinical trial design and safeguard the highest standards
for vaccine safety and efficacy. The challenge is considerable in achieving
understanding of the adverse effects, finding ways to avoid them and yet notcompromising the known efficacy of the existing product—and without
incurring the costs of developing, testing and registering a new product. In
this dimension, research on animal models and in vitro systems that better
predict safety and efficacy would shorten the time for developing safe andeffective vaccines and for making them available to communities. Knowledgeof the correlates of protection and safety will greatly help to bring thesesecond-generation products to licensure and use.
With respect to delivery, priority areas to improve programme efficiency andincrease vaccine coverage and impact should include research on the useof effective information through modern communication technologies andsocial research in order to understand the cultural, economic and organizational
determinants of immunization. Health economic analysis will guide the introduction and prioritization of vaccines, and hence representative epidemiological,
immunological and operational studies and studies of vaccine impact will
be needed.
Operational research on the most effective delivery approaches is also neededin order to overcome the challenges posed by life-course immunization(newborn, infant, adolescent, pregnant women, elderly, among others) andvaccination in emergency and outbreak situations. Research on immunologicalinterference effects and optimization of delivery schedules will be required as
more new vaccines are introduced into routine programmes and immunization
is extended beyond the first year of life. In the case of special populations,such as pregnant women, confirmation of safety will be particularly important.
Furthermore, research is required in order to develop bio-markers for validating
immunization coverage estimates and enabling better measurement of
population-level immunity profiles. In addition, research to develop field-usable
and cost-effective diagnostic tools for establishing etiology that are suited for use
at point-of-care in low-income countries will be valuable additions to improving
surveillance quality.

page 69

Concerted action among the research community, manufacturers, healthprofessionals, programme managers, national immunization technical advisorygroups, vaccine regulatory agencies and development partners will be needed
to attain the full potential of research and development in the next decade.
Methods and arguments for prioritization and allocation of scarce resources
will have to be agreed upon by these groups, balancing the tensions between
country-driven choices and the need for large-scale research efforts and markets
in order to sustain development and commercialization. Health professionals,
programme managers, vaccine regulatory agencies and national immunization
technical advisory groups can help to identify areas where innovations could
be made, and assess their real demand and added value. Development partners
can help promote a judicious allocation of some resources for research anddevelopment, according to the agreed priorities. The research community andmanufacturers will have prime responsibility for promoting innovation andpursuing the research agenda defined above.

Operational research on
the most effective delivery
approaches is also neededin order to overcome
the challenges posed bylife-course immunization

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Strategic Objective 6

Global Vaccine Action Plan

page 71

Table 7: Summary of recommended actions for strategic objective 6Country, regional, and global research and development innovations
maximize the benefits of immunization.
Expand capabilities and increase
engagement with end-users.
Engage with end-users to prioritize
vaccines and innovations according toperceived demand and added value.
Establish platforms for exchange of
information on immunization researchand consensus building.
Build more capacity and humanresources in low- and middle-income
countries to conduct research anddevelopment and operational research.
Increase networking among research
centres for efficient building of partnerships among the institutions of high-,
middle- and low-income countries.
Promote collaboration between
traditional research disciplines andscientists from disciplines notpreviously engaged in vaccine research.

Improve programme efficiencies
and increase coverage and impact.
Research the use of more effective
information through modern
communication technologies.

Conduct representative
epidemiological, immunological,
social and operational studies
and investigations of vaccine impact
to guide health economics analysis.

Develop thermostable rotavirus
and measles vaccines.

Perform operational research on
improved delivery approaches
for life-course immunization, andvaccination in humanitarian
emergencies, so-called fragile States
and countries in and emerging
from conflict.

Develop a global, regulatory science
research agenda.

Perform research on interference
effects and optimum delivery schedules.

Enable the development of
new vaccines.

Perform research to develop improved
diagnostic tools for conducting
surveillance in low-income countries.

Research on the fundamentals of
innate and adaptive immune responses,
particularly in humans.

Accelerate development, licensing
and uptake of vaccines.
Promote greater access to technology,
expertise and intellectual property
for adjuvants and their formulation
into vaccines.
Develop non-syringe delivery
mechanisms and vaccine packaging
that best suit the needs and constraintsof national programmes.

Develop new bioprocessing andmanufacturing technologies.

Adopt best practices in portfolio
and partnership management for
research and development.

Research on immunological andmolecular characteristics of microbes.
Improve understanding of the extent
and causes of variation in pathogens
and human population responses
to vaccines.

A spectrum of researchand development needs
is presented acrossdiscovery, development
and delivery

page 72

Global Vaccine Action PlanTitle of Section (TK)

Health Returns
on Investment in
Immunization
The Global Vaccine Action Plan has outlined a set of
ambitious goals and strategic objectives for the decade
to broaden the impact and reach of immunization
across the globe. By extending coverage for existing
vaccines, introducing new vaccines and pursuing
elimination and eradication for specific diseases,
millions of deaths can be averted and billions of dollars
in economic benefit can be generated.

i
All stakeholders investing
together will drive asignificant health andeconomic impact

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Global Vaccine Action Plan

Health Returns on Investment in Immunization

Cost projection to reach elimination anderadication goals in the world’s 94 low- andlower-middle-income countries

It is projected that costs to sustain and scale up current immunization
programmes, introduce new and underutilized vaccines, and conduct
supplemental immunization activities to reach elimination and eradication
goals in the world’s 94 low- and lower-middle-income countries will risefrom between US$ 3500 million and US$ 4500 million in 2011 to between
US$ 6000 million and US$ 8000 million in 2020, costing approximately
between US$ 50 000 million and US$ 60 000 million cumulatively over thecourse of the decade (from 2011 to 2020). The following estimates all pertain
to these 94 countries.9

2020
US$ 6000 million –US$ 8000 million

2011
US$ 3500 million –US$ 4500 million

COSTS cumulatively overthe course of the decade(2011-2020)

US$ 50 000 million –US$ 60 000 million

COVERAGE EXAMPLES
2011 			2020pneumococcal vaccine coverage

8
supplementary
immunization activities
for accelerated disease
control and eradication andelimination efforts
throughout the decade

15%(supplementary)85%
routineimmunization
programmes

90

%

%

pentavalent vaccine

50

%

90

%

An estimated US$ 42 000 million to US$ 51 000 million of these costs(roughly 85% of the total) will support expanding routine immunization coverageand introducing additional vaccines to routine immunization programmes.10
For example, pneumococcal vaccine coverage for the birth cohort in the 94
countries is projected to go from 8% in 2011 to approximately 90% by 2020.
Similarly, coverage with the pentavalent vaccine (against diphtheria-tetanuspertussis hepatitis B and Hib) is projected to move from 50% in 2011 to morethan 90% by 2020. To take another example, it is anticipated that up to five
additional vaccines that are currently not licensed or widely used in low- andlower-middle-income countries will be introduced across many of the countries
in the analysis during the decade: vaccines against cholera, dengue and malaria,
inactivated poliovirus vaccine, and typhoid Vi conjugate vaccine. Delivery
programmes will need to be strengthened to ensure they meet current needs,
are well-maintained over the decade, have sufficient capacity to accommodate
additional vaccines that are planned to be introduced, and facilitate immunization
coverage aspirations across low- and lower-middle-income countries. As aconsequence, the costs of annual routine immunization will increase fromapproximately US$ 2500 million in 2011 to US$ 7500 million by 2020.
Of these costs, an estimated cumulative figure of between US$ 8000 million
and US$ 9000 million (the remaining 15% of the total) will be for supplementary
immunization activities for accelerated disease control and eradication andelimination efforts throughout the decade, which will complement routine
immunization programmes. This analysis assumes that these efforts will befocused on measles, meningococcus A meningitis, poliomyelitis, rubella,tetanus and yellow fever.

up to five additional vaccines
9	Countries included in the scope of the costing analysis include 92 low- and lower-middle-income countries according to the July
2011 World Blank Classification (available at http://www.icsoffice.org/Documents/DocumentsDownload.aspx?Documentid=474,
accessed 11 April 2012) in addition to two upper-middle-income countries (Azerbaijan and Cuba) which receive GAVI Alliancesupport for existing vaccines, but which have graduated from support for future vaccines.

24-26
million future deaths
could be averted

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Health Returns on Investment in Immunization

Global Vaccine Action Plan

The costs described above for routine and supplementary immunization activities
encompass the projected costs of the acquisition of vaccines and injection
supplies, as well as the delivery of those vaccines and supplies, includingtransportation and cold chain logistics, human resources, training, social mobilization, surveillance and programme management. These costs do not include
the additional costs or efficiencies that may be generated through the actions
recommended in the global vaccine action plan where there is an insufficientevidence base for these costs at this time. Specifically, it does not include
the additional cost of scaling up seasonal influenza vaccination or the additional
resource needs for increased surveillance, increased civil society engagement,
and current and additional technical agency support to implement the Global
Vaccine Action Plan. Nevertheless, the costs do represent the majority of thecost of achieving the strategic objectives of the Decade of Vaccines (2011–2020).
The governments of low- and lower-middle-income countries will continue toplay a pivotal role in meeting resource needs. Assuming that country funding
for immunization grows in line with projected gross domestic product and
all GAVI Alliance-eligible countries fully meet its co-financing requirements,
it is estimated that the available funding from country governments forroutine immunization and supplemental immunization activities could total
approximately US$ 20 000 million over the decade. In addition, if the GAVI
Alliance renews its current level of funding for the 2016–2020 period, its
resources will generate an estimated additional US$ 12 000 million of funds
for the decade, approximately US$ 11 000 million for routine immunization
programmes and approximately US$ 1000 million for programmes involving
supplementary immunization activities. Based on these assumptions,country governments and the GAVI Alliance combined could provide a total of
approximately US$ 32 000 million in funding for the decade. These estimates
could be considered the minimum available financing over the decade because
they do not include contributions from development partners beyond thatprovided through the GAVI Alliance (owing to the considerable uncertainty
surrounding future levels of development partner financing).
Meeting the estimated US$ 18 000 million to US$ 28 000 million in additional
funding will require commitment from all stakeholders, with governments
needing to continue making immunization a priority in resource allocation
decisions; development partners needing to sustain and bolster access to

10 Diseases covered by the vaccines included in the scope of the costing analysis include: diphtheria-tetanus-pertussis,
hepatitis B, Haemophilus influenzae type b, human papillomavirus, Japanese encephalitis, measles, meningococcus A,
mumps, pneumococcus, poliomyelitis, rotavirus, rubella, tuberculosis and yellow fever.

If the GAVI Alliance renews
its current level of funding
for the 2016–2020 period,
its resources will generate
an estimated additional US$
12 000 million for the decade:11 000
million

1 000
millionroutineimmunization
programmes

supplementary
immunization
activities

funding for immunization in spite of competing priorities; and the entire
community needing to continue efforts to reduce the cost of vaccine acquisition
and immunization service delivery.
All stakeholders investing together will drive a significant health and economic
impact. Work to sustain or extend coverage of existing vaccines and efforts tointroduce new vaccines, if undertaken together, have the potential to avert
millions of future deaths, as well as hundreds of millions of cases of disease,and generate hundreds of billions of dollars in economic impact over the decade.
As an example of the potential impact of immunization, a sub-analysis of 10
vaccines, delivered during the decade, that represent an estimated US$ 42 000
million of the US$ 50 000 million to US$ 60 000 million cost for the decade,11
have the potential to avert in total between 24 and 26 million future deaths(Table 8) as compared with a hypothetical scenario under which these vaccines
have zero coverage.12

11	Vaccines included in health benefits analysis cover the following diseases in countries representing 99.5% of the birth cohortof the 94 countries included in the costing analysis: hepatitis B, Haemophilus influenzae type b, human papillomavirus,
Japanese encephalitis, meningitis A, pneumococcus, rotavirus, rubella, yellow fever and measles.
12 Data were insufficient to estimate morbidity averted through immunization in these countries.

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Health Returns on Investment in Immunization

Global Vaccine Action Plan

Table 8:table 8: Total future deaths averted, 2011–2020, assuming no vaccination as the counterfactualGroup

Original Expanded Programmeon Immunization vaccinec

The figures for deaths averted represent the full estimated benefits that canbe achieved during the decade for these 10 vaccines, through sustaining or
enhancing current immunization levels and introducing additional vaccines into
the national immunization programmes of the selected countries, using novaccination as the counterfactual. They are not limited to only the incremental
benefits of the additional actions undertaken during the Decade of Vaccines(2011–2020).
The current projections of costs, available funding and health impact will evolveas additional analysis is completed and new and better data become available.
Additional analysis will allow for the expansion of the scope described by thisdocument, including increasing the number of diseases covered by the cost andhealth benefits analysis, quantifying impact on morbidity, quantifying economic
benefits and further increasing the level of detail of costing and funding
projections. Additional analysis is needed in order to better understand vaccine
research and development costs and benefits, which are not included in thecurrent projections. New and better data will, among other things, enhance theanalysis with revised disease burden statistics, better vaccine price forecasts,
improved population information and more consistent data across all countries.
In addition, a process should be developed and maintained to allow for updates
to cost, funding, and health and economic impact estimates at the country andglobal levels, ideally on an annual basis. This will facilitate enhanced planning,
coordination and engagement among the many stakeholders that will be required
to achieve the strategic objectives and goals of the Decade of Vaccines (2011–2020).

