Running a health system with Mozambique’s staggering level of disease burden would challenge even the world’s richest nations. An estimated 13% of under-five deaths are caused by pneumonia, there are very high levels of malaria, and HIV creates another crushing burden with prevalence rates of more than 30 percent in some areas with resultant tuberculosis epidemics.
Yet Mozambique is not only one of the world’s poorest countries. Its poverty is compounded by the lasting impact of a 16-year civil war (1977-92) that severely disrupted health services, and recurrent floods that continue to undermine a fragile network of health centres.
This makes the Health Ministry’s efforts to put in place an effective and efficient immunisation system even more remarkable. During a recent three-day visit, I witnessed evidence of the Ministry’s success: from orderly vaccination sessions and the rigorous registration of immunisation cards at Manhiça district hospital, 70km from Maputo, to the well-trained personnel and cold chain system operating at the nearby Maragra health centre.
All of the clinics (albeit in a relatively high functioning area) that I visited took advantage of vaccination sessions to provide maternal and child health check-ups – a best practice long observed in developed countries. Far from having to convince mothers to vaccinate their children, I saw that immunisation is considered an important social occasion, with mothers dressing-up for a visit to the local clinic.
With the Health Ministry poised to introduce pneumococcal vaccine using GAVI support, there can be no room for complacency. Yet my visit also revealed some clear and present danger signs.
The Expanded Programme for Immunisation (EPI) group in Maputo confirmed that immunisation coverage rates for Mozambique dropped in 2010. This is borne out by an inability to lift pentavalent vaccine coverage to high-levels and an increase in measles outbreaks. Data shows that Mozambique is close to a full birth cohort of measles susceptibles; if there is a large outbreak, it will spread very quickly. Polio immunisation rates are disturbingly low which also means if there is a reintroduction, there is risk of a sizeable outbreak.
On the ground, local health centres explained to me the difficulties in running mobile immunisation clinics; essential to reach Mozambique’s often widely dispersed villages. In Manhiça district, the vehicle used for delivering vaccines to remote communities usually doubles-up as an ambulance – in emergencies, the mobile clinics can be cancelled at the last moment. There are also shortages of fuel and spare parts. And in more remote districts particularly in the North, this takes on a more concerning note: more than 40% of Mozambique’s citizens are not served by fixed based facilities, so for many, outreach is the norm.
Reassuringly, Mozambique’s Prime Minister Aires Ali told me that the national immunisation programme is a priority for his Government. Vice Health Minister Naira Abdula revealed her ambitious plans and that she has invited Mozambique’s Head of State to attend the launch of the pneumococcal vaccine, scheduled within the next two years.
There is also interest from the Health Ministry and GAVI’s in-country partners WHO and UNICEF in using GAVI’s health system strengthening support to meet the challenge of building a more sustainable vaccine delivery system.
The role of CSO’s in helping to solve these challenging problems has also been demonstrated. We observed Village Reach operating in Manhiça district, an NGO of which I am very familiar as I was a former board member. Village Reach has worked on vaccine delivery logistics in Mozambique for a number of years. They provide 4×4 vehicles to ensure there is no vaccine stock-out at local health centres, help to provide support for the cold chain as well as training health workers. You can learn more about this particular experience by visiting our website .
The challenge will be extending these kinds of collaborative solutions to Mozambique’s 127 other districts. Two decades after the end of the civil war, facilities and trained personnel remain in very short supply especially in the northern rural areas.
One of the most encouraging signs for Mozambique’s future is the full integration into the national health system of the Manhiça Foundation research facility. The centre is perhaps best known as one of 11 centres spread across seven African countries currently involved in phase III trials of the RTSS malaria vaccine candidate. However, the research facility is also doing trials of a new TB vaccine candidate and preparing for potential HIV vaccine trials. Moreover, their work goes far beyond vaccine trials. By following a large demographic cohort of >90,000 persons in the district (some of which dates back to 1996), they are providing real-time information on local disease burden and the on-going impact of public health interventions.
Furthermore, the Foundation is grooming a cadre of highly trained Mozambican scientists dedicated to improving people’s health in their country. Dr. Betuel Sigavque is one such example. Educated at Maputo’s medical school, Betuel joined the Manhiça Foundation in 2001, trained in Pediatrics and tropical medicine, and took his PHD in public health in Barcelona, Spain. Today, he doubles up as the Foundation’s director of research for pneumococcal vaccine research and for potential future HIV vaccine trails, and as the Chief Medical Officer at the Manhiça District hospital.
Thanks to the likes of Betuel and his many well trained colleagues at the Manhiça Foundation, as well as the Government’s vote of confidence in vaccines, I left Maputo with the sense that Mozambique’s immunisation system is likely to have a bright future. I and my colleagues at GAVI look forward to assisting Mozambique in any way that we can with this vision.
For girls in developing countries, good health in childhood and adolescence is a key to a bright future. When girls grow into healthy women, nations and communities benefit. Everybody benefits.
In GAVI we are committed to giving all children a good start in life by delivering life-saving vaccines including against two leading killers, pneumonia and diarrhoea, to the developing world.
While globally there is little difference in immunisation coverage rates between boys and girls, in countries where families prefer having sons over daughters, more boys than girls get immunised. Where women have low status, their children – both girls and boys – are less likely to be immunised. So we work with these countries to overcome gender-related barriers to immunisation. Countries identify the barriers to immunisation and GAVI provides health systems funding support to help reach those who are excluded.
Vaccines protect the health of women and mothers. With UNICEF we have reached more than 40 million women with maternal and neonatal tetanus vaccines, which protect against a lethal consequence of unclean deliveries.
Now, GAVI is supporting two more vaccines which can benefit the health of women and girls: human papillomavirus (HPV) vaccines against cervical cancer and rubella vaccines against congenital rubella syndrome.
Worldwide, over one quarter of a million women die every year from cervical cancer. The vast majority of those deaths occur in developing countries. In Asia and Latin America, deaths from cervical cancer even outnumber those from pregnancy-related causes. So in the global fight to reduce mortality among women of reproductive age we have a new weapon: HPV vaccines that can prevent 70% of cervical cancer cases.
HPV vaccines are critically important to developing countries as cancer screening and treatment services are often unavailable. So in response to the enormous demand from countries, GAVI is working to ensure that HPV and other vaccines are affordable to the countries that need them the most. Last year, a vaccine manufacturer offered an indicative price for HPV vaccines to GAVI countries at US$ 5 per dose, a two-thirds reduction on the lowest public price. GAVI continues to work with vaccine manufacturers to achieve acceptable price commitments.
We are working with cancer, reproductive health and women’s organisations to help countries deliver HPV vaccines cost-effectively. We know how important it is to make sure that vaccination is delivered in an integrated way, with other important interventions for girls such as adolescent reproductive health, HIV prevention, nutrition, family planning and safe motherhood. Our goal is that by 2020, over 28 million girls will be immunised with HPV vaccines.
The other good news for women is GAVI’s support for rubella vaccination. Every year, 90,000 children are born in GAVI-eligible countries with severe birth defects just because their mothers were infected with rubella virus during pregnancy. This is totally preventable through the power of vaccines. GAVI will now support combined measles-rubella (MR) catch-up campaigns in countries immediately introducing MR vaccine into their routine immunisation programmes. By building on the momentum of accelerated measles control activities we believe that one billion children can be immunised against measles-rubella by 2020.
New vaccines, new delivery systems and affordable prices for new vaccines. GAVI is committed to delivering on its promise for women and girls – their right to a healthy future, no matter who they are, no matter where they live.