By Desmond McNeill
Modern vaccines are among the most powerful tools available to public health. They have saved millions of lives, protected millions more against the ravages of crippling and debilitating disease, and have the capacity to save many more. But like all complex and sophisticated tools, they can be used for different purposes, in different ways, and with various consequences.
When polio eradication was proposed as a global objective, in the late 1980s, it was vigorously debated. No one doubted the power of the polio vaccine to protect children. But experts differed in how they thought it should best be used. Some have regarded vaccination programmes as a means of strengthening primary health care, whilst others have seen them as likely to divert attention and resources from needed improvements in health services. At issue in such debates is not the immunological properties of a vaccine, but the way in which it should best be used. Taking the health care needs of children, and especially those whose health is most at risk, as the key objective, how should vaccines best be deployed?
The question is even more relevant today, as more and more new vaccines are becoming available, and huge financial resources are being deployed to promote global immunisation. These donor-funded programmes now account for a major part of the effort devoted to improving the health of children in developing countries.
Three distinctive, but interrelated, trends can be identified in international public health in recent years:
- A growing reliance on health technologies, and on vaccines in particular;
- A global perspective that is increasingly taken for granted;
- Quantifiable targets, and especially the Millennium Development Goals (MDGs), play a very important role.
Health policy makers at national level are expected to implement global immunisation programmes in a standard manner and report progress according to standard indicators. Pressures and incentives to meet the targets set are then transmitted down to the community level health worker who actually meets the parents and children to implement these programmes.
Today, despite continuing or even increased talk of ‘country ownership’, there are growing demands for performance accountability, reflected in demands for measurement of performance — not just outputs, but also outcomes and impacts — based on objective quantitative indicators. The MDGs have contributed to the process. One of the attractions of vaccines is precisely their measurability: both as regards specifying targets and measuring achievement. Dividing the number of vaccines distributed by the number of children of the appropriate age in the target population is made to yield two simple but powerful numbers: percentage coverage, and number of lives saved
Although we are not questioning the intentions of global actors who contribute to this situation, we do note that the effect of their actions is to strengthen the ‘verticality’ in the global health system. In this system money, and vaccines themselves, emanate from the global level and travel down from national to district and to village levels, accompanied by technical advice, exhortation and targets to be achieved. In return — up the chain, emanating from the most local level — come reports on performance, and measures of achievements, expressed in terms of numbers of children vaccinated. In this way, not only is the autonomy of national governments reduced, their accountability may even be reversed. Instead of being accountable ‘downwards’ to their citizens, they become accountable ‘upwards’ to global actors.
The need to show progress can create distortions and lead to the production of misleading data, and an unwillingness to report problems. Vaccines could more effectively serve children’s health needs if immunisation programmes were better understood and acknowledged, and if local knowledge and realities were enabled to inform national and international health policy.
Desmond McNeill is co-editor, along with Sidsel Roalkvam and Stuart Blume, of Protecting the World’s Children: Immunisation policies and Practices (2013). He is Professor, and former Director, at SUM, the Centre for Development and Environment at the University of Oslo. He heads the research area on Governance for Sustainable Development, and is Director of SUMs Research School. He has worked in over 15 developing countries in Africa, Asia and Latin America and written extensively on aid and global governance.