New or underutilized vaccines

VaccineMeasles 1st dose
Measles 2nd dose
Measles supplementary
immunization activities
Hepatitis Bd
Haemophilus influenzae type b
Pneumococcus
Rotavirus
Human papillomavirus
Yellow fevere
Meningococcal A meningitisf
Japanese encephalitisg
RubellaTotal (2011–2020)a	The estimated future deaths averted was developed by a working group that included staff from WHO, the GAVI Alliance,
the Bill & Melinda Gates Foundation and PATH. The estimate uses a mix of static and dynamic cohort models and various
data sources across the 10 vaccines, including the Lives Saved Tool. Vaccine coverage projections are from the GAVI Strategic
Demand Forecast 4.0 (4 October 2011) and from the GAVI Adjusted Demand Forecast.
b	Ranges shown for estimates where alternative assumptions were considered for the scope of countries and the demand
forecast.
c	Data were insufficient to allow estimation of deaths averted from BCG, diphtheria, tetanus or pertussis vaccines.
d Scaled up in the decade 2001 to 2010.
e Disease burden limited to only a few regions.
f Same as above.
g Same as above.

No. of future
deaths averted a,b
10.6M
0.4M
3.1M

5.3–6.0M
1.4–1.7M
1.6–1.8M
0.8–0.9M
0.5M
0.03–0.04M
0.03M
0.07M
0.4M

24.6–25.8M

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page 80

Global Vaccine Action PlanTitle of Section (TK)page 81Continuing Momentum
for the Decade of
Vaccines (2011–2020)
Ensuring success throughout the Decade of Vaccinesrequires additional focus and action beyond thedevelopment of the Global Vaccine Action Plan. Fourcritical sets of activities will be required in order totranslate the action plan into actions and results:
development of tools for translation of the plan;development of a complete accountability framework;
securing commitments from the stakeholder
community; and communicating Decade of Vaccines
opportunities and challenges.

iTools are needed [to] help
stakeholders better
understand how to translate
the actions recommended
in the action plan into the
local context

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Global Vaccine Action Plan

Tools are needed that provide the full thinking behind the Global Vaccine
Action Plan, together with details, to enable implementation. The production,
publication and communication of these tools will help stakeholders better
understand how to translate the actions recommended in the action plan into
the local context.
The Global Vaccine Action Plan lays the groundwork for an accountability
framework, which will be finalized with more detailed roles and responsibilities
for stakeholders, a complete set of indicators, the methodology and data
sources for each indicator detailed and baselines established where required.
Investments are needed to improve data quality and develop more robust
in-country monitoring and evaluation systems. Regular audits should be
conducted to verify data quality. Progress should be reviewed annually, beginningin 2013, by country, the WHO regional committees and the Health Assembly.
Commitments aligned to the Global Vaccine Action Plan from countries, civilsociety organizations, multilateral agencies, development partners and vaccine
manufacturers can transform the action plan from a document to a movement.
Efforts to build these commitments and a strategy for coordinating them will be
required at the global, regional and country levels. Appropriate channels mustbe identified and targeted communications developed to ensure that Decade of
Vaccines messages reach and resonate with all stakeholders.
The period of time immediately following the Sixty-fifth World Health Assembly
will be critical for ensuring that the agenda-setting translates into effective
action. Key opportunities to sustain and build on the current momentum
during the remainder of 2012 include the WHO regional committee meetings,
the meeting of the Board of the GAVI Alliance, the UNICEF Executive Board
meeting, the GAVI Alliance Partners’ Forum and the Child Survival: A Call to
Action summit.
The Decade of Vaccines collaboration was a time-limited effort that ended withthe completion of the Global Vaccine Action Plan and related activities identified
above. There will be no new structure to support the implementation phaseof the Decade of Vaccines/Global Vaccine Action Plan. Lead stakeholders needto assume ownership to support implementation and progress monitoring.

Continuing Momentum for the Decade of Vaccines (2011–2020)

WHO will play a leadership role for the action plan as the normative leadagency in global health, including the defining of norms and standards
for production and quality control of vaccines, as well for strengthening
immunization delivery, programme monitoring and surveillance systems.
In collaboration with other stakeholders, the WHO Secretariat will also
advocate for and provide technical support to Member States in promoting
greater country ownership, creating synergies between immunizationand other primary health-care programmes and implementing research,
notably to increase programme efficiencies and impact.

page 83

The Decade of Vaccinescollaboration was a timelimited effort that ended
with the completion of the
Global Vaccine Action
Plan and related activities
identified abovepage 84

3.

Global Vaccine Action Plan

World Health Assembly Resolution

World Health
Assembly Resolution
SIXTY-FIFTH WORLD HEALTH ASSEMBLY
WHA65.17 Agenda item 13.12 26 May 2012
Global Vaccine Action Plan
The Sixty-fifth World Health Assembly,
Having considered the report on the draft Global
Vaccine Action Plan;1 Recognizing the importanceof immunization as one of the most cost-effective
interventions in public health, which should berecognized as a core component of the human rightto health;Acknowledging the remarkable progress made in
immunization in several countries to ensure that every
eligible individual is immunized with all appropriate
vaccines, irrespective of geographical location, age,gender, disability, educational level, socioeconomic
level, ethnic group or work condition;

1 Document A65/22.

page 85

page 86

World Health Assembly Resolution

Global Vaccine Action Plan

Applauding the contribution of successful immunization programmes in achieving
global health goals, in particular in reducing childhood mortality and morbidity, and theirpotential for reducing mortality and morbidity across the life-course; Noting that the
introduction of new vaccines targeted against several important causes of major killer
diseases such as pneumonia, diarrhoea and cervical cancer can be used as a catalyst to
scale up complementary interventions and create synergies between primary health careprogrammes; and that beyond the mortality gains, these new vaccines will prevent
morbidity with resulting economic returns even in countries that have already succeededin reducing mortality;
Concerned that, despite the progress already made, disease eradication and elimination
goals such as the eradication of poliomyelitis, the elimination of measles, rubella, andmaternal and neonatal tetanus cannot be met without achieving and sustaining high andequitable coverage;
Concerned that low-income and middle-income countries where the adoption of available
vaccines has been slower may not have the opportunity to access newer and improved
vaccines expected to become available during this decade; Alarmed that globally routine
immunization services are not reaching one child in five, and that substantial gaps persist
in routine immunization coverage within countries;
Recalling resolutions WHA58.15 and WHA61.15 on the global immunization strategy,
1 Document A65/22. WHA65.17

page 87

Tenth plenary meeting, 26 May 2012 A65/VR/10
1. ENDORSES the Global
Vaccine Action Plan;

2. URGES Members States:

3. REQUESTS the
Director-General:(1) to apply the vision and the strategies of
the Global Vaccine Action Plan in orderto develop the vaccines and immunization
components of their national healthstrategy and plans, paying particularattention to improving performance of the
Expanded Programme on Immunization,
and according to the epidemiologicalsituation in their respective countries;(1) to foster alignment and coordinationof global immunization efforts by
all stakeholders in support of theimplementation of the Global Vaccine
Action Plan;

(2) to commit themselves to allocating
adequate human and financial resourcesto achieve the immunization goals andother relevant key milestones;
(3) to report every year to the regional
committees during a dedicated Decadeof Vaccines session, on lessons learnt,
progress made, remaining challenges
and updated actions to reach thenational immunization targets;(2) to ensure that the support provided to
the Global Vaccine Action Plan’s
implementation at regional and country
level includes a strong focus on
strengthening routine immunization;(3) to identify human and financial
resources for the provision oftechnical support in order toimplement the national plans of
the Global Vaccine Action Plan andmonitor their impact;(4) to mobilize more financial resourcesin order to support implementation of
the Global Vaccine Action Plan in lowincome and middle-income countries;(5) to monitor progress and reportannually, through the Executive Board,
to the Health Assembly, until theSeventy-first World Health Assembly,
on progress towards achievementof global immunization targets, as a
substantive agenda item, using the
proposed accountability framework to
guide discussions and future actions.

page 88

4.

AnnexesGlobal Vaccine Action Plan

Annexes

page 89

page 90

Global Vaccine Action PlanTitle of Section (TK)

Annex 1:
Recommended Indicators
Proposed Goal-Level indicators & targets1

Goal

Target by 2015

Target by 2020

Achieve a world freeof poliomyelitis

Interrupt wild poliovirus transmission globally(by 2014)

Certification of poliomyelitis eradication(by 2018)

Meet global and regionalelimination targets

Neonatal tetanus eliminated in all WHO regions

Measles and rubella eliminated in at least fiveWHO regions

Measles eliminated in at least four WHO regions
Rubella/congenital rubella syndrome eliminatedin at least two WHO regions

Meet vaccination
coverage targets in every
region, country andcommunity

Reach 90% national coverage and 80% in every
district or equivalent administrative unit withthree doses of diphtheria-tetanus-pertussiscontaining vaccines

Reach 90% national coverage and 80% inevery district or equivalent administrative unit
with all vaccines in national programmes, unlessotherwise recommended

Develop and introduce
new and improved
vaccines and technologies

At least 90 low-income and middle-income
countries have introduced one or more newor underutilized vaccines

All low-income and middle-income countries haveintroduced 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 and 2015,
the under-five mortality rate (Target 4.A)

Exceed the Millennium Development Goal 4
Target 4.A for reducing child mortality1	These proposed indicators will be presented to the WHO EB and World Health Assembly for final review in 2013. The Strategic
Advisory Group of Experts on immunization will also consider the development and addition of indicators to monitor equity inaccess to vaccines between countries, and integration of immunization systems into broader health systems, respectively.

page 91

page 92

Annex 1: Summary of Recommended Indicators

Global Vaccine Action Plan

page 93

Proposed Strategic Objective-Level Indicators

Strategic objective

1

All countries commit toimmunization as a priority.

2

Individuals and communities
understand the value of vaccinesand demand immunization both asa right and a responsibility.

3

The benefits of immunization are
equitably extended to all people.

4

5

6

Percentage of countries that haveassessed (or measured) confidence invaccination at subnational level2

Percentage of districts with 80%
or greater coverage with three dosesof diphtheria-tetanus-pertussiscontaining vaccine

Dropout rate between first dose andthird dose of diphtheria-tetanus-pertussiscontaining vaccines

Percentage of doses of vaccine usedworldwide that are of assured quality

Progress towards development ofHIV, TB, and malaria vaccines

Strong immunization systems are an
integral part of a well-functioning
health system.

Immunization programmes havesustainable access to predictable
funding, quality supply andinnovative technologies.3

Country, regional and global
research and development
innovations maximize the benefitsof immunization.

Indicators
Domestic expenditures for
immunization per person targeted
Presence of an independent
technical advisory group that meets
defined criteria

Percentage of un- and under-vaccinatedin whom lack of confidence was a factor
that influenced their decision2

Reduction in coverage gaps between
lowest and highest wealth quintile andanother appropriate equity indicator

Sustained coverage of diphtheria-tetanuspertussis-containing vaccines 90% forthree or more years
Immunization coverage data assessed ashigh quality by WHO and UNICEF
Number of countries with case-based
surveillance for vaccine preventablediseases that meet quality standards

Progress towards a universal influenza
vaccine (protecting against drift andshift variants)
Progress towards institutional and technicalcapacity carry out vaccine clinical trials
Number of vaccines that have either
been re-licensed or licensed for use in
a controlled-temperature chain attemperatures above the traditional
2-8 °C range
Number of vaccine delivery technologies(devices and equipment) that have received
WHO pre-qualification compared to 2010

2 Provisional indicator to be finalized based on outcomes of pilot assessment in selected regions

3 The report on progress will also include a narrative report on progress with vaccine supply, pricing and procurement.

page 94

Global Vaccine Action Plan

Annex 2: Stakeholder
Responsibilities
There is an opportunity to achieve real progressin the next decade. Realization of this potential iscontingent upon all stakeholders having clearly
defined and coordinated responsibilities. Primary
responsibility is held by individuals and communities,
governments and health professionals, as recipientsand providers of immunization respectively. Other
stakeholders also have an important role in achieving
the objectives.

Title of Section (TK)page 95

page 96

Annex 2: Stakeholder Responsibilities

Global Vaccine Action Plan	Provide the core data, methods
and arguments that help drive
the continued prioritization of
immunization both globally and locally.

	Respond with timely information whenpublic concerns are raised about safety
and efficacy to sustain public trust.

	Individuals and communities,
as recipients of immunization,
should do the following:	Governments, as the main
providers of immunization,
should do the following:Understand the risk and benefits ofvaccines and immunization, viewing thisas part of being a responsible citizen.

	Increase support for national
immunization programmes and ensure
financial sustainability by 2020.

	Demand safe and effective immunization programmes as a right from theirleaders and government, and holdleaders and government accountablefor providing them.

	Depending upon countries’ income andas economies grow, fund an increasing
proportion of domestic immunization
programmes, progressing to the full
funding of domestic programmes, andthen funding global immunization efforts.

 articipate in public-health discussionsPand be involved in key decisions about
immunization processes.
 articipate and contribute to theP
immunization delivery process andconvey the needs and perspectives of
their communities to the policy-makers.

