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Financing Vaccines: In Search Of Solutions That WorkThe fragile processes that lead to the immunization of populations are increasingly subject to breakdown, as the U.S. shortages of influenza vaccine demonstrated the past two winters. These episodes are emblematic of an unrelenting series of vaccine shortages that have occurred over many years. For example, since 1998, nine of twelve vaccines routinely recommended for children have been in short supply. If past is prologue, once these crises subside, policymakers’ rapt attention dissipates, and the problems that dog the reliable distribution of vaccines remain. What prompts this failure to connect the dots between these continuing shortages and a crystal-clear recognition that immunization of populations is a public health imperative yielding enormous benefits that far outweigh its costs? This seemingly straightforward question has many answers that illuminate the complexities of the intricate world of vaccines. To help build better understanding of this world, we are devoting the bulk of this issue to papers that cover its past successes and future challenges. These include a reduction in the number of companies that produce vaccines from twenty-six in 1967 to five in 2004; higher prices associated with new vaccines; low or inconsistent insurance reimbursement; low levels of immunization for adults with chronic illnesses; the persistent disparities in immunization levels among different populations; and how best to harness the potential of new technologies. We open with a thoughtful overview by Walter Orenstein, Gordon Douglas, Lance Rodewald, and Alan Hinman, all of whom play important roles in the vaccine enterprise. We particularly appreciate the efforts of Orenstein, who recently retired as director of the National Immunization Program at the Centers for Disease Control and Prevention (CDC), and Rodewald, who remains a leader of the CDC’s vaccines program, because they served as our editorial advisers. At Health Affairs, Parmeeth Atwal, a deputy editor, supervised the issue’s development. It contains a wealth of material on vaccines—from their history to their economics and financing. The paper by Mark Pauly, accompanied by Perspectives by Amie Batson, Patricia Danzon and Nuno Sousa Pereira, Henry Grabowski, and Alan Hinman, discusses solutions to the vaccine financing conundrum. Other papers look at efforts to ensure an adequate supply and the reality that vaccines are a critical component of improving population health in industrialized countries and, even more importantly, in the developing world, where they are arguably the most promising approach to conquering diseases. In 1974, about 5 percent of the world’s children were vaccinated; today, three-quarters are immunized, saving about three million lives a year. Because poor countries lack the resources, little research and development is conducted on vaccines for diseases that primarily affect them. In the past several years, momentum has been building around an idea that if purchasers would commit, in advance of product development, to pay for vaccines at a fixed, predetermined price, it would eliminate economic uncertainty for vaccine manufacturers and guarantee a market. Ernst Berndt and John Hurvitz describe this novel approach, which is gaining support among governments and private organizations. Other papers with international dimensions include those by Tracy Lieu and colleagues, who point out that collaborations engaging private philanthropy and governments have led to increased uses of vaccines in developing countries; an action plan for maximizing access to needed vaccines in low-income countries by Julie Milstien and colleagues; a view by David Salisbury on how the U.K. National Health Service manages vaccines; and a review by Robert Northrup of a book by Ruth Levine and others that details diverse stories of success in addressing health problems in the developing world. The Merck Company Foundation, which has long been involved in global health philanthropy, provided both financial and intellectual support that enabled us to publish this issue, and we hereby acknowledge their contributions. The most ambitious effort to promote vaccines in the developing world has come through the Bill and Melinda Gates Foundation, which began a decade ago to invest billions in this pursuit. The Gates Foundation, with assets totaling $26 billion, is supporting multiple efforts to find new ways to stop some of the world’s greatest scourges: AIDS, malaria, and tuberculosis. Recently, Health Affairs was awarded a five-year grant of support from the foundation to engage more actively in the global health policy debate. The papers in this issue that focus on the international dimensions of vaccines reflect the journal’s initiative in this regard. In our last issue, we published an essay by Ilavenil Ramiah and Michael Reich of Harvard University that detailed the public-private partnership involving the Gates and Merck foundations and the government of Botswana through which antiretroviral drugs were introduced in that country (March/April 2005, p. 545).
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