Develop and introduce laws, regulations,and policies that support immunization
programmes and a secure, high-quality
supply base, if necessary.
	Develop region- and country-specificplans, together with other stakeholders
in region/country.

	Ensure immunization programmes areadequately staffed with personnel who
are well trained and given appropriate
incentives to manage the programmeand deliver services.
	Increase awareness of the importanceof immunization to improve a population’s
health and its contributions tostrengthening health systems andprimary health care.
Effectively convey messages on
vaccines to create demand.
Engage in dialogue with communities
and media and use effective
communications techniques to convey
messages about vaccines and to address
safety concerns.
	Encourage and support research on
vaccines and vaccination issues;and encourage education at all levels
on vaccines.

 rioritize and assume full ownershipPof national immunization programmes inorder to create equity-driven programmesthat reach every community.

C ollaborate regionally and internationally in advocacy programmes, evidence
sharing, and coordinated preparedness.

 ork with stakeholders within andWoutside governments.

 articipate in open dialogues withP
manufacturers to ensure affordabilityof current and new vaccines.

page 97	Health professionals should
do the following:	Academia should do
the following:	Provide high-quality immunization
services and information on them.

 romote innovation to acceleratePthe development of new and improved
vaccines, contribute to the optimizationof vaccine formulation and immunization
programme logistics, and lay thegroundwork for the impact of
immunization in future decades.

	Introduce vaccine educationalcourses on immunization at universities
and institutions training health-care
professionals as well as continuing
education for all health-care providers(medical, nursing, pharmacy and publichealth practitioners).
Identify areas where immunization
services could be improved andinnovations made.
Serve as proactive, credible voices forthe value of vaccines and recruit otheradvocacy voices.
Use existing and emerging technologies
to improve delivery and better capture
information.
Engage in dialogue with communities
and the media and use effective
communications techniques to convey
messages about vaccines and toaddress safety concerns.

	Pursue a multidisciplinary research
agenda that focuses on transformational
impact and is based on the needs of
end users.

	Engage more with systematic
reviews to identify areas where solid
scientific evidence exists (whichshould be the basis of health policies)
and those areas where such evidenceis lacking (which would be the basis
for future primary research).
 rovide evidence and outline
P
best immunization practices.
	Support the development of
manufacturing capabilities.
 romote budget allocation forP
vaccine and immunization research.

	Develop vaccines and technologies
that will optimize and maximize
vaccine delivery.
	Embrace new ways of working
that speed up scientific progress.
Improve dialogue with otherresearchers, regulators andmanufacturers in order to alignactions and increase effectivenessin responding to local and global
immunization challenges.

	Manufacturers should do
the following:C ontinue to develop, produce andsupply innovative and high-quality
vaccines that meet countries’ needs.
Support research and an education
agenda for immunization.

page 98

Annex 2: Stakeholder Responsibilities

Global Vaccine Action Plan	Participate in open dialogues withcountries and the public sector toensure sustainable access to current
and new vaccines.
	Continue to innovate manufacturing
processes and pricing structures.
Support the media outreach for the
Expanded Programme on Immunization toincrease awareness.

	Continue to define norms and guidelines
to improve vaccine and immunization
services, striving to achieve greater
equity and sensitivity to gender andsubpopulation (including, among others,
minorities and age groups).
	Promote synergies between immunizationand other health services as wellwith other sectors such as, education,
economic development and financing.

	Promote a dialogue between
manufacturers and countries toalign supply and demand.
 ursue innovative financing andPprocurement mechanisms that reinforce
country ownership, and promote
equity and affordability for low- andmiddle-income countries.

	Fund the provision of vaccines andimmunization-related activities.

Develop partnerships that support thegrowth of manufacturing capabilities andincrease vaccine supply and innovation.

	Work with all stakeholders to improve
technical assistance to strengthen
immunization and other components ofhealth systems.

	Development partners, such as
bilateral agencies, foundations
and philanthropists, should do
the following:Encourage, share and support evidencebased decision-making across the
spectrum of development, health andimmunization stakeholders.

	Fulfil institutional mandates andmissions in the health field.

Global agencies, such as WHO,
UNICEF, the World Bank, regional
development banks and the GAVI
Alliance, should do the following:	Advocate for and provide technicalsupport to promote country ownership.
	Strengthen national capabilities
and regional infrastructure.

Engage partners to generate populardemand for immunization and support
programme research and improvements.
	Promote the idea of sustainable national
funding and engage rapidly emerging
economies as funding partners.
Develop mechanisms for mutual
accountability that hold all governments,
programmes and development partners
responsible for committed levels of support.
		Participate in the development
and testing of innovative approaches
to deliver immunization services thatreach the most vulnerable people.

 rovide predictable long-term funding
Paligned with national plans andencourage new and existing partners tofund vaccines and immunization.

Follow national guidelines andregulations in the design and deliveryof immunization programmes that
fulfil the duty of accountability tonational authorities.

Build civil society capacity andsupport civil society organization
activities in countries.

Support rapid scale-up and adoption
as new or improved vaccines emerge.

	Work in coordination with other partners
on vaccine and immunization advocacy.

	Promote comprehensive, integrated
packages of essential interventions andservices that include vaccines and immunization and strengthen health systems.

	Support countries and regional entities
to achieve national and regional goals,
and contribute to the advancement of
their priorities.
	Promote country ownership andcountry-led health, vaccine andimmunization plans that include budgets
for improving access to services andreducing the equity gap in coverage.

 articipate in international advocacyPthrough access to open evidence thatcan be shared.
 aintain transparent and coordinatedM
funding, accompanied by performancebased evaluation.

	Educate, empower and engage vulnerable groups and communities on theirright to health, including vaccines andimmunization.

page 99

Media should do the following:Understand the benefits of, andconcerns about, immunization in orderto accurately report on and effectively
promote immunization programmes.
	Engage in country, regional and global
advocacy beyond the immunization
community to ensure vaccines and immunization are understood as a right for all.
	Use effective communications
techniques to convey messages about
vaccines and to address safety concerns.

	Build grass-roots initiatives withincommunities to track progress and holdgovernments, development partners
and other stakeholders accountable forproviding high-quality immunization
services.
	Contribute to improved evaluation andmonitoring systems within countries.

	Civil society, including
nongovernmental organizations
and professional societies,
should do the following:	Engage in country, regional andglobal advocacy beyond the immunization community to ensure vaccines
and immunization are understood asa right for all.

Get involved in the promotion andimplementation of immunization
programmes at both country andglobal level.

C ollaborate within and acrosscountries to share strategies andbuild momentum for improved
health, vaccines and immunization.

	The private sector should do
the following:	Support the diversification of funding
sources for immunization programmes(among others, private sector, insurance
providers and patients).
	Engage in country, regional and global
advocacy beyond the immunization
community and serve as champions
for immunization to ensure vaccines
and immunization are understood as aright for all.

page 100

Global Vaccine Action PlanTitle of Section (TK)

Annex 3: Costing andFunding Methodology
and Assumptions
Projecting the costs and available finances for
scaling up immunization in an effort to achieve theobjectives of the Decade of Vaccines Collaboration
Global Vaccine Action Plan, 2011-2020

Objective

Methods

To project the financial resource
availability and requirements
to facilitate the vision delineatedin the GVAP

Projections of annual and cumulative total costs and financial
flows were made to characterise the resource needs fordelivering a range of existing and key pipeline vaccines overthe decade in world’s poorest countries where the benefits ofimmunization are expected to be greatest. The projections draw
upon and consolidate information from existing forecasts andcosting studies as well as country-specific data available fromcountry immunization plans. The analysis focuses on projecting
costs and financial flows likely to be available to cover thosecosts for vaccines and injection supplies, associated delivery
efforts and immunization-specific system costs (e.g. cold chain).
The financing projections model the domestic funding flows
from country governments, support received through the GAVI
Alliance, and other major sources of development assistancefor immunization.

page 101

page 102

Annex 3: Costing and Funding Methodology and Assumptions

Global Vaccine Action Plan

Introduction
A critical component in moving from a set of documents to action and results
is an analysis of financial resource availability and requirements to facilitate
the vision delineated in the GVAP. The remainder of this document providesof an overview of the methodology and approach that underpins this analysis.
Instead of covering all actions in the GVAP, this analysis focuses on the costs,
projected financing, and resulting funding gap, under different scenarios, toimmunize target populations in low and lower-middle-income countries withexisting vaccines and upcoming vaccines that are expected to address significant
disease burden in these countries.

Table 9: Country scope for analysis

This analysis focuses on thecosts, projected financing,and resulting funding gap,
under different scenarios

Afghanistan

MalawiCongo, Rep

Moldova

TuvaluBangladeshMali

Côte d'Ivoire

Mongolia

UkraineBenin

Mozambique

Djibouti

MoroccoUzbekistan

Burkina Faso

Myanmar

Egypt

Nicaragua

Vanuatu

BurundiNepal

El Salvador

Nigeria

Viet Nam

Cambodia

Niger

Fiji

PakistanWest Bank & Gaza

CAR

RwandaGeorgia

Papua New Guinea

Yemen

Chad

Sierra Leone

Ghana

Paraguay

ZambiaComoros

Somalia

GuatemalaPhilippines

Azerbaijan

Methods

Congo, DR

Tajikistan

Guyana

Samoa

Cuba

EritreaTanzania

HondurasSão Tomé & Principe

Countries included

Ethiopia

Togo

Indonesia

SenegalGambiaUgandaIndia

Solomon Islands

GuineaZimbabwe

Iraq

Sri Lanka

Guinea-Bissau

AngolaKiribati

Sudan, N.

Haiti

Armenia

KosovoSudan, S.

Kenya

BelizeLao, PDR

Swaziland

Korea, DR

BhutanLesotho

Syria

Kyrgyzstan

Bolivia

Marshall Islands

Timor-Leste

Liberia

Cameroon

Mauritania

Tonga

Madagascar

Cape VerdeMicronesia

Turkmenistan

While the Decade of Vaccines Collaboration (DoVC) is intended as a global
enterprise, the immunization cost and financing projections analysis focusedon 94 countries, consisting of all those classified as low (35) or lower-middleincome (57) by the World Bank in 2011, as well as two countries that are now inthe process of graduating from GAVI eligibility and are classified as uppermiddle-income countries.4 A table listing the specific countries included in thisanalysis can be found below. Due to data availability for key variables, the analysis
sample consisted of 89 countries representing >99% of the total birth cohortof the original 94 countries. Of the 89 analysis countries, 57 are currently
eligible for new GAVI support, 16 are countries that are currently graduatingfrom GAVI support, and 21 countries are ineligible for GAVI support.

>99%of the total birth cohortof the original 94
countries represented

The analysis has focused on these countries in part because given highly constrained government spending on health in these countries, they are in a general
sense least likely to have the financial capability to completely self-fund desired
immunization services and, therefore will require the most support of the global
community to achieve the objectives of the GVAP.

4	World Bank income classification released July 2011, based on 2010 GNI per capita. Low-income countries have a 2010 GNI
per capita of US$1005 or less. Lower-middle-income countries have a GNI per capita of between US$1006 and US$3975.

WB IncomeClassification

LIC
LMIC
UMIC

page 103

page 104

Annex 3: Costing and Funding Methodology and Assumptions

Global Vaccine Action Plan

Vaccines included
While all vaccines are important within the wider scope of the DoVC, thevaccines that have been included in the scope of this analysis are those vaccinesthat are for use in humans, currently available, and in many cases, widelyused, along with newer vaccines that are expected to significantly address thevaccine-preventable disease burden5 within the 94 countries included in
the country scope identified above. In addition to vaccines licensed and available
today, the analysis also accounts for the expected introduction of several new
vaccines over the course of the decade. Veterinary vaccines and vaccines primarily
recommended for therapeutic use (e.g. Rabies vaccines) as well as vaccines
predominantly employed outside of resource-poor settings (e.g. Seasonal Flu
vaccines) were excluded from the analyses.
For the purposes of defining methods and identifying data sources, two(non-mutually exclusive) categories were used to classify the vaccines coveredin the analysis: (1) Vaccines delivered via campaigns and associated withAccelerated Disease Control (ADC), Eradication, or Elimination initiatives and(2) Vaccines delivered through routine immunization programs. This categorization was helpful since delivery costs differ markedly depending on the delivery
strategies (e.g. primarily through in-frequent vaccination campaigns versus theroutine vaccination), and the timing and intensity of delivery efforts (that affectcosts) differ depending on whether the vaccines/disease were associated withhigh-level global or regional eradication, elimination or ADC initiatives.
The table below summarizes the vaccines/diseases in each of the categories.
The vaccination schedule and targeting strategies selected for each of thesevaccines was based on global guidance (e.g. from WHO Position Papers, SAGE
Guidance). While for pipeline vaccines where such information is often notavailable, assumptions about the delivery strategy as well as the expected timingof licensure were based on the advice of vaccine development experts particularly
from relevant Product Development Partnerships. These were analyticalassumption rather than pre-suppositions of guidance and decisions on the partof regulators and individual countries.

5	The list of vaccines was drawn from a previous effort undertaken by WHO on behalf of GAVI to characterize vaccines by
public health priority. The terms of reference of this work are available here: http://www.who.int/immunization/sage/
Categorization_Activity_SAGE.pdf. While the main findings from this work are summarized here: http://fr.gavialliance.org/
resources/3____Vaccine_Investment_Strategy.pdf.

Table 10:
Vaccine/Disease Scope for analysis(1)	ADC/ Elimination/
Eradication Vaccines(Delivered via campaigns)
Conjugated Meningitis A
Measles
Oral Polio Vaccine (OPV)
Rubella
Tetanus
Yellow Fever(2) Routine Vaccination Programs
Cholera (campaign)
Conjugated Meningitis A
Dengue (routine)
Hepatitis B
Human Papilloma Virus
Inactivated Polio Vaccine (IPV)	Japanese Encephalitis		(routine and catch up)
Malaria (routine)
Measles (1st and 2nd dose)	Non-penta DTP and		
inc. tetravalent combinations
OPV
Penta (DTP-HepB-Hib)
Pneumococcal
Rotavirus
RubellaTuberculosis (BCG)
Typhoid (conjugate) (routine)
Yellow Fever

page 105

Cost and financing components included
For each of the above categories included in the analysis, costs were developedin three segments: vaccine and injection supplies, vaccine delivery (including
capital cold chain operation costs) and capital investment in cold chain capacity.
The vaccine delivery and capital investment in cold chain costs were then
combined into a single delivery cost category.

Delivery costs for supplemental
campaigns include:

Delivery costs for routine
services include: uman resourcesH(national, subnational, district
and service levels)C old chain equipment
and their overheads(installation, energy, maintenanceand repairs)

Vehicles and transport
Programme management
Training and capacity building
Social mobilization, IEC
and advocacy
Disease surveillance

Costs refer to immunization-specific costs only and human resources costs forindividuals partially dedicated to immunization. Other shared health systemcosts such as buildings were excluded. Total costs to sustain current gains andto incremental needs to scale up over the next decade were included.
Cost projections on a country-by-country basis were developed and aggregated
for the categories of vaccines described in Table 2 covering the period 2011-2020.
The assumptions and methodology for the baseline cost scenario are summarized
below. In addition, low and high scenarios were created. All costs are presented inconstant 2010 US$.
For each of the vaccine groups included in the analysis, financing flows were
projected from three financing sources: (i) Country Governments, (ii) the GAVI
Alliance, and (iii) Other Development Partners (i.e. bilateral donors, multilateralagencies and philanthropic agents).

Operational costs of campaigns(incl. for epidemic response)
Social mobilization
Disease surveillanceTechnical assistance(at country level only)page 106

Annex 3: Costing and Funding Methodology and Assumptions

Global Vaccine Action Plan

(1) Accelerated Disease Control (ADCs),
Elimination and Eradication programs
The World Health Organisation (WHO) and United Nations Children’s Fund
(UNICEF) lead the implementation of country-level programmes for a variety of
disease control, eradication and elimination efforts to combat vaccine-preventablediseases (listed in Table 10 above). These programmes produce plans andforecasts detailing the key activities, and the cost associated with the implementationof these programs.
These plans and forecasts have been used as the basis for projecting both thecosts of vaccine and injection supplies, and vaccination delivery for each of these
programmes over the decade as well as for other critical activities necessary foradministering the programs.

value from the programme plans where available. In the absence of long-term
projections for this cost component, recent core cost estimates were projected
forward based on the programme forecasts. Operational costs encompass
all running costs outside of vaccines and core costs to implement a vaccination
campaign. Country-specific operational cost information recorded incomprehensive multi-year immunization plans (cMYPs) were used to generate
metrics which were applied to the aforementioned forecasts to project therunning costs of all planned campaigns. Finally, contingency funds include
the resource needs to procure and manage vaccine stockpiles and monies held
in reserve to implement reactive campaigns in the event of disease outbreaks —These amounts are based on historic needs and taper off over time as it
is assumed the ADC, Elimination and Eradication programmes make progress
towards their respective goals. These costs were also taken directly fromprogramme plans.

(2) Routine Vaccination programmes(a) Vaccine Costs(a) Vaccine Costs
The target populations and planned timing of vaccination campaigns to achieve
the relevant disease control, eradication or elimination goals over the course of
the decade were taken from the plans as delineated by the programs. These
were combined with estimates of current vaccine prices (provided by UNICEF
Supply Division) to create forecasts of the vaccine/injection supply costs ofthese programs.

(b) Delivery Costs
Delivery costs for the ADC, Eradication and Elimination programmes wereseparated into core costs incurred primarily by implementing partners tofacilitate programs, operational costs to physically deliver vaccines and run thevaccination campaigns and contingency funds in the case of disease outbreaks.
Core costs cover critical activities—for example to stimulate demand(Social Mobilization) and to monitor the incidence and prevalence of disease(Surveillance) in affected countries. Core cost projections were also taken at face

Demand forecasts for traditional routine vaccines already on the market were
estimated on a country-by-country basis using existing demand forecasts
from WHO, UNICEF as well as GAVI (Strategic Demand Forecast version 4.0
and Adjusted Demand Forecast version 4.0). These demand forecasts werethen combined with estimated prices to project the costs of these vaccines andrelated injection supplies. For GAVI-eligible countries, GAVI-like price forecasts
were used on a disease-by-disease basis. For the non-GAVI lower-middle-income
countries (LMICs) in the analysis, baseline prices were assumed to be held
constant at the same differential between current GAVI prices and PAHO
Revolving Fund prices. Using the demand forecasts and price forecasts, theacquisition costs of vaccines and associated supplies were projected.
For vaccines still in the pipeline, demand forecasts were developed based on
expert input obtained through interviews with Product Development Partnership(PDP) representatives and other external stakeholders familiar with thesevaccines under development. Expected acquisition costs for these vaccines were
projected by applying these demand forecasts to a projected price per dose foreach of the vaccines in this segment.

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Projecting both the costsof vaccine and injection
supplies, and vaccinationdelivery for each of these
programmes over the decadepage 108

Annex 3: Costing and Funding Methodology and Assumptions

Global Vaccine Action Plan

values for the remaining 35% of countries for which point estimates were notavailable. The needs for scaling up were derived from a variety of sources
linked to the anticipated coverage projections and how countries have identified
priorities, strategies and needs within their cMYPs.
The vaccine delivery costs are those that are needed to ensure adequate supplyof vaccines through the health system and to store and transport vaccines in asafe and effective manner throughout the entire supply chain and logistics
systems of countries (from the national vaccine store to a service delivery point
in a health centre or outreach post). In other words, these encompassed all
the cold chain costs for storing vaccines (whether the capital equipment or theirrecurrent overheads) and the logistics of transporting vaccines (whether thevehicles or their recurrent overheads).

(b) Delivery Costs
Delivery costs include the main components of routine immunization service
delivery systems: human resources at all levels of the system and ongoing
capacity building (training); the supply chain and logistics systems needed tostore and transport vaccines (cold chain equipment, vehicles, transport…),and the cost of programme management (information systems, M&E…), social
mobilisation and disease surveillance. The approach to estimate the delivery
costs rested on separating those costs for service delivery and those costs for
vaccine delivery.
The service delivery costs are those that are needed to implement the national
immunization programme to deliver the immunization services. Information
provided by countries in their cMYPs was the basis of the costing and financing
estimates for delivery. Under the auspices of the Global Immunization Vision
and Strategy (GIVS), countries launched a process to strategically plan for theirnational immunization programme including estimating the current and future
costs required to reach the goals and targets of their programme. Based on thewealth of information available for approximately 65% of the countries (58)
in scope, a bottom-up costing exercise using a standard ingredients approach tocosting was undertaken by countries. From this sample of real data fromcountries, average unit costs by typology of country was used to impute missing

Countries launched aprocess to strategicallyplan for their national
immunization programme
including estimating
the current and future
costs required to reachthe goals and targets of
their programme

The WHO global forecast for cold chain and logistics is the basis of the costingfor vaccine delivery. The global forecast tool estimates (using the same demand
forecast assumptions for vaccines) the on-going needs to maintain the existingcold chain infrastructure in place along with the incremental needs to scale upneeds to raise coverage and introduce new vaccines.
Incremental capital cold chain costs were analyzed on a country-by-country
basis. Total expected volume of vaccines was compared to country-level cold
chain capacity. If capacity was projected to exceed country capacity in a given
year, incremental cold chain needed was estimated using relevant cost pervolume cold chain benchmarks.
Due to its unique service delivery, HPV delivery costs were defined on the basisof findings from several pilot demonstration projects as reported by PATH.

65%

of the countries undertook a bottomup costing exercise using a standard
ingredients approach to costing

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page 110Annex 3: Costing and Funding Methodology and Assumptions

Global Vaccine Action Plan

Financing projections

Table 11: Summary of the approach to estimate the cost of Delivery

Financing projections were developed across three main sources: public
spending on health from government’s own sources, GAVI Alliance funding,and other development partners. These projections were calculated for thevaccines described in Table 10.

Delivery

Costs included

Service Delivery

Vaccine Delivery(i) Government flows for immunization

costs included
Information
Sources
Human resources
At all levels of the system

cMYPs data from58 countries with
unitcosting andtypologies approach
to extrapolate toother countries.

Programme management
Including M&E, information
systems, planning…etc
Training
Training of health care
workers and on-going
capacity building
Social mobilization
Activities to stimulate demandfor immunization services
including IEC, advocacy andcommunications
Disease surveillance

Cold chain equipment
At all levels of the system

Cold chain overheads
Installation costs; energy
to run the cold chain(electricity, fuel, propane…),
maintenance costs andspare parts/repairs

WHO Global Forecast cold
chain forecast at national
level. Subnational needs
extrapolated using cMYP
data on the % of cold chain
costs by level of the system.
Country specific indicators
derived from cMYP data
(cold chain overheads as
a % of cold chain equipment
by level of the system).

VehiclesAt all levels of the system(ex: refrigerated trucks,
4WD, motorcycles…)

Country specific indicators
derived from cMYP data(vehicle costs % of cold
chain equipment by
vehicle type and by levelof the system).

Transport
Cost of fuel,maintenance,
overheads(registration/insurance)
repairs/spare parts…

Country specificindicators derived fromcMYP data (Transport as
a % the cost of vehicles
by vehicle type andby level of the system).

The methodology to project government flows for immunization rested onrelying on the available financing data provided by countries in their national
multi-year immunization plans (cMYPs). The analysis of this data was the basisof the government financing estimates for both vaccines and systems costs.
For countries that did not have cMYP, a methodology of unit financing andtypologies was applied in a similar fashion as done on the costing side. For SIAs,
typologies were based on population groupings since the per capita investments
by governments tend to be lower for midsize/larger countries (i.e. population≥10 million) than much smaller countries (i.e. population <10 million)—mainly
due to economies of scale that can be leveraged in the former. For government
financing for routine vaccination services, rather than using a typology by
population groups, the GAVI co-financing groupings were used that stratify
countries since these groups provide a proxy of the ability to finance vaccines andimmunization. This typology groups countries into Low-Income, Intermediate,
Graduating and Non-GAVI.
In broad terms the method for projecting government flows involved generating abaseline estimate of government funding for the year 2010 derived from thecMYP data. This baseline estimate was projected forward between 2011 and 2020
based on IMF projections of real GDP growth. The assumption underlying the
projection methods is that growth in the health budget of countries will growat the same rate as economic growth. In other words, the base case funding
assumes that governments will continue to provide the same share of the healthbudget for immunization as they currently do over time—despite the fact thatin absolute terms, the amount governments contribute will increase in line witheconomic growth forecasts.

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page 112Annex 3: Costing and Funding Methodology and Assumptions

Global Vaccine Action Plan

In the baseline scenario, no additional government funding was assumed
to be available for the mainly new or pipeline vaccines that are not part of
the traditional/basic EPI vaccines or those supported by GAVI (e.g. malaria,
dengue vaccines)(ii) GAVI Alliance Funding
For those vaccines delivered through campaigns and that are part of ADC
activities but that are funded by GAVI, (i.e. MenA, yellow fever, rubella), GAVI
Alliance funding was assumed to cover the full costs of the vaccines/injection
supplies, while for operational costs, it was assumed that GAVI will provide
funding at least equivalent to current levels (i.e.US$0.30 per targeted person).
For routine GAVI-supported vaccines, GAVI’s own financing projection
assumptions were applied through 2020 to determine the amount of finances
GAVI will provide for New Vaccine Support over the decade. The analysis
does not include any GAVI funding that is and might be made available fordelivery activities associated with routine vaccination programmes/systems.

(iii) Other Development Partner Funding
For routine programs, country-specific levels of other development partner
funding (in a sample of 40 cMYPs that included programs with PCV, pentavalent,
and rotavirus vaccines) were used to generate two population-weighted
indicators: 1) OD partner financing of vaccines as a share of GHE; and 2) OD
partner financing of delivery costs as a share of GHE by two population groups(<100 million and >100 million) using STATA10. Population-weighted averages
were applied to each country in the model based on their population group,and multiplied by GHE to project over the period. This method assumes that2010 levels of other donor support for vaccines and routine program delivery
relative to GHE remain constant over time. This represents a baseline level ofother donor financing, above which additional other partner financing for new
vaccines might be added.
Other development partner funding aside from contributions to immunizationthat occur through GAVI Alliance funding have not been included for the
purposes of this analysis.

page 113

Developing estimated future resource requirements
Vaccine acquisition costs and delivery cost projections have been combinedwith aggregated financing flow projections on an annual basis to estimate thefunding gaps/incremental resource requirements on an annual basis needed
to successfully scale up immunization programmes globally in line with thecoverage targets outlined within the GVAP.

Limitations
This exercise does not analyse or attempt to approximate thecost of the implementation of the Global Vaccine Action Plan.
The analysis described above is only an exercise to determine
the vaccine acquisition and service delivery cost and resource
availability for increasing coverage of existing vaccines andthe introduction of new vaccines over the course of the decade.
The costs projections produced from this effort to do notinclude the agency overhead costs for the implementation andmaintenance of the GVAP – there will be additional resources
required for this activity.

Costs and funding for Advocacy and Political Support activity
are not captured in this analysis.
The approach taken for this exercise builds on existing sourcesof information and global projection of needs generated bydifferent groups (e.g. Polio, Measles, etc) in order to leverage thebest data available, when possible. Because of this approach,
it is difficult to ensure a consistency in the methods throughout
the work, and a complete mitigation of double counting risks.
The costs are limited to a priority set of countries although theaspirations of the Decade of Vaccine and GVAP are global.

Costs and funding for Research and Development activity are
not captured in this analysis.

While it is important to acknowledge the limitations of the analysis that was
conducted, it is not believed that any of the limitations outlined above will alter
the directional nature of the results of this exercise.

page 114

Global Vaccine Action Plan

Annex 4: HealthImpact Methodology
and Assumptions
Projecting the total impact of vaccination
administered between 2011–2020, relative to a
no vaccination scenario, for selected vaccines

Title of Section (TK)page 115

page 116Annex 4: Health Impact Methodology and Assumptions

Global Vaccine Action Plan

Forecast impact of vaccination administered between 2011–2020

A. Sample data output

B. Indicator

Data shown for persons vaccinated for DoV impact scenario

Future deaths averted calculated over period of mortality risk in vaccinated cohorts,
relative to a no vaccination scenario, for vaccines delivered during the period 2011–2020.

Group

Original EPI vaccines

New orunderutilized
vaccines

Vaccine-preventable
DiseaseVaccination
strategy

Number of future
deaths averted

Number of deaths
averted per 1,000
persons vaccinatedMeasles – 1st doseroutine

10.6M

16.5

Measles – 2nd doseroutine

0.4M

1.9

Measles – SIA

campaign

3.1M

3.5

Hepatitis B

routine

5.3-6.0M

8.3

Hib

routine1.4-1.7M

2.6

Pneumococcal

routine1.6-1.8M

4.3

Rotavirus

routine0.8-0.9M

3.1

Human papillomavirus

routine

0.5M

15.1

Yellow fever

routine0.03-0.04M

0.2

Meningococcal
meningitis A

campaign & routine

0.03M

0.8

Japanese encephalitis

campaign & routine

0.07M

0.1

Rubellacampaign & routine

0.4M

0.4

C. Countries
94 countries, consisting of all those classified as low (35) or lower-middle-income (57) by
the World Bank in 2011, as well as two countries that are now in the process of graduatingfrom GAVI Alliance eligibility and are classified as upper-middle-income countries wereconsidered in scope for the purposes of this analysis. Due to data availability, 13 countries
with small populations were omitted; it will not alter the directional nature of this analysis.

D. Population projections
UN Population Division 2008 (hepatitis B, YF, NmA, JE, HPV, rubella) or2010 (Hib, rotavirus, Sp, measles) revision.

E. Coverage projections

TOTAL (2011-2020)24.6-25.8M

GAVI Strategic Demand Forecast 4.0, 4 October 2011; GAVI Adjusted Demand Forecast(SDF 4.4 October 2011 was used for the 73 GAVI eligible countries.) A different projection,
however, was used for the non-GAVI eligible countries.

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page 118

Annex 4: Health Impact Methodology and Assumptions

Global Vaccine Action Plan

F. Vaccines and vaccination strategies

Hepatitis B

Routine infant

G. Model source and structure

Centers for Disease
ControlStatic natural history population-based cohort

H. Underlying disease burden

Hepatitis B

Pre-vaccination HBsAg serosurvey data (many countries)

Hib

WHO/CHERG 2008 under-5 pneumonia deaths (many countries) x pre-vaccination
proportion radiographic pneumonia cases due to Hib (probe studies in 6 countries)

Pneumococcal

WHO/CHERG 2008 under-5 pneumonia deaths (many countries) x pre-vaccination
proportion radiographic pneumonia cases due to Sp (probe studies in 3 countries)

Rotavirus

WHO/CHERG 2008 under-5 diarrhoea deaths (many countries) x pre-vaccination
proportion severe gastroenteritis due to rotavirus infection (many countries)

Human papillomavirus

Pre-vaccination retrospective surveys of women with invasive cervical cancer withuse of molecular techniques to determine the proportion due to HPB and due tospecific HPV genotypes (many countries)

Hib

Routine infant

Johns Hopkins University Static cohort(Lives Saved Tool model)

Pneumococcal

Routine infant

Johns Hopkins University Static cohort(Lives Saved Tool model)

Rotavirus

Routine infant

Johns Hopkins University Static cohort(Lives Saved Tool model)

Human papillomavirus

Routine10-13 year old girls

Harvard
University

Static cohort

Yellow fever

Routine infant(following SIAs
conducted prior
to 2011)GAVI(Long Range Cost andImpact model)

Estimate of 0.2 deaths averted per 1,000
vaccinated from a static cohort model
estimate for Nigeria applied to projected
numbers vaccinated during 2011-2020

Yellow fever

Pre-vaccination 1993 study modelling the impact of vaccination in Nigeria during
1991-2026. Model based on several disease burden studies in Nigeria (one country,
little comparable data elsewhere). Only epidemic disease burden considered.
Impact based on marginal increase in coverage since year prior to start of GAVI support

Meningococcal
meningitis

Routine infant +one-time SIA(all 1-29 year olds)

GAVI(Long Range Cost andImpact model)

Estimate of 1.04 (SIA) and 0.08 (routine infant)deaths averted per 1,000 vaccinated froma static cohort model estimate of the NmA
investment case applied to projected numbers
vaccinated by each strategy during 2011-2020

Meningococcal
meningitis

Based on a pre-vaccination prospective hospital surveillance study in Niger conductedduring 1981-1996 (one country, little comparable data elsewhere)

Japanese encephalitis

Based on a 2011 review of population-based surveillance studies.
Some pre-vaccination some post-vaccination ) (several countries)

Japanese encephalitis

Routine infant + one-time
SIA (all 1-15 year olds)

PATH

Static cohort

RubellaPre-vaccination retrospective rubella serosurveys to determine age-specificincidence (many countries)

RubellaOne-time SIA v(all 9 month-14 year
old boys and girls)

UK Health Protection
Agency Centre for
Infections, CDC, WHO

Dynamic cohort

MeaslesCase fatality ratios from Wolfson et al 2009 review of CFRs for children under five.
CFRs for 5-9 years old assumed 50% of CFRs for 1-4 year olds and CFRs wereassumed to be 0 above 10 years of age. Age distribution derived from case based
surveillance data, using first dose coverage and regions as covariates

Routine infant
Routine childhood
Variable

WHO/Department of
Immunization,
Vaccines and Biologicals(2012)

Dynamic natural history model informedby surveillance data

Measles
Measles – 1st dose
Measles – 2nd dose
Measles – SIA

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page 120Annex 5: Countries and Organizations that Contributed to the Elaboration of the GVAP

Global Vaccine Action Plan

Annex 5: Countries
and Organizations thatContributed to the
Elaboration of the GVAP

Organizations whose members haveprovided inputs and comments to the
Global Vaccine Action Plan
Government entities:
Africa Regional Certification
Commission, Albanian Institute of
Public Health, Centro Nacional para
la Salud de la Infancia y la Adolescenciade México, Chinese Centers for
Disease Control, Chinese National
Institute for Food and Drug Control,
European Medicines Agency,
Federación de Planificación Familiar
Estatal, Forum des parlementaires
africains et arabes pour la population
et le developpement, Health Canada,

Indian Department of Biotechnology,
Indian National Institute of
Immunology, National Primary
Healthcare Development Agency of
Nigeria, Paul Ehrlich Institut,
President’s Emergency Plan for AIDS
Relief, Dutch National Institute of
Public Health & Environment, Sudan
National Medicines & Poisons Board,
U.K. Department of Health, U.K.
Health Protection Agency, U.K.
National Institute of BiologicalStandards and Control, U.S. Army,
U.S. Centers for Disease Control andPrevention, U.S. Department of
Defense, U.S. Department of Healthand Human Services, U.S. Departmentof State, U.S. Food and Drug
Administration, U.S. National Institutesof Health - National Institute ofAllergy and Infectious Diseases,
Yemen Supreme Board for Drugs.

Health professionals:
American Academy of Pediatrics,
Asociación Mexicana de Pediatría,
Confederación Nacional de Pediatríade México, Hôspital d’ Enfants deRabat, Indian Academy of Pediatrics,
International Pediatric Association,
Leiden University Medical Center,
Sudan Pediatric Association, Uganda
Paediatric Association.

Academia:
Aga Khan University, American
Association for the Advancement of
Science, Australian National Centre
for Immunisation Research &Surveillance, Banaras Hindu University,
Barcelona Centre for International
Health Research, Barcelona Institutefor Global Health, Center Esther
Koplowitz, Centre for Health Sciences
Training, Research and Development,
Centro para Vacunas en Desarrollo
de Chile, Centro de Investigación yde Estudios Avanzados del Instituto
Politécnico Nacional, Chandigarh
Post Graduate Institute of Medical
Education and Research, Christian
Medical College, Chulalongkorn
University, Emory University Hospital,
Fred Hutchinson Cancer ResearchCenter, Fundacio Clinic per a la
Recerca Biomedica, Georgia Instituteof Technology, Gorgas Institute,
Griffith University, Hospital Clínic,Indian Council for Medical Research,
Indian International Centre for
Genetic Engineering and Biotechnology,
Infectious Diseases ResearchInstitute, Institut Català d’Oncologia,
Institut d’Investigacions Biomèdiques
August Pi i Sunyer, Institut Pasteur,
Institute of Medical Sciences, Institutode Salud Pública Universidad
Veracruzana, International Agency for
Research on Cancer, International
Centre for Diarrhoeal Disease Research

Bangladesh (ICDDRB), Jawaharlal
Nehru University, Johns Hopkins
University, Jordan University Hospital,
Karolinska Institute, London Schoolof Hygiene & Tropical Medicine,
Lund University, Mahidol University,
Makerere University, Mali’s Center
for Vaccine Development, Marrakech
Faculté de Médecine, Maxwell Schoolof Syracuse University, Mayo Clinic
Vaccine Research Group, Medical
Research Council, Menzies School of
Health Research, Methodist
Hospital Research Institute, Molecular
Biophysics Unit Indian Institute of
Science, New York Academy of
Sciences, Novartis Vaccines Institutefor Global Health, Oswaldo Cruz
Foundation, Pakistan’s National
Institute of Child Health, Pakistan’s
National Institute of Health, Princeton
University, Ragon Institute, Rockefeller
University, Sandra Rotman Centre
for Global Health, Tehran Universityof Medical Sciences, The Wharton
School University of Pennsylvania,
Universidad Autónoma de México,
Universidad Autónoma de Yucatán,
Universidad Autónoma San Luís
Potosí, Universidad del Valle deGuatemala, Universidad Peruana
Cayetano Heredia, University College
London, University of Alabama,
University of Antwerp, University ofCalifornia – San Francisco, Universityof Cape Town, University of Erfurt,
University of Geneva, University

page 121of Goettingen, University of Hong
Kong, University of Kwazulu-Natal,
University of Maryland, University of
Melbourne, University of Michigan,
University of Minnesota, Universityof Oxford, University of Philippines,
University of Tennessee, Universityof Toronto, University of Warwick,
University of Yaounde, Walter Reed/
Armed Forces Research Institute ofMedical Sciences Research Unit
Nepal, Wellcome Trust.

Product Development Partnerships:
Aeras—Global TB Vaccine Foundation,
Dengue Vaccine Initiative, European
Vaccine Initiative, International
AIDS Vaccine Initiative, International
Vaccine Institute, Malaria Vaccine
Development Program, Malaria
Vaccine Initiative, Medicines for
Malaria Venture, Meningitis Vaccine
Project, Tuberculosis Vaccine Initiative.
Manufacturers:
Aridis Pharmaceuticals, Baxter, Bharat
Biotech, BIO, Biofarma, Biological
E, Bio-Manguinhos/Fiocruz, Biovac
Institute, Birmex, Butantan Institute,
Centro de Ingenieria y Biotecnología
de Cuba, CNBG, Crucell Vaccines,
Developing Countries Vaccine Manufacturers Network, GlaxoSmithKline
Biologicals, Indian Immunological
Limited, Inovio Pharmaceuticals,Intercell, International Federation ofpage 122

Annex 5: Countries and Organizations that Contributed to the Elaboration of the GVAP

Global Vaccine Action Plan

Pharmaceutical Manufacturers
and Associations, Laboratorio Emea,
Merck, NasVax, Novartis Pharma
AG, Novartis Vaccine Institute for
Global Health, Novavax, Pfizer,
Sanofi-Aventis, Sanofi-Pasteur, Serum
Institute, Shanta Biotechnics
Limited, Vaxinnate Corporation,
Xiamen Innovax Biotech Co. Limited,
Zydus Cadilla.

Global agencies:
African Leaders Malaria Alliance, the
GAVI Alliance, Partnership for
Maternal, Newborn, and Child Health,
United Nations Population Fund,
UNICEF, United Nations, World Bank,World Health Organizationand its regional offices.
Development partners:
African Development Bank,
Australian Agency for International
Development, Bill & Melinda Gates
Foundation, Canadian International
Development Agency, European
Union, Inter-American Development
Bank, Japan International Cooperation
Agency, Norwegian Agency for
Development Cooperation, Spanish
Agency for International Development
Cooperation, Swedish International
Development Cooperation Agency,
U.K. Department for International
Development, U.S. Agency forInternational Development.

Civil society:@Verdade, ACTION, Action for
Global Health, ActionAid, Afro Global
Alliance, Aga Khan Health Services,
Agence de Médecine Préventive,
Alternative Santé, American Association
for Cancer Research, American Cancer
Society, Inc., Americans for Informed
Democracy, American Red Cross,American Society of Tropical Medicine
and Hygiene, Asociation Lalla Salmade Lutte contre le Cancer, Associationd’Assistance aux Développement,
Associazione Italiana Donne per lo
Sviluppo – Italian Association for
Women in Development, BIO Venturesfor Global Health, Carlos Slim
Foundation, Catholic Relief Services,Center for Global Development, Center
for Strategic & International Studies,
Cestas – Centro di educazione sanitaria
e tecnologie appropriate sanitarie,
Civil Society Human and Institutional
Development Programme, Clinton
Health Access Initiative, Communication for Development Centre in
Nigeria, Consortium of Christian
Relief and Development Associations
in Ethiopia, CORE Group, Ethiopian
Catholic Secretariat, European
Parliamentary Forum, European
Public Health Alliance, Every Childby Two, Farmamundi, GAVI CSO
Constituency, German Foundation
for World Population (DSW), Ghana
Coalition of NGOs in Health,Global Action for Children, Global

Commission on HIV and the Law,
Global Eye, Global Health
Advocates, Global Health Council,
Global Health Technologies
Coalition, Global Poverty Project,
Health Action International, Healthand Rights Education Program,
Health Development Consultancy
Services (HEDECS), HealthNet
TPO, Interact Worldwide,
International Council of Voluntary
Agencies, International Federationof Red Cross and Red CrescentSocieties, International HIV/AIDS
Alliance, International Research
Foundation for Development, Kaiser
Family Foundation, Kenya AIDS
NGOs Consortium, Kenya Community Health Network, Kenya Red
Cross, Kid Risk, Inc., Knowledge
Ecology International, Light Africa
International, Lions Club International Foundation, Malaria No More,Management Sciences for Health,Millennium Development Goals
Health Alliance, Médecins
du Monde, Medecins Sans
Frontières, Medicos del Mundo,
Medicus Mundi International,
Mundo Sano, Niger’s Regroupement
des ONGs et Associations duSecteur de la Santé, Nothing But
Nets, ONE, Oxfam, Partnershipfor Maternal, Newborn, and Child
Health CSO constituency, PATH,
Philippine Foundation for
Vaccination, Plan International,

Planeta Salud, Policy Cures, PSI,
Réseau des Plates-formes nationales
d’ONG d’Afrique de l’Ouest et duCentre, RESULTS, Results forDevelopment, Rotary International,
Sabin Vaccine Institute, Save theChildren, Sightsavers, Soins de Sante
Primaires en Milieu Rural, Stop AIDS
Alliance, Strengthening Rights andEquality by Empowering Teams,
Swaasthya, Task Force for Global
Health, TB Alert, Terre des Hommes,
The Centre for Health Policy, The
Communications Initiative, The
INCLEN Trust International, Uniondes ONG du Togo, Union forInternational Cancer Control, United
Methodist Church General Board of
Church and Society, United Nations
Foundation, U.S. Fund for UNICEF,
Vaccines for Africa Initiative,
Welthungerhilfe, World Vision.

Private sector:
Applied Strategies, Bernard Fanget
Consulting, Boston Consulting Group,
Codexis, Dynavax, Evergreen
Associates, Global Health Strategies,
GMMB, John Snow, Inc., Johnson &Johnson, Kleiner Perkins Caufield& Byers, Lion’s Head Global Partners,
Liquidia Technologies, McKinsey& Company, MedImmune, NeoVacs,
S.A., PricewaterhouseCoopers,
Weber Shandwick.

Countries that provided inputs
and comments to the Global Vaccine
Action Plan:
Afghanistan, Albania, Algeria, Angola,
Argentina, Armenia, Australia,
Austria, the Bahamas, Bangladesh,
Barbados, Belgium, Belize, Benin,
Bolivia (Plurinational State of),Botswana, Brazil, Brunei Darussalam,
Burkina Faso, Burundi, Cambodia,
Cameroon, Canada, Cape Verde, theCentral African Republic, Chad, Chile,
China, Colombia, Congo, Costa Rica,
Cote d’Ivoire, Cuba, Cyprus, theDemocratic Republic of Congo,
Denmark, the Dominican Republic,
Ecuador, Egypt, El Salvador, Equatorial
Guinea, Estonia, Ethiopia, Finland,
the Former Yugoslav Republic ofMacedonia, France, French Guiana,
Gabon, the Gambia, Georgia,
Germany, Ghana, Greece, Guatemala,Guinea, Guinea-Bissau, Haiti,
Honduras, Hungary, India, Indonesia,
Ireland, the Islamic Republic of Iran,
Italy, Jamaica, Japan, Jordan,
Kazakhstan, Kenya, Kyrgyzstan,
Lao (People’s Democratic Republic),
Lebanon, Lesotho, Liberia, Libya,
Madagascar, Malawi, Maldives,
Mali, Mauritania, Mauritius, Mexico,
Monaco, Mongolia, Morocco,
Mozambique, Myanmar, Namibia,
Nepal, the Netherlands, Nicaragua,
Niger, Nigeria, Norway, Pakistan,
Panama, Papua New Guinea,
Paraguay, Peru, the Philippines,

page 123

Poland, Portugal, Qatar, Republic ofKorea, Russian Federation, Rwanda,
Sao Tome and Principe, Saudi Arabia,
Senegal, Serbia, Seychelles, Sierra
Leone, Singapore, Somalia, South
Africa, South Sudan, Spain, Sudan,
Suriname, Swaziland, Sweden,
Switzerland, the Syrian Arab Republic,
Thailand, Timor-Leste, Togo, Trinidad
and Tobago, Tunisia, Turkey, the Turksand Caicos Islands, Uganda, Ukraine,
the United Kingdom of Great Britain
and Northern Ireland, the United
Republic of Tanzania, the United Statesof America, Uruguay, Uzbekistan,Venezuela (Bolivarian Republic of),Viet Nam, Yemen, Zambia, Zimbabwe.

page 124

Global Vaccine Action Plan

Annex 6: The
Monitoring and Evaluation/
Accountability Framework
Background
The Monitoring and Evaluation/Accountability Framework
is a critically important element of the Global Vaccine
Action Plan (GVAP). Recognizing the importance to closely
monitor the GVAP implementation progress, the World
Health Assembly (WHA) resolution called for annual
reports on progress at each Regional Committee meeting
and at the WHA, through the WHO Executive Board (EB).

Title of Section (TK)page 125

page 126

Annex 6: The Monitoring & Evaluation/Accountability Framework

Global Vaccine Action Plan

In defining the scope of the M&E/A Framework,
the GVAP refers to the need:to finalize a complete set of GVAP
indicators with the appropriate
methodology and data sources for eachindicator defined and baselines
established, where required.

to secure commitments aligned with
the GVAP from different stakeholders,
including countries, civil society
organizations, multilateral agencies,
private foundations, development
partners, and vaccine manufacturers.

Figure 1:
The Accountability Framework for the UN Secretary General’sGlobal Strategy for Women’s and Children’s Healthto develop a mechanism forcoordinating the implementation ofthese commitments at global, regionaland national levels.

Country accountability

to ensure annual reporting of
progress at each Regional Committee
meeting and at the WHA, through the
WHO EB.
ACt

1. Vital Events

The Accountability Framework for the United
Nations (UN) Secretary General’s Global Strategy
for Women’s and Children’s Health

2. health indicators
4. Resource tracking

Global Accountability

MONITORto invest in improving data qualityand developing more robust in-country
monitoring and evaluation systems.

3. Innovation

10. Global oversight

5. country compacts
7. National oversight

8. transparency

The GVAP calls for leveraging the recommendations of the Commission
for Information and Accountability for Women’s and Children’s Health andaligning work, wherever possible, with other accountability efforts.
The Accountability Framework of the UN Secretary General’s Global Strategy
for Women’s and Children’s Health refers to a cyclical process of monitoring,
review and remedy/action to assess progress, document success, identify
problems that need to be rectified and take prompt action as and where needed.
This process needs to occur at the country and global levels as illustrated in
Figure 1.6 To have a better oversight of progress an independent Expert Review
Group (iERG)7 reports annually to the UN Secretary General on the results andresources related to the Global Strategy and on progress in implementation of
the Commission’s recommendations. The Decade of Vaccines annual report thatwill be submitted to the WHA will also be shared with the iERG as information
for their annual report to the UN Secretary General.

6	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/)7	iERG members http://www.who.int/woman_child_accountability/ierg/members/en/

page 127

6. reaching women and children

review

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Proposed Process for the GVAP Monitoringand Evaluation / Accountability Framework
A similar cyclical process of monitoring, review, and recommendations foraction is proposed for the GVAP M&E/A Framework. In addition to thenational and global levels, another level of GVAP M&E/A at the regional levelis required to accommodate the requirement of reporting annually to the
WHO Regional Committees.
Using a similar framework allows for complementarity with the accountability
process for the UN Secretary General Global Strategy for Women’s andChildren’s Health and provides opportunities to leverage and/or use theseprocesses for tracking and reporting on some of the aspects of GVAP. Thisapplies in particular to the process to monitor commitments and resources
as described in the related documents for this session. Figure 2 illustrates
the proposed GVAP M&E/A Framework process. Guidelines for making
immunization commitments under the UN Secretary General Global Strategy
for Women’s and Children’s Health framework can be found on each Decadeof Vaccines (DoV) Collaboration Leadership Council website.

Figure 2:
Proposed GVAP Monitoring and Evaluation/Accountability Framework

ADMINISTRATIVE DATA
other data

Countryreports andreview

jrf8

surveysjrf | other

iERG

EB/WHASAGE

Global levelindicators e.g. R&D

SAGE
WG

reports on resources
and commitments

The GVAP M&E/A Framework will be applied to: (1) monitoring results (definedas progress against the GVAP Goals’ and Strategic Objectives’ indicators);(2) documenting and monitoring stakeholder commitments to GVAP and DoV;
(3) tracking resources invested in vaccines and immunization; and (4) inclusionof independent oversight and review of progress, through the World HealthOrganization Strategic Advisory Group of Experts (SAGE) on Immunization,in the reporting to the governing bodies.

Global level: The annual review process will go through SAGE, the WHO EB and
the WHA. The report will also be shared with iERG for their women’s and children’s
health annual report to the UN Secretary General.

A final set of GVAP indicators (see Table 12 and Table 13) was reviewed andapproved by SAGE during their 6-8 November 2012 meeting, and will bepresented to the WHO EB in January 2013 and the WHA in May 2013.

Regional level: The WHO Regional Offices are developing their mechanisms forreview and reporting to the Regional Committees. Regional Technical Advisory Groups
on Immunization may take on that role, similar to the SAGE role at the global level.

Monitoring commitments and resources:

Country level: The National Immunization Technical Advisory Groups (NITAGs)
and the Interagency Coordination Committees (ICCs) could also assume roles ofmonitoring commitments and resources at the country level. This will be determined
as countries continue to develop their national plans.

The M&E/A Framework will also document and monitor stakeholders
commitments to GVAP and track resources invested in vaccines and immunization.

regional
reports andreview

8	JRF is the WHO and UNICEF Joint Reporting Form.

GVAP M&A
secretariat

annual reports fromkey stakeholders

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Global Vaccine Action Plan

page 131

TABLE 12: Proposed Extended Goals Indicators

1
Indicators

Operational definition

Data source/collection

Baseline

TargetMilestones

1. Achieve a world freeof poliomyelitis

2. M
 eet global and regionalelimination targets

2.1. Neonatal tetanus elimination

2.2. Measles elimination

2.3. Rubella/CRS elimination< 1 NT case/1,000 live births in each
district and maintenance of elimination
based on annual WHO/UNICEF District
Data Spreadsheet

Number of regions with 100% of countries
having declared interruption of endemic
measles virus transmission for a period of> 12 months in the presence of high quality
surveillance

Number regions with 100% of countries
having declared interruption of endemic
rubella virus transmission for a periodof > 12 months without occurrenceof CRS cases associated with endemictransmission in the presence of highquality surveillance

1.1. Interrupt wild poliovirustransmission globally

1.2. Certification ofpoliomyelitis eradication

No wild poliovirus isolated globally for atleast 1 year, in the presence of certification
quality AFP surveillance (annual non-polio
AFP rate of at least 1/100,000 population< 15 years at national and sub-national
level, with adequate stool specimens
collected from at least 80% of AFP cases)

No wild poliovirus isolated globally for atleast 3 years in the presence of certification
quality AFP surveillance

National AFP surveillance systems +supplementary surveillance data whereavailable (environmental surveillance orenterovirus surveillance through national
lab networks)

Final national documentation onpolio-free status submitted by NCCs andaccepted by RCCs

WHO/UNICEF District Data Spreadsheet,and WHO validation report (based on LQA
in worst performing district)

Each region has a verificationcommission which annually reviews
the status of all countries

Each region has a verificationcommission which annually reviews
the status of all countries

2011: 650 WPV-confirmed cases reported
from 16 countries

2011: National documentation on polio-freestatus accepted by RCCs in 168 out of 194
WHO member states (87%)

2010(40 countries still to achieve elimination)

2010(0/5 regions - AMRO, WPRO,
EMRO, EURO, AFRO)

2010(0/2 regions - AMRO, EURO)

2014

2018

2015

2015: 4 WHO regions

2015: 2 WHO regions

2020: 5 WHO regions

2020: 5 WHO regions

Monitor # and % of countries ineach region that are verified as having
eliminated diseases

Monitor # and % of countries ineach region that are verified as having
eliminated diseases

The surveillance quality will be assessed
as described in criteria for verification ofelimination

Track number of countries with national
documentation of polio-free status,
accepted by RCCs

10 countries eliminated NT by 2012;
22 countries eliminated NT by 2013;36 countries eliminated NT by 2014;
40 countries eliminated NT by 20152020: 5 WHO regions

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1
Indicators

Operational definition

3. Meet vaccination coverage targets inevery region, country and community

3.1. Reach 90% national coverage and 80%
in every district or equivalent administrative
unit with three doses of diphtheria-tetanuspertussis containing vaccines
WHO UNICEF Estimates of National
Immunization Coverage (WUENIC)*
for national coverage;
District data:- accept JRF admin data if WUENIC based on
administrative coverage; missing district
reports =indicator not met, encouragereporting;- if WUENIC not based on administrative
coverage, repeated measure (at least two

Data source/collection

Baseline

TargetMilestones

3.2. Reach 90% national coverage and 80% inevery district or equivalent administrative unit
for all vaccines in national programmes, unlessotherwise recommended surveys or special studies to document
district coverage); early measure (2009 to2015) and later measure (2016 to 2020)- countries may choose to conduct surveys inselected “high risk” districts likely to have
low coverage- surveys should be conducted at least twicein the decade (baseline and one othertime) but countries should aim for more
frequent surveys

Determination of national and district level
coverage as defined above

Coverage refers to coverage with primaryseries of vaccine

Indicator applies to all vaccines being used
for country-wide, universal immunization(exception of HPV, where country-wide
universal immunization of girls would be
included)

For pneumococcal and rotavirus vaccines,
this will be coverage with primary series
by 12 months of age. For other vaccines,
the exact measurement of coverage needs
to be defined, but will be as reported in the
WUENICWUENIC, JRF, surveys or special studies

WUENIC, JRF

2010 or early measure2010 or early measure (for district data)

2015 – all Member states

2020: All Member States

Monitor trends in coverage

Monitor trends in coverage

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4. Develop and introduce new and improved
vaccines and technologies

Indicators

Operational definition

Baseline

TargetMilestones

5. Exceed the Millennium Development
Goal 4 target for reducing child mortality

4.1. Licensure and launch of vaccine or
vaccines against one or more major currently
non-vaccine preventable diseases

4.2. Licensure and launch of at least
one platform delivery technology

4.3. Number of low-income and middleincome countries that have introduced one
or more new or underutilized vaccines

5.1. Reduce under-five mortality rate

Licensure relates to registration by afunctional National Regulatory Authority(NRA)

Licensure relates to registration by
a functional NRA

Low- and middle-income countries=
world bank classification 2012

Under-five mortality rate per1000 live births

New platform delivery technology is defined
as a new mechanism for delivering
vaccines to individual recipients thatfacilitates coverage, improves performance,or reduces cost of vaccine or delivery,e.g. jet injectors, microneedles, aerosol etc.

Vaccine is added in national immunization scheduleand used for a sustained period of at least 12 months(excluding those used only in the private sector andnot in national immunization schedule; includes
vaccines included in national schedule but for selective
use at risk populations, e.g. seasonal influenza)

Launch as defined for new vaccine
introduction (see above indicator)

New and underutilized vaccines refers to all
vaccines that were not previously in national
immunization schedule

Annual surveys with NRA’s; JRF for launchof vaccine; WB for definition of low andmiddle income countries

Annual surveys with NRA’s; JRF for launch;
WB for definition of low and middle
income countries

World Bank, JRF

0

0

2010

2020: one or more

2020: one or more

2015: at least 90
2020: all low and middle income countries

2015:2/3 reduction compared to 1990
2020: exceed 2015 target

Incremental progress (i.e. number of
products in phase 1, 2 or 3 clinical trials)
on development to be reported andassessed by SAGE

Incremental progress on development(i.e. number of products in phase 1, 2
or 3 clinical trials) to be reported andassessed by SAGE

Monitor trends in vaccine introduction

Monitor trends

Launch is defined as addition of the vaccine
to the national immunization schedule in
one or more low or middle income countries(WB definition) and sustained for a periodof at least 12 months. Excludes use onlyin the private sector. Includes vaccines innational schedule that may be selectively
used in “at risk” populations

Data source/collection

MDG4* WUENIC= WHO UNICEF Estimates of Nactional Immunization Coverage					page 135

United National Interagency Group on
Mortality Estimates (IGME)

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Annex 6: The Monitoring & Evaluation/Accountability Framework

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TABLE 13: Proposed extended Strategic Objective Indicators

1
All countries commit toimmunization as a priority

Operational definition

Data source/collection

Baseline

TargetMilestones

2

Indicators
1.1. Domestic expenditures for
immunization per person targeted

1.2. Presence of an independent technicaladvisory group that meets defined criteria

Immunization expenditure fromnational domestic resources, asreported in the JRF

National Immunization TechnicalAdvisory Groups meeting all WHO
criteria of functionality

Size of target populations asreported in JRF

Criteria of functionality are as
described in the WHO/UNICEF JRF

Individuals and communities
understand the value of vaccinesand demand immunization both asa right and a responsibility

Operational definition

JRF

JRF

Reported expenditure for 2010

2010

Increasing trend in country allocation tonational immunization programmes

Functional National Immunization TechnicalAdvisory Groups in all countries

TargetMonitor and report trends

Increasing trend in number of countries
with functional NITAGs

Milestones

Data source/collection

Baseline

Indicators
2.1. Percentage of countries thathave assessed (or measured) the levelof confidence in vaccination at
subnational level**

2.2. Percentage of un- andunder-vaccinated in whom lackof confidence was a factor that
influenced their decision**

Vaccination confidence: Trust in theusefulness and safety of vaccines and in
the system that delivers them. Vaccination
confidence exists on a continuum and is
one of the factors that influences behavior
ranging from acceptance to refusal.

Vaccination confidence: Trust in theusefulness and safety of vaccines andin the system that delivers them. Vaccination confidence exists on a continuum
and is one of the factors that influences
behavior ranging from acceptance to refusal.

Determination, whether there beensome assessment (or measurement) of
the level of confidence in vaccination at
subnational level.

Determination of % of un- and undervaccinated in whom lack of confidence
was a factor that influenced their decision(this applies to all vaccines)and whether
this % was measured or estimated.

JRF

JRF

TBD

TBD

Increasing trend in the % of countries
having assessed the level of confidence invaccination at subnational level

Decreasing trend in the distribution of% of un- and under-vaccinated in whomlack of confidence is a factor at thenational level.

Monitor and report trends

Monitor and report trends** Provisional indicator to be finalized based on outcomes of pilot assessment in selected regions.

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3
The benefits of immunization
are equitably extended to
all people

Operational definition

4

Indicators
3.1. Percentage of districts with 80%
or greater coverage with three dosesof diphtheria-tetanus-pertussiscontaining vaccine

3.2. Reduction in coverage gaps between
wealth quintiles and other appropriate
equity indicator(s)Same process for determining districtlevel coverage as for Goal 3

Determination of wealth index as definedin DHS and UNICEF Multi-indicator cluster
surveys (MICS);

Strong immunization systems
are an integral part of awell-functioning health system

Operational definition

page 139

Indicators
4.1. Dropout rate between first dose
(DTP1) and third dose (DTP3) of diphtheriatetanus-pertussis-containing vaccines

4.2. Sustained coverage of diptheriatetanus-pertussis-containing vaccines
90% or greater for three or more years((DTP1-DTP3)*100)/DTP1

Countries sustaining coverageof 90% or higher for three consecutive
years, based on WUENICWUENICWUENIC

2010

2010

Decreasing trend in drop out rate

All countries by 2020

Trends in drop-out rates

Increasing trend in number of countries
sustaining coverage of 90% or higher

If wealth quintile is used should reportcoverage across all quintiles and not justlowest and highest quintile;
Data collection by repeated measure(special study or survey), with at least two
measurements, early measure (2009-2015)
and late measure (2016-2020)
JRF annual, or special studies/surveys
for repeated measures

Household survey or special study
representative of entire population2010 or early measure

Early measure

TargetAll countries with all districts
80% DTP3 coverage by 2020

Increasing trend in equity in immunization
coverage; Proposed target to align with GAVI
targets: proportion of countries with < 20%
difference in coverage between wealthquintiles 60% by 2015 and 75% by 2020

TargetMilestones

Monitor trends in number ofcountries meeting the target

Increasing trend in equity in
immunization coverage

Milestones

Data source/collection

Baseline

Data source/collection

Baseline

4 continued on page 140

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4
continued

Operational definition

5

Indicators
4.3. Immunization coverage data assessedas high quality by WHO and UNICEF

4.4. Number of countries withcase-based surveillance for
vaccine-preventable diseases

Use qualitative assessment of data quality
in WUENIC, based on nationally reported
data, consistency in data on estimates ofsize of target population, and consistency
between estimates from administrativeand other data sources (surveys and otherprogrammatic information)# countries reporting that they have established surveillance in the JRF and whose
reports are included in WHO databases
Vaccine preventable disease surveillance
will contain, at a minimum:- country-wide surveillance
for poliomyelitis, measles andneonatal tetanus;

Data source/collection

Baseline

TargetMilestones

WUENIC Grade of Confidence

Immunization programmes havesustainable access to predictable
funding, quality supply andinnovative technologies***- h ospital-based sentinel site
surveillance for invasive bacterial
diseases and rotavirus diarrhoea
with laboratory confirmation of cases

Operational definition

Data source/collection

Baseline2010

All countries to have highquality immunization coveragedata by 2020100% of countries for polio andmeasles surveillance by 2015

Monitor trends in number ofcountries meeting the target

Increasing trend

75% of low and middle income
countries for sentinel site surveillanceby 2020

Indicator
5.1. Percentage of doses ofvaccine used worldwide that areof assured quality

Number of doses of vaccines ofassured quality used in a country /total doses of vaccines used innational immunization programme
Vaccines of assured quality include:- Vaccines produced in a country
with a functional national
regulatory authority- Vaccines prequalified by WHO

Established WHO quality standards
will be used for assessing surveillance
quality; a analysis of surveillance
quality will be included in narrative
report on this indicator

JRF and surveillance reports to WHO

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TargetMilestones***The report on progress will also include a narrative report on progress with vaccine supply, pricing and procurement.
					

JRF; Assessment by by the WHO team on
quality, safety and standards for vaccines

2010

100% of doses vaccines by 2020

Increasing trend

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6
Country, regional and global
research and development
innovations maximize the benefitsof immunization.

Operational definition

Data source/collection

Indicators
6.1. Progress towards developmentof HIV, TB, and malaria vaccines

6.2. Progress towards a universal
influenza vaccine (protecting against
drift and shift variants)

6.3. Progress towards institutional andtechnical capacity carry out vaccine
clinical trials

6.4. Number of vaccines that have
either been re-licensed or licensed
for use in a controlled-temperature
chain at temperatures above thetraditional. 2-8 °C range

6.5. Number of vaccine delivery
technologies (devices and equipment)that have received WHO prequalification against the 2010 baseline

Number of HIV, TB, and malaria vaccine
clinical trials assessing clinical efficacy
completed and with results reported

Number of influenza clinical trials assessing
clinically the breadth of protection completed and reported

Number of countries per WHO region
having reported conduct of a vaccine
clinical trials that meet quality standards(to be specified)

As defined in indicator

Four categories of equipment
would be tracked:- Refrigerators and freezers- Cold boxes and vaccine carriers- Coolant packs- Temperature monitoring devices

WHO,
NIH and other clinical trial registries

WHO,
NIH and other clinical trial registries

WHO,
NIH and other clinical trial registries

Reports from NRAs

PQS data base

Incremental above 2010

Incremental above 2010

Increasing number of vaccines

Increasing number of technologies

Baseline

TargetMilestones

page 143

Proof of concept for a vaccine that shows
greater or equal to 75% efficacy for HIV/
AIDS, tuberculosis, or malaria vaccines

At least one vaccine providing
broad spectrum protection against
influenza A virus licensed

Narrative report on progress indevelopment of these vaccines

Narrative report on progress indevelopment of these vaccines

The SAGE Decade of Vaccines Working Group that will review the annual GVAP progress report will also consider thedevelopment and addition of indicators that measure equity in access to vaccines between countries, and an indicator tomonitor integration of immunization systems into broader health systems.					Every Region has a solid base ofcountries competent in hosting andmanaging vaccine trials

page 144

5.

Global Vaccine Action Plan

Acknowledgements & Contacts

Acknowledgements& Contacts
Approximately 1,100 participants from more than
140 countries and 290 organizations provided ideas,
feedback, and comments to the Global Vaccine
Action Plan.
This document was developed under the auspicesof the Decade of Vaccines Collaboration LeadershipCouncil, composed of Seth Berkley (GAVI Alliance),
Margaret Chan (World Health Organization),
Christopher Elias (Bill & Melinda Gates Foundation),
Anthony Fauci (US National Institute of Allergy and
Infectious Diseases), Anthony Lake (UNICEF), and
Joy Phumaphi (African Leaders Malaria Alliance).

page 145

page 146

Acknowledgements & Contacts

Global Vaccine Action Plan

The Decade of Vaccines CollaboratiOn
Steering Committee Guided theDevelopment of the GVAP:
Pedro Alonso (co-chair DoVC Steering
Committee, the Barcelona Institutefor Global Health), Ciro de Quadros(co-chair DoVC Steering Committee,
the Sabin Vaccine Institute), Nicole
Bates (co-chair Public & Political
Support Working Group, Bill andMelinda Gates Foundation), Zulfiqar
Bhutta (Aga Khan University), Lola
Dare (The Centre for Health Sciences
Training, Research and Development),
Helen Evans (the GAVI Alliance), Lee
Hall (National Institute of Allergy
and Infectious Diseases), T. Jacob John
(retired, Christian Medical College,
Vellore, India), Jean-Marie Okwo-Bele(co-chair Delivery Working Group,
the World Health Organization), Orin
Levine (co-chair Global AccessWorking Group, Johns Hopkins
Bloomberg School of Public Health),
David Salisbury (co-chair Research& Development Working Group,
the United Kingdom Department of
Health), Anne Schuchat (National
Center for Immunization andRespiratory Diseases, the U.S. Centers
for Disease Control and Prevention),
Peter A. Singer (co-chair Public &Political Support Working Group,
Sandra Rotman Centre, University
Health Network and University ofToronto), Lucky Slamet (the National
Agency of Drug and Food Control,Indonesia), Gina Tambini (the Pan
American Health Organization), Jos
Vandelaer (co-chair Delivery Working
Group, UNICEF), and Sandy
Wrobel (co-chair Global AccessWorking Group, Applied Strategies).

Eight working groups:(Delivery, Global Access, Public &Political Support, Research &Development, Costing & Funding,
Health & Economic Benefits,
Monitoring & Evaluation/
Accountability Framework Indicators,
Communications) involving morethan 100 participants have collaborated
in the development of the document.
More than additional 180 people
participated in the working
group discussions.
The Following Individuals Have Been
Members Of The Working Groups:
Delivery Working Group
Core Members:
Amani Abdelmoniem (Ministry of
Health, Sudan), Mercy Ahun (theGAVI Alliance), Shams el Arifeen
ICDDRB), Silvia Bino (Instituteof Public Health, Albania), Brent
Burkholder (CDC), Pradeep Haldar(Ministry of Health and Family
Welfare, India), Clifford Kamara(the Sabin Vaccine Institute), Najwa
Khuri-Bulos (Jordan University
Hospital), Rebecca Martin (CDC),

Susan McKinney (USAID), Robert
Steinglass (John Snow, Inc.),
Liang Xiaofeng (Chinese CDC),
John Wecker (PATH), Simon Wright(Save The Children UK).
More than 70 additional individuals
participated in the discussions of the
Delivery Working Group, and thefollowing resource persons assisted
the group: Teresa Aguado (WHO),
Thomas Cherian (WHO), Rudi
Eggers (WHO), Gian Gandhi(UNICEF), Ed Hoekstra (UNICEF),
Steve Jarrett (UNICEF), Lidija
Kamara (WHO), Patrick Lydon (WHO),
Osman Mansoor (UNICEF), Carsten
Mantel (WHO), Violaine Mitchell(Bill & Melinda Gates Foundation),
Dragoslav Popovic (UNICEF), andDaniel Tarantola (WHO).

Global Access Working Group
core members:
Girindre Beeharry (Bill & Melinda
Gates Foundation), Kim Bush (Bill& Melinda Gates Foundation), David
Cook (IAVI), Gerard Cunningham(Bill & Melinda Gates Foundation),
Harkesh Dabas (Clinton HealthAccess Initiative), Patricia Danzon(The Wharton School, University ofPennsylvania), James Droop (the U.K.
Department for International
Development), Christopher EgertonWarburton (Lion’s Head Global Partners), David Ferreira (the GAVI

Alliance), Lauren Franzel (PATH),
Björn Gillsater (UNICEF), Amanda
Glassman (Center for Global
Development), Shanelle Hall
(UNICEF), Robert Hecht (Results forDevelopment), Miloud Kaddar (WHO),
Subhash Kapre (retired, the Serum
Institute), Lothe Lene Jeanette(Norwegian Agency for Development
Cooperation), Ian Lewis (UNICEF),
Margie McGlynn (IAVI), Julie Milstien(University of Maryland), Neeraj
Mohan (Clinton Health Access
Initiative), Melinda Moree (BIO
Ventures for Global Health), MaryC. Muduuli (African Development
Bank), Raja Rao (Bill & Melinda Gates
Foundation), Daniel Rodriguez (thePan American Health Organization),
Helen Saxenian (Results for Development), Meredith Shirey (UNICEF),
Maya Vijayaraghavan (CDC), Melinda
Wharton (CDC), Piers Whitehead(NeoVacs), Prashant Yadav (Universityof Michigan), Michel Zaffran (WHO).
Johns Hopkins Bloomberg School of
Public Health provided the support ofKyla Hayford to the group.

Public & Political Support
Working Group core members:
Geoff Adlide (the GAVI Alliance),
Luis Barreto (retired, Sanofi Pasteur
Canada), Shereen El Feki (Global
Commission on HIV and the Law),
David Gold (Global Health Strategies),
Elizabeth Gore (UN Foundation),

Jennifer Kates (Kaiser Family
Foundation), Kaia Lenhart (GMMB),
Jesus Lopez-Macedo (UNICEF),
Adrian Lovett (ONE), Maziko Matemba(Health and Rights Education
Program, Malawi), Gregory Poland(Vaccine), Kammerle Schneider(IAVI), Kamel Senouci (Agénce deMedecine Preventive), Nelson
Sewankambo (Makerere University),
Damian Walker (Bill & Melinda Gates
Foundation), Peg Willingham(UN Foundation). Over 30 additional
individuals participated in thediscussions of the Public and Political
Support Group. The working group
received support from Stephanie Lazar,
consultant to the Bill & Melinda Gates
Foundation, and Lauren Leahy fromthe Sandra Rotman Centre.

Research & Development
Working Group core members:
Alex von Gabain (Intercell), Bruce
Gellin (U.S. Department of Healthand Human Services), Jesse Goodman(Food and Drug Administration),
Marie-Paule Kieny (WHO), Margaret
Liu (ProTherImmune), Christian
Loucq (International Vaccine
Institute), Adel Mahmoud (Princeton
University), Tom Monath (Kleiner
Perkins Caufield & Byers), Gary Nabel(National Institutes of Health), Regina
Rabinovich (Bill & Melinda Gates
Foundation), Rino Rappuoli(Novartis Vaccines & Diagnostics),
Steve Reed (Infectious Diseases

page 147

Research Institute), Adam Sabow(McKinsey & Company), Chris Wilson(Bill & Melinda Gates Foundation).
Around 110 individuals participated in
the discussions of the R&D
Working Group.

DoV Costing & Funding
Technical Working Group:
Logan Brenzel (Bill & Melinda Gates
Foundation), Hugh Chang (PATH and
DOVC Secretariat), Santiago Cornejo(GAVI Alliance), Eliane Furrer (GAVI
Alliance), Lauren Franzel (PATH),
Gian Gandhi (UNICEF), Patrick Lydon(WHO), Carol Marzetta (Applied
Strategies), Helen Saxenian (Resultsfor Development), and Sandra Wrobel(Applied Strategies), with consultancy
services provided by The Boston
Consulting Group.
Health & Economic Benefits
Working Group:
Jessica Atwell (Johns Hopkins
University), Dagna Constenla (Johns
Hopkins University), S. Deblina Datta(the GAVI Alliance), Ingrid Friberg(Johns Hopkins University), Marta
Gacic-Dobo (WHO), Sue Goldie(Harvard School of Public Health),Peter Hansen (the GAVI Alliance), Lisa
Lee (the GAVI Alliance), Orin Levine(Johns Hopkins University), Meredith
O’Shea (Harvard School of Public
Health), Sachiko Ozawa (Johns
Hopkins University), Susan Reef

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Global Vaccine Action Plan

(CDC), Meghan Stack (Johns Hopkins
University), Peter Strebel (WHO),
Chutima Suraratdecha (PATH),
Steven Sweet (Harvard School of
Public Health), Yvonne Tam(Johns Hopkins University), Emilia
Vynnycky (Health Protection Agency),
Damian Walker (Bill & Melinda
Gates Foundation), Neff Walker(Johns Hopkins University), Steve
Wiersma (WHO).

Monitoring & Evaluation/
Accountability Framework
Indicators Working Group:David Brown (UNICEF), Tony Burton(WHO), John Grove (Bill & Melinda
Gates Foundation), Chung-Won Lee(CDC), Dragoslav Popovic (UNICEF),
Daniel Thornton (GAVI Alliance),with consultancy services provided by
The Boston Consulting Group.
Communications Working Group:
Courtney Billet (NIAID), Hayatee
Hasan (WHO), Hannah Kurtis(PAHO), Christian Moen (UNICEF),
Jeffrey Rowland (the GAVI Alliance),
Karen Lowry Miller (Bill & Melinda
Gates Foundation).

The World Health Assembly in May
2011 and the WHO Executive Board
in January 2012 reviewed the initial
drafts of the GVAP and provided
valuable inputs and guidance on theprocess and the content of the GVAP.
UNICEF organized a briefing ofUN member states representatives
on the 19 January 2012 in New York.
Appendix 5 contains a list of all
countries and organizations that havecontributed to the document.
The DoV Collaboration Secretariat
was responsible for preparing andmanaging the consultation processof the Global Vaccine Action Plan inclose coordination with the Steering
Committee and the Working Groups.
The members of the Secretariat were:
Magdalena Robert (Director), Altaf
Lal (Technical Director), Hugh Chang(Advisor to Co-chairs), Enric Jané(Advisor to Co-chairs), Santiago Porto(Project Manager), Laura Moya
(Working Group Coordinator for
Delivery and Research & Development
Working Groups), Laurie Werner(Working Group Coordinator for
Global Access and Public andPolitical Support Working Groups),
Laia Bertran (Project Officer), Richard
Hatzfeld (Communications), Amy

Alabaster (Communications),
Dan Epstein (Communications),
Joan Tallada (CSOs Coordinator),
Claudia Hernandez (Project
Assistant), Yolanda Amat (Project
Assistant), Desirée Van der Mei(Project Assistant), Monique Shields(Project Assistant).
The Steering Committee members
endorse the Global Vaccine Action
Plan and generally agree with its
findings. The document represents
a common vision of the Steering
Committee, incorporating inputs frommembers of the different working
groups, academia, civil society, andindustry, and inputs received throughvarious consultations. Naturally, notevery view expressed in this document
reflects the views of all individuals andinstitutions that participated in thedevelopment of the plan. Individuals
and institutions might have different
perspectives on some of the issues.
The views expressed by individuals
do not represent the position of theinstitutions to which they belong. The
Steering Committee members would
like to publicly thank all stakeholders
engaged in this collaboration.

Questions about the Global Vaccine Action Plan canbe directed to representatives from the Decade of
Vaccines Collaboration Leadership Council agencies.

Bill & Melinda Gates Foundation
Email: media@gatesfoundation.org

GAVI Alliance
Email: info@gavialliance.org

United Nations Children’s Fund
(UNICEF)
Email: immunization@unicef.org

World Health Organization (WHO)Email: vaccines@who.int

The Decade of Vaccines Collaboration Secretariat
was hosted by:

National Institute of Allergy and
Infectious Diseases (NIAID)
Email: ocpostoffice@niaid.nih.